MCQs Pediatric Otolaryngology

Q1:

Otitis media occurring during the first 4  weeks of life deserves special consideration, because the bacteria responsible for infections during this time may be different from those that affect older infants and children. Which of the following organisms is the most likely to cause otitis media in these infants?

(A) Chlamydia trachomatis

(B) E. coli

(C) Neisseria gonorrhoeae

(D) Treponema pallidum

(E) Toxoplasma gondii

Answer:

(B)

C. trachomatis is considered an unusual cause of otitis media at any age. N. gonorrhoeae causes conjunctivitis in the newborn. Syphilis and toxoplasmosis cause congenital infections. E. coli is one of the neonatal pathogens that also causes otitis media in neonates. The symptoms of otitis media in newborns are often similar to those of sepsis; they are subtle and nonspecific and may include poor feeding, lethargy,
vomiting, or diarrhea. Once the diagnosis is established, the initial therapy should be similar to that for neonatal sepsis, such as parenteral ampicillin and cefotaxime. Under ideal circumstances, the results of cultures obtained by tympanocentesis may then allow further treatment with a more specific antibiotic of low
toxicity. Older infants may respond well to oral therapy but require frequent observation.

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Q 2:

A 6-month-old infant is diagnosed with her first episode of otitis media. She does not have any allergies to medications. Which of the following medications would be the recommended initial therapy for this infant?

(A) amoxicillin
(B) amoxicillin-clavulanic acid
(C) cephalexin
(D) ceftriaxone
(E) erythromycin

Answer

(A) H. influenzae, S. pneumoniae, and Moraxella catarrhalis are the most common bacterial pathogens in otitis media of children. Amoxicillin is still the initial drug to use in uncomplicated otitis media because of its good coverage, except for beta-lactamase-positive organisms, and its excellent safety profile. The other drugs (except for erythromycin) are acceptable second-line medications.


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Q 3:

A 4-year-old previously healthy but unimmunized boy presents with sudden onset of high fever, inspiratory stridor, and refusal to drink. Of the following causes of inspiratory stridor, which best fits this clinical scenario?

(A) epiglottitis
(B) vascular ring
(C) croup
(D) foreign body aspiration
(E) laryngeal tumor


Answer:

(A)

Croup and epiglottitis have similar presentations but need to be distinguished immediately. Croup usually results from a viral infection of the larynx and epiglottitis from a bacterial (H. influenzae type B) infection of the epiglottis. Children with epiglottitis tend to be toxic in appearance. Croup involves the airway,
and epiglottitis involves the airway and the digestive tract. Children with croup usually will swallow and drink. Children with epiglottitis most often will refuse to drink and may even drool as a result of their refusal to swallow saliva. Patients with foreign bodies in their upper airways do not typically have fever.
Patients with vascular rings and laryngeal tumors have more gradual onset of symptoms.


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Q 4:

A 10-year-old boy is brought in with a chief complaint of multiple colds. On further questioning, you elicit a history of chronic, clear nasal discharge with no seasonal variation. Other symptoms include sneezing, itching of the nose and eyes, as well as tearing and occasional eye redness. Some relief is obtained with
an over-the-counter cold medicine containing antihistamine and a decongestant. His history suggests which of the following?

(A) nasal foreign body
(B) immunologic deficiency
(C) rhinitis medicamentosa
(D) chronic sinusitis
(E) allergic rhinitis

Anser


(E)

The symptoms are suggestive of perennial allergic rhinitis. Causative agents are usually those to which the child is exposed year round, such as house dust, mold spores, or pet danders.

Seasonal allergic rhinitis is attributable to sensitization to pollens of trees, grasses, and weeds. Nasal foreign bodies usually result in a foul smelling, unilateral purulent, and occasionally blood tinged, discharge. Recurrent
infections may rarely be attributable to immunologic deficiencies. Recurrent pneumonias are the most common complaint.

Rhinitis medicamentosa occurs secondary to excessive use of vasoconstrictor nose drops or sprays,
resulting in rebound nasal obstruction.

Sinusitis is suggested by a bilateral purulent nasal discharge, often accompanied by fever,
cough, headache, and sometimes sinus tenderness.

MSQs In bone diseases

Q1:

A 1-year-old Saudi infant is in for well-child care. He is primarily breast-fed. His parents do not give him much solid food because he has no teeth. He receives no medications or supplements. His parents are concerned about his bowed legs. On examination, you note some other bony abnormalities including frontal bossing, enlargement of the costochondral junctions, a protuberant sternum (pigeon chest), and severe bowing of the legs. You obtain x-rays to confirm your clinical diagnosis and also note a healing fracture of the

left femur. Which of the following is the most likely diagnosis?

(A) osteogenesis imperfecta

(B) scurvy

(C) congenital syphilis

(D) rickets

(E) chondrodystrophy

Answer

(D)

 Babies who are exclusively breast-fed for prolonged periods of time are at risk for developing rickets. Dark-skinned infants are at high risk, especially during winter months when they receive inadequate sunlight. Supplementation with vitamin D is recommended in children who are at high risk, as well as pregnant and lactating mothers. Clinical features include craniotabes, a thinning of the outer table of the skull.

This may also occur in osteogenesis imperfecta. Enlargement of the costochondral junctions (rachitic rosary) may be seen in rickets, scurvy, and chondrodystrophy. Other features may include delayed primary teeth, enamel defects, and caries. There may be thickening of the wrists and ankles; bending of the femur, tibia, and
fibula result in bowlegs or knock-knees.

Greenstick fractures of long bones may occur without symptoms.

 Diagnosis is based on history of inadequate vitamin D intake and clinical features. Diagnosis may be confirmed by x-rays and chemistry; serum calcium is low or normal, serum phosphorus is low, serum
alkaline phosphatase is elevated, and serum 25-hydroxycholecalciferol is decreased. Breast milk contains adequate vitamin C as long as the mother is not deficient.

MCQs In Pediatric Urology

Q1 :

A14-year-old boy presents with sudden onset of pain and swelling of his right testicle. There was no history of trauma, he is not sexually active, and denies any history of penile discharge. On examination, the scrotum is swollen and tender. The cremasteric reflex is absent. A testicular flow scan shows a “cold spot” or

absent flow to the affected side. Which of the following is the most likely cause?

(A) inguinal hernia

(B) hydrocele

(C) epididymitis

(D) testicular torsion

(E) torsion of the appendix testis

Answer :

(D) 

Testicular torsion is the most common cause of testicular pain in boys 12 years and older and is uncommon in those under 10 years. It may be sometimes related to trauma or injury but may occur spontaneously. If not diagnosed early, loss of blood flow to the testicle may result in permanent loss of testicularfunction. 

Torsion of the testicular appendix usually occurs between the ages of 2 and 11 years. The testicular appendix is a vestigial stalk at the upper pole of the testis. Torsion results in pain and swelling of the scrotum, but

the onset of pain is more gradual. There is a 3- to 5-mm indurated, tender mass at the upper pole of the testis. It may sometimes be visible as

a “blue-dot.” Testicular scan may be helpful when this cannot be clinically differentiated from testicular torsion. A hydrocele is a painless collection of fluid in the tunica vaginalis.

Transillumination confirms that the mass is filled with fluid. Hydroceles are present in 1–2% of male newborns and usually resolve by age 1 year. In older boys, a communicating hydrocele may be associated with an inguinal hernia. Inguinal hernias usually appear as a bulge in the inguinal area extending into the scrotum. Hernias are painless, and are more noticeable during crying or straining. They are painful only when strangulated or incarcerated. Epididymitis is an acute inflammation of the epididymis, and is more common in sexually active adolescents. Urinalysis showspyuria and the etiology may be gonococcus or chlamydia but is often undetermined.

MCQs In Pediatric Rheumatology

Q 1:

A17-year-old girl comes to the clinic with several weeks of joint pain and rash. The joint pain is most prominent in the hands. She states that the pain is most severe in the morning and tends to improve over the day. She has noted some swelling of her fingers. She has also had a rash on her face that becomes more prominent when she is outdoors. She states that sunlight tends to bother her eyes. On further questioning, she states that she has not felt well for several months. She has had intermittent fever, has been more tired than usual, and has lost weight although she has not been restricting her diet. On physical examination, she looks tired. She has lost 5 lbs since her last visit 1 year ago. She has an erythematous rash on her cheeks. She has several shallow ulcers in her mouth. She has fusiform swelling of her fingers and pain with movement of her fingers. Which of the following is the most likely diagnosis?

(A) systemic lupus erythematosus (SLE)

(B) dermatomyositis

(C) juvenile rheumatoid arthritis

(D) rheumatic fever

(E) Lyme disease

Answer

(A)

 SLE is an autoimmune disorder that affects multiple organs. The diagnosis is based on the presence of four or more major criteria. These include malar rash, oral ulcers, arthritis, and photosensitivity. This patient has all of these symptoms, as well as the systemic symptoms often seen at presentation. The disorder is predominately a disease of women and, in the pediatric population, is a disease of adolescence.

Chronic renal disease is an important and common cause of morbidity and mortality among patients with SLE.

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Q 2:

A 3-year-old boy has had fever for 4 days. On physical examination he has bilateral cervical lymphadenopathy, injected pharynx, and dry cracked lips. A throat swab is done and the rapid strep test is negative. The child is sent home and advised to follow-up if symptoms worsen. The child is brought back 2 days later with all previous findings including a maculopapular rash, swollen hands, and conjunctivitis.
Which of the following is the most likely diagnosis?

(A) Scarlett fever
(B) Kawasaki disease
(C) toxic shock syndrome
(D) infectious mononucleosis
(E) erythema infectiosum

B

Criteria require fever of at least 5 days’ duration for a clinical diagnosis of Kawasaki disease.

 According to these criteria, patients also must have at least four of five other findings, including bilateral conjunctival infection, one or more changes of the oral mucous membranes (e.g., pharyngeal erythema; dry, fissured, and erythematous lips; and strawberry tongue), one or more changes of the extremities (e.g.,
erythema, edema, and desquamation), rash, and cervical lymphadenopathy. Kawasaki disease occurs most commonly during the first 2 years of life. Thrombocytosis, rather than thrombocytopenia, is an almost invariable feature late in the course of illness. The most common serious complication of Kawasaki disease is coronary artery aneurysm formation which can result in thrombosis, aneurysmal rupture, or other cardiac effects. 

MCQs In Syndromes

Q 1 -2 :

A 12-year-old boy comes to the clinic for a sports physical. He is new to your practice. He comes with

his foster mother, who states that he was recently placed in her care because of his mother’s problems with drug abuse. Although a complete medical history is not available, she knows that he has not

received regular care. He does not have any chronic medical problems. She also knows that his father

died of heart disease when he was 35. On physical examination, the boy’s height is greater than the

95th percentile. His arm span exceeds his height. 

Q 1: 

Which of the following is the most likely cause of his tall stature?

(A) Ehlers-Danlos syndrome

(B) Kleinfelter syndrome

(C) Marfan syndrome

(D) Noonan syndrome

(E) Williams syndrome

Q2:

 As you continue your physical examination, you remember that congenital heart disease is common in this particular syndrome. Which of the following is the most likely congenital heart defect in patients with this syndrome?

(A) supravalvular aortic stenosis

(B) AV canal defects

(C) coarctation of the aorta

(D) pulmonary valvular stenosis

(E) mitral valve prolapse


Q 1 :

(C) Marfan syndrome is a genetic disorder of connective tissue. It is transmitted in an autosomal
dominant manner. Patients have tall stature and skeletal disproportion, where the
arm span exceeds the height. Other important clinical features include subluxation of the
ocular lens which occurs in 50–80% of patients.

Progressive dilatation of the aortic root and ascending aorta can lead to dissection or rupture.

Q 2:

 (E) Marfan syndrome is associated with mitral valve prolapse and aortic root dilatation.

MCQs In Pediatric Oncology

Q1 :

Amother brings in her 3-year-old girl because  she felt a smooth mass on the left side of her belly when she was giving her a bath. Which of the following is the most likely diagnosis?

(A) Wilms tumor

(B) neuroblastoma

(C) acute lymphoblastic leukemia

(D) Hodgkin’s disease

(E) hepatoblastoma

Answer

(A)

 Wilms tumor is a malignant embryonal neoplasm of the kidney. It is the second most common solid tumor of childhood. Girls are affected more frequently than boys (2:1). The incidence of Wilms tumor peaks at 1–3 years of age.

 The classic presentation is a painless abdominal mass that is usually hard, smooth,and unilateral. Hematuria occurs in 12–25% of children with Wilms tumor, and hypertension has been reported in up to 60% of patients.

Aniridia or hemihypertrophy may be observed in patients with Wilms tumor.


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MCQs In Puberty

Q 1:

A 14-year-old boy complains of breast enlargement on the left side. He denies pain, discharge,

or any drug use. He is on no medications and is otherwise healthy. On physical examination, his both genitalia and pubic hair growth. Initial management should include which of the following?\

(A) magnetic resonance imaging of the head

(B) urine drug screen for marijuana

(C) chromosome analysis

(D) reassurance that this is a normal condition

(E) ultrasound imaging of the abdomen and testes

Answers :

(D) Gynecomastia is the enlargement of male breast tissue and occurs in approximately onethird of adolescent males during early- to midpuberty.

It usually resolves spontaneously and requires no further evaluation beyond a careful history and physical examination. Features include: breast tissue <4 cm in diameter and resembling female breast budding, and pubertal development between Tanner stage II and IV.

Pubertal development signs precede gynecomastia by at least 6 months. It may be more
noticeable in obese boys. A drug and medication history should be obtained; these include estrogens, androgens, human chorionic gonadotropin (hCG), cardiovascular drugs (reserpine, methyldopa, digitalis),
cytotoxic agents (busulfan, vincristine), antituberculosis drugs (INH), psychoactive drugs (tricyclic antidepressants, diazepam), ketoconazole, spironolactone, cimetidine, and phenytoin. Illegal drugs include marijuana, heroin, methadone, amphetamines, as well as alcohol.

If there is evidence of precocious puberty, hypogonadism or macrogynecomastia (breast tissue >5 cm diameter), laboratory testing should be done including dehydroepiandrosterone sulfate (DHAS), FSH, and LH, hCG, estradiol, and testosterone. Thyroid-stimulating hormone (TSH) may be obtained to rule out
hyperthyroidism. Boys with Klinefelter syndrome have hypogonadism (testes <3 cm in diameter), delayed pubertal development, and gynecomastia. Laboratory tests reveal increased FSH and LH, and decreased testosterone; the diagnosis is confirmed by chromosome
analysis.

If DHAS, hCG, or estradiol levels are increased, an MRI of the head to exclude a CNS tumor and ultrasound of abdomen and testes to rule out an adrenal, liver, or testicular tumor should be considered.

MCQs In Pediatric Emergencies

Q 1:

A 2-month-old infant is brought to the emergency department with irritability and lethargy.  The parents state that he was well until he rolled off the couch on to the floor yesterday. On examination, he is inconsolable and afebrile. The fontanels are full and tense. He has a generalized tonic-clonic seizure. Which of the following is the most important initial diagnostic study to order?

(A) serum calcium, phosphorus, and magnesium levels

(B) analysis of cerebrospinal fluid (CSF)

(C) cranial computed tomography (CT) scan

(D) serum ammonia level

(E) serum acetaminophen level

Answer :

(C)

Though infection must be considered as an etiology, acute trauma is more likely in this scenario.
This case represents the classic picture of the shaken baby syndrome which produces intracranial trauma without obvious external findings. This infant is critically ill and lacks preceding illness or constitutional symptoms.

The tense fontanels reflect increased intracranial pressure. Acranial CT scan may show diffuse edema or a localized lesion, such as a subdural hemorrhage. Metabolic causes of seizures do not cause increased intracranial pressure. Acetaminophen toxicity does not cause CNS symptoms.


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Q 2:

A5-year-old pedestrian is hit by a car in a mall parking lot and he is brought to the emergency department. There was loss of consciousness for less than 1 minute. On evaluation, the child has no neurologic deficits and a CT scan of the head reveals no intracranial abnormalities and no obvious skull fractures. The parents want to know what possible long-term problems there might be. You remember that problems after head trauma may include the development of seizures and that the risk of developing posttraumatic epilepsy is increased by which of the following?

(A) a brief loss of consciousness
(B) an acute intracranial hemorrhage
(C) retrograde amnesia
(D) posttraumatic vomiting
(E) a small linear skull fracture

Answer

(B)

Late posttraumatic epilepsy is diagnosed when a seizure occurs for the first time more than 1 week after a head injury. Factors that correlate with an increased risk of developing posttraumatic epilepsy include presence of a depressed skull fracture, acute intracranial hemorrhage, cerebral contusion, or unconsciousness lasting more than 24 hours. Because the risk of a subsequent seizure is approximately
75%, acute and chronic treatment with anticonvulsants is indicated. Loss of consciousness,
retrograde amnesia, and vomiting are relatively common immediate consequences of head trauma. They are usually transient and are not highly correlated with a risk of subsequent posttraumatic seizures.

MCQs In Pediatric Ophthalmology

Q 1:

A 5-year-old child was hit in the right eye by a toy. He is rubbing at his eye, which is watering

profusely. There is a small abrasion at the corner of the eye. He is mildly photophobic, but

his pupils are equal, symmetric, and reactive to light and accommodation. His vision is normal.

Which of the following is the most appropriate next step in the management of this patient?

(A) Perform a fluorescein dye stain of the cornea to determine if there is a corneal abrasion.

(B) Refer him immediately to an ophthalmologist.

(C) Irrigate the eye with sterile normal saline.

(D) Discharge him to home with antibiotic eye ointment.

(E) Apply a patch to the eye and follow-up in a week.

Answer:

(A)

Superficial corneal injuries expose underlying layers causing pain, photophobia, tearing, and decreased vision. Irrigation is recommended only if a foreign body is suspected.

Abrasions are detected by instilling fluorescein dye and inspecting the cornea using blue-filtered light. Treatment consists of frequent applications of topical antibiotic ointment until the epithelium is healed. The use of a patch does not accelerate healing, and if improperly applied, may abrade the cornea. Referral to an
ophthalmologist should be considered if there are significant changes in vision, or signs of
deeper or more penetrating injury which often result in papillary abnormalities.

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Q 2:


A 5-year-old febrile child presents with swelling of the right eyelid. Proptosis and limitation
of ocular movements is noted. Which of the following is the most likely diagnosis?

(A) retinoblastoma
(B) orbital cellulitis
(C) periorbital cellulitis
(D) neuroblastoma
(E) hyphema

answer:


(B)

 Orbital (also referred to as postseptal) cellulitis is a medical emergency. It is a bacterial infection of the orbit. It must be distinguished from periorbital (also referred to as preseptal) cellulitis by the presence of proptosis or limitations of extraocular movements.

When orbital cellulitis is suspected, cultures of blood and CSF should be obtained, appropriate antibiotics should be administered intravenously, an ophthalmologist should be consulted, and CT films should be obtained to delineate the extent of the infectious process.Both retinoblastoma and battered child syndrome
may present with lid edema.

Typically, these children are afebrile and nontoxic in appearance. Hyphema is hemorrhage into the anterior chamber of the eye and is caused by trauma. Twenty percent of patients with neuroblastoma present with eye symptoms from metastasis. Proptosis is one of the possible presentations and can be of relatively acute onset.

In general, other systemic symptoms are present and have developed more gradually.


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Q 3:

Among the conditions that cause edema of the eyelids is orbital cellulitis. This is a serious infection that must be recognized early and treated aggressively if complications are to be avoided. Which of the following features is useful in differentiating orbital cellulitis from periorbital (preseptal) cellulitis?

(A) proptosis
(B) elevated WBC count
(C) fever
(D) lid swelling
(E) conjunctival inflammation


Answer:

(A)

Proptosis and limitation of extraocular motility distinguish orbital cellulitis from periorbital cellulitis. Fever, lid swelling, redness of the eye, and leukocytosis generally are present in either condition. Orbital cellulitis (infection within the orbit) may follow directly from a wound near the orbit or may result from bacteremia,
but the most common source involves extension from the paranasal sinuses. The organisms most frequently implicated as pathogens are H. influenzae, S. aureus, group A beta-hemolytic Streptococci, and S. pneumoniae. The risk of complication is great, with extension resulting in cavernous sinus thrombosis,
meningitis, or brain abscess. Prompt hospitalization and parenteral antibiotic therapy are indicated. 

MCQs In General Pediatrics

Q 1:

A young mother claims that her 4-week-old child sleeps best on his stomach. You tell her

that the safest sleep position for infants is which of the following?

(A) on the back

(B) on the stomach

(C) on the side

(D) on the back with the head elevated by a pillow

(E) in the parents’ bed

(A)

Prone sleeping is a major risk factor for sudden infant death syndrome (SIDS). Since the 1992 American Academy of Pediatrics (AAP) recommendation that infants be placed to sleep on their backs, the frequency of prone sleeping has decreased from 70 to 20%, and the SIDS rate has decreased by >40%. Side sleeping has a slightly higher SIDS risk than supine but is still safer than the prone position. Other risk
factors include maternal smoking, soft bedding, overheating, younger maternal age, prematurity,
low birth weight, and male gender.

Q 2:

A 2-year-old girl has severe dental caries of the upper and lower incisors. Her teeth are brushed twice daily with a small amount of fluoride-containing toothpaste. What is the feeding practice most likely to result in this
pattern of dental caries?

(A) drinking juice from a cup at snack time
(B) drinking juice from a bottle at snack time
(C) drinking milk from a bottle at meal time
(D) prolonged breast-feeding beyond the first year
(E) drinking a bottle of juice in bed

Answer :

(E)

Organic acids produced by bacterial fermentation lower the pH of dental plaque causing demineralization and caries of the adjacent tooth. Nursing bottle caries is a pattern of caries involving the upper and lower incisors. It occurs because of prolonged contact of the tooth to a sugar-containing liquid (juice or milk). This
is more likely to occur with overnight exposure or with use of a bottle. Asimilar pattern of caries
may rarely occur with breast-fed babies who feed through the night. Cup feeding or drinks
given during mealtimes are less likely to cause prolonged contact to the teeth.

MCQs In Viral Hepatitis

Q 1:

A baby is born to a mother who is positive for hepatitis B surface antigen (HBsAg). Your plan

is to do which of the following?

(A) Give the infant a hepatitis B immunization.

(B) Give the infant hepatitis B immune globulin (HBIG).

(C) Give the infant a hepatitis B immunization and HBIG.

(D) Obtain liver function tests and hepatitis serology of the infant.

(E) Give the HBIG only if the child is positive for HBsAg.

C

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Q 2:

You receive a call from the parents of a 1 year old who is due for his well-child visit next week. They have just received a letter from their daycare center that an employee has hepatitis A. Which of the following is the best treatment plan?

(A) Give hepatitis A immune globulin and hepatitis A vaccine.
(B) Treat with hepatitis A immune globulin.
(C) Obtain hepatitis A serology and give hepatitis A vaccine.
(D) Give hepatitis A vaccine.
(E) No treatment is needed.

(A)

 Children, especially those in daycare, commonly are infected with the hepatitis A virus. Unlike adults, children most often are asymptomatic. Frequently, outbreaks of hepatitis A in a daycare center are not recognized until a daycare worker or parent of an attendee becomes ill. Immunization against hepatitis A
virus is now routinely recommended because of this. After exposure both immune globulin
and vaccine should be given to the unvaccinated individual.