MCQs In Neonatal Cardiology

Q 1:

Included in your rounds today is a 36-hour-old boy who was born at term by normal, spontaneous vaginal delivery. His respiratory rate is 80 breaths/min and heart rate is 168 beats/min. He has easily palpable, bounding pulses in all four extremities, and his blood pressure is 72/30 mm Hg. Precordial examination reveals a lift and a 3/6 systolic ejection murmur at the upper left sternal border . You also note a murmur over the anterior fontanelle. Of the following, the MOST likely diagnosis is

A. aortic coarctation with congestive heart failure

B. aortic insufficiency

C. large ventricular septal defect with congestive heart failure

D. left-to-right extracardiac shunting with congestive heart failure

E. right-to-left extracardiac shunting with right heart failure

Anwer

D


The newborn described in the vignette has physical findings and blood pressure that
suggest a run-off lesion from the aorta, which could be significant aortic insufficiency, a largevolume
ductus arteriosus, or an arteriovenous malformation. There is no diastolic murmur to
suggest aortic insufficiency, and at 36 hours of age, a ductus arteriosus would not be expected
to lead to symptoms. Similarly, a large ventricular septal defect might present with a holosystolic
murmur and rarely leads to symptoms in the first few days after birth. Coarctation often leads to
narrowed blood pressure and is associated with a pressure load on the left ventricle rather than
a volume load, as in this patient. Right-to-left extracardiac shunting can occur only when
pressure in the venous (right) vessel exceeds that in the arterial (left) vessel. This is a situation
that does not exist.

MCQs In Pediatric GIT didorders

Q 1:

A 6-year-old boy has complained of periumbilical abdominal pain for the past 2 months. He has a

history of mild constipation that his mother has managed successfully by increasing juice and

fruits in his diet. The mother is frustrated because the boy has been sent home from school

frequently due to complaints of pain. She reports that he is being evaluated for dyslexia. The

pain occasionally occurs on weekends and school vacation breaks.

Of the following, the MOST likely diagnosis is

A. chronic constipation with fecal impaction

B. factitious abdominal pain

C. Helicobacter pylori gastritis

D. recurrent (functional) abdominal pain syndrome

E. school phobia

Answer

D


The symptoms exhibited by the child described in the vignette are most consistent with
recurrent (functional) abdominal pain. The mother states that she has managed the child’s mild
constipation successfully, and there is no history of encopresis to suggest fecal impaction.
School phobia is less likely because the pain also occurs on weekends and school holidays.
Although Helicobacter pylori gastritis is a possibility in children who have epigastric abdominal
pain, those affected often have associated nausea and vomiting.

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Q 2


A 12-year-old girl who has Crohn disease has had poor appetite and chronic diarrhea despite
her medical treatment. In evaluating her nutritional state, you document a low plasma zinc
concentration and initiate zinc supplementation.
Of the following, a TRUE statement about zinc supplementation is that it

A. decreases serum alkaline phosphatase values
B. impairs wound healing
C. inhibits the absorption of dietary copper
D. should be given with dairy products
E. usually decreases appetite

Answer

C


Both copper and zinc are absorbed from the intestine. Zinc-containing foods include beef,
cheese, and legumes (beans and nuts). Copper-containing foods include liver, fish, and
legumes. Both zinc and iron can interfere with intestinal copper absorption. Therefore, if a zinc
supplement is given to a patient who has chronic malnutrition, the patient should be monitored for
potential copper deficiency. Zinc absorption can be impaired if zinc is given at the same time as
dairy products. Patients who have zinc deficiency often have impaired wound healing, reduced
alkaline phosphatase activity, and impaired taste that may affect appetite, all of which should
improve after zinc supplementation.

MCQs In General Pediatrics

Q 1:

An 18-month-old boy lives with his single mother and three older siblings, ages 3, 5, and 6 years. He takes most of his fluids by bottle and has nursing bottle caries. His mother states that he cries inconsolably when she tries to take the bottle away, and she can't tolerate the crying. She leaves a bottle containing milk in his crib so that he can drink during the night without waking her. As you are discussing the problems associated with dental caries, the mother bursts into tears.

Of the following, the BEST intervention is to:

A.  refer him to a pediatric dentist

B.  refer the family to a mental health clinician

C.  slowly wean him from the bottle over 1 to 2 months

D.  stop all bottle feedings to encourage the transition to using a cup

E.   stop the night feedings, but allow him to continue taking the daytime bottle

Answer

B

The mother described in the vignette has multiple stresses and needs the assistance and support of a mental health professional. The signs of a disordered relationship between infant and mother are manifested by feeding the infant to quiet him and difficulty with weaning from the bottle. Other common indications of a disordered relationship between parent and child include poor growth, immunization delay, poor hygiene with chronic dermatitis, recurrent missed appointments, and behavior problems in older children.

            The children in this family are at increased risk for abuse and neglect. Parents at high risk of becoming abusive to their children tend to be young, single, and poor, with a history of exposure to violence. Children at high risk of being abused include preterm infants, children who have chronic medical conditions, babies who have colic, and children who have behavior problems.

            The child in the vignette should see a dentist, but this is not the primary concern for the family. The bottle should be weaned, but the increased stress caused by this intervention may cause more difficulty in this family and should be deferred until the family can receive assistance.

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Q 2:

A mother brings in her 6-month-old child for a health supervision visit. She explains that the

family just moved from a rural area where they had obtained their water from a private well. In the past, she needed to give supplemental fluoride to her children beginning at age 6 months and wonders if this is necessary for this child.

Of the following, you are MOST likely to reply that

A. all children should receive fluoride supplementation starting at birth

B. children should not be supplemented if bottled drinking water is used

C. fluoride 0.25 mg/d supplementation should begin at age 6 months if there is less than 0.03 ppm in 

     community water

D. once the baby’s teeth erupt, fluoridated toothpaste will be sufficient

E. supplementation may stop when the child’s deciduous teeth begin to fall out

Answer:

C

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Q 3:


A 6-month-old previously healthy girl is brought to your office because she has not been eating
well today. The mother reports that the baby is interested in taking the bottle, but stops feeding
within 1 minute and seems to have trouble breathing. She is irritable but consolable in her
mother’s arms. She is pale, afebrile, and has a respiratory rate of 70 breaths/min. Her heart rate
is too fast to count, she has palpable pulses in all extremities, and her perfusion is fair, with a
capillary refill time of 2 to 3 seconds.
Of the following, the MOST likely additional finding expected in this child is

A. crackles over the lungs
B. conjunctivitis
C. hepatomegaly
D. nuchal rigidity
E. rash on the extremities


Answer

C


The infant described in the vignette has a heart rate that is too fast to count and most likely
suffers from an atrial arrhythmia such as supraventricular tachycardia. Because the heart rate
in such disorders is typically greater than 240 beats/min, time for the ventricle to fill during
diastole is greatly diminished. This leads to rising left atrial pressure, with subsequent pulmonary
congestion as the pulmonary vessels face increased downstream pressure. The rising
pressure in the pulmonary circuit leads to an increase in pressure on the right heart, which also
faces the difficulty of diminished diastolic time with rising right atrial pressure. This is transmitted
to the systemic veins and often is manifested on physical examination by distension of the
jugular veins and hepatic congestion with hepatomegaly. The tachypnea that results from the
pulmonary vascular congestion leads to difficulty feeding and may exacerbate the appearance
of irritability. In addition, for children who have significant alteration of cardiac output resulting
from the arrhythmia, irritability and lethargy may be the result of inadequate cerebral perfusion.

Children may manifest crackles over the lungs when in congestive heart failure, but this is
not as typical a finding as it is in adults. One reason may be the relative inability of children to
cooperate with deep and prolonged inspiration. Cardiac dysrhythmias would not present with
conjunctivitis, nuchal rigidity, or rash, as might be expected with systemic or central nervous
system infection.

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Q 3


A 9-month-old infant who had been born at 25 weeks’ gestation is receiving daily diuretics and nasal cannula oxygen with a baseline of 0.1 L/min flow. His mother called this morning, reporting that he had a temperature of 100.5°F (38.1°C), nasal congestion, increased work of breathing with a rapid respiratory rate, and “wheezing” cough. You instructed her to increase the oxygen flow rate to 0.5 L/min and advised her to bring him to your office. On arrival at the clinic, pulse oximetry reveals an oxygen saturation of 85% at rest. On physical examination, you note intercostal and subcostal retractions, a respiratory rate of 80 breaths/min, a heart rate of 140 beats/min, and a prolonged expiratory phase with audible wheezing. A copious clear nasal
discharge is present. There is no heart murmur or gallop.

Of the following, the BEST explanation for this child’s presenting signs of respiratory distress is

A. acute cor pulmonale
B. acute sinusitis
C. gastroesophageal reflux
D. lower respiratory tract infection
E. upper respiratory tract infection

Answer

D

The preterm infant who has chronic lung disease (CLD) with an oxygen requirement at the time

of discharge from the neonatal intensive care unit is at risk for a number of complications in the

first 12 to 24 months at home. Chief among these are infections that may compromise

pulmonary function. The infant described in the vignette was an extremely low-birthweight

(ELBW) (<1,000 g) preterm infant whose CLD is being managed with diuretics and oxygen. The

sudden onset of a low-grade fever, upper respiratory tract signs of congestion, lower respiratory

tract signs of small airways constriction (wheezing and a prolonged expiratory phase),

increased work of breathing, and increased oxygen requirement are best explained by a lower

respiratory tract infection. Common viral pathogens include respiratory syncytial virus,

parainfluenza virus, and human metapneumovirus. Lower respiratory tract processes may

involve bronchiolitis or pneumonia. Chest radiographs may demonstrate hyperinflation with airtrapping,

atelectasis, and patchy interstitial infiltrates.

MCQs in Pediatric Immunology

Q 1:

A 10-month-old child, who is below the 5th percentile for height and weight, has recurrent thrush and chronic diarrhea. He has received his primary series of diphtheria, tetanus, acellular pertussis vaccine; poliovirus vaccine, inactivated; hepatitis B; Haemophilus influenzae type B; and pneumococcal conjugate vaccine.

Of the following, the BEST skin test to evaluate the adequacy of delayed hypersensitivity in this child is:

A. coccidioidin

B. histoplasmin

C. Schick test

D. tetanus toxoid

E. tuberculin, purified protein derivative

Answer

D

Intradermal skin testing for delayed-type hypersensitivity is the best measure of T cell-mediated immunity. This usually is performed by applying Candida, Trichophyton, and tetanus skin tests. A healthy host who has had prior exposure to these antigens will develop induration at the site of skin testing. A host who has a defect in T-cell activity or production will be unable to mount the delayed hypersensitivity response.

            Coccidioidin is used to diagnose coccidioidomycosis, histoplasmin is used in epidemiologic studies to detect Histoplasma exposure, the Schick test is used to determine immunity to diphtheria, and the tuberculin, purified protein derivative is used to diagnose infection with Mycobacterium tuberculosis.

MCQs In Emergency And Critical Pediatrics

Q 1:

A 12-year-old boy who plays wide receiver is undercut by a tackler while leaping to catch a pass. He drops the ball and, after getting to his feet, is confused and walks to the opposing team’s side of the field. He remains confused while walking into the locker room for halftime but then seems normal by the start of the second half. However, he continues to have some amnesia for the details of the play in which he was tackled.

Of the following, the recommendation you are MOST likely to make as team physician is

A. daily neurologic examinations for 2 weeks

B. emergency department evaluation and clearance before returning to play

C. return to play at the start of the second half

D. return to play in 30 minutes if symptoms resolve

E. return to play in 7 to 10 days if symptoms resolve

Answer :

E

The boy in the vignette has experienced a concussion characterized by transient cognitive symptoms of amnesia and disorientation after a fall. In this setting, it is best to disallow return to play during this game. He should be evaluated in the office but does not need daily neurologic examinations for 2 weeks. He may return to play in 7 to 10 days if symptoms completely resolve.

The symptoms described are mild enough (no loss of consciousness) that urgent referral to the emergency department is not warranted. However, he should be sent to the emergency department for evaluation if he experiences repeated vomiting, severe or progressively worsening headache, a seizure, unsteady gait, weakness or numbness, slurred speech, unusual behavior, signs of a basilar skull fracture, or worsening mental status.

Guidelines regarding concussion and sports continue to evolve as they are informed by research on traumatic encephalopathy in contact sports. The most important feature of current guidelines for return to play is that assessment needs to be careful and that return to play should not occur until all cognitive symptoms have resolved. An experienced physician should examine the student and ascertain that all symptoms have resolved at rest and with exercise before the student returns to play. Provocative exercise may include a 40-yard sprint, 5 pushups, 5 situps, and 5 knee bends; the examiner evaluates for emergence of headache, dizziness, nausea, visual symptoms, and mental or emotional changes.

Neuroimaging is not indicated according to this presentation. However, if headache or cognitive symptoms worsen over the next week or if seizures or focal neurologic deficits are identified, imaging should be considered. Findings on imaging of brain swelling or contusion would be an indication to terminate participation for the rest of the season.

MCQs In Pediatric Oncolology

Q1:

A 2-year-old boy you have followed up since birth presents to your office for a health supervision visit.  He was born at term and has had normal growth and development. The mother recently noticed that he looks “cross-eyed” at times. There is no family history of eye abnormalities. On physical examination, his left eye is deviated nasally with a white pupillary reflex . There is no proptosis, conjunctival injection, or pain with eye movements. The remainder of results for the physical examination are normal. Results of the complete blood cell count are within normal limits.

Of the following, the MOST likely diagnosis for this patient is

A. bilateral retinoblastoma

B. congenital cataract

C. leukemia with chloroma

D.  neuroblastoma

E. unilateral retinoblastoma

Answer:

E

In this vignette, the age of the child, the lack of findings in right eye, and the relatively higher frequency of unilateral disease over bilateral disease make unilateral retinoblastoma the most likely diagnosis in this patient. Leukemia with chloroma, or intraocular leukemic infiltration, is a less likely diagnosis given the normal blood cell count. Neuroblastoma can present in this age group but is not associated with leukocoria.  Ocular findings typically seen in neuroblastoma include Horner syndrome (miosis, ptosis, enophthalmos, and anhydrosis), periorbital hemorrhage, proptosis, papilledema, retinal hemorrhage, strabismus, and opsoclonus. Congenital cataracts are also a common cause of leukocoria but are usually apparent at birth or early infancy (Item C12). Cataracts can be associated with congenital infections or various systemic disorders (eg, diabetes mellitus, galactosemia, Turner syndrome, Down syndrome, peroxisomal disorders).

One of the most common causes of leukocoria (white pupillary reflex) in children is retinoblastoma (47% of cases); therefore, all children with a new finding of leukocoria should be referred immediately to an ophthalmologist who is experienced in examining children. Other causes include persistent fetal vasculature, retinopathy of prematurity, cataracts, optic disc abnormalities, uveitis, or vitreous hemorrhage.

MCQs In Neonatology Part III

Q 1:

A full-term male newborn is admitted to the regular nursery after an uneventful delivery. Apgar scores are 8 at 1 minute and 9 at 5 minutes. He feeds well initially, but 32 hours after birth you are called by the nurse because he is feeding poorly and seems “lethargic.” You arrange for transfer of the newborn to the intensive care nursery, where the resident on duty obtains a blood culture and provides appropriate antibiotic coverage.

Of the following, if sepsis is ruled out, the test MOST likely to be diagnostic in this newborn is

A.  a complete blood cell count with differential

B.  an electroencephalogram

C.  head ultrasonography

D.  liver function tests

E.  serum ammonia and urine organic acids

Answer:

E

The child in this vignette is a healthy, full-term newborn who has developed mental status changes within 48 hours after birth. Although sepsis is the most likely diagnosis in this scenario, the newborn’s presentation is also typical of an inborn error of metabolism, such as a urea cycle defect or organic acidemia. Therefore, serum ammonia and urine organic acid testing should be considered and done in parallel with blood cultures and antibiotic administration. Early identification of an inborn error with immediate treatment may minimize potential neurologic sequelae from complications such as severe metabolic acidosis or coma secondary to hyperammonemia. 

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Q 2


An infant who was born at 26 weeks’ gestation, weighing 700 g, is nearing 37 weeks corrected
age. He is receiving nasal cannula oxygen (0.2 L/min) and being treated with diuretics for
chronic lung disease. He has no intracranial hemorrhage and is growing well on enteral feedings
via a nasogastric tube. Attempts at oral feeding have been unsuccessful because of frequent
oxygen desaturation, bradycardia, and concerns over the inability to coordinate suckingswallowing.
The mother asks why you are continuing to feed her son via a feeding tube.
Of the following, the condition that BEST explains why her son has feeding problems is

A. apnea of prematurity
B. chronic lung disease
C. gastroesophageal reflux
D. necrotizing enterocolitis
E. tracheoesophageal fistula

Answer

B


The infant described in the vignette has CLD and demonstrates problems in coordinating breathing with suckling and swallowing. Accordingly, he continues to be assisted with nasogastric tube feedings despite reaching a postconceptive age of 37 weeks.

 Apnea of prematurity is not present; the infant has passed the gestational age equivalent of prematurity.
Gastroesophageal reflux does not occur during a feeding but typically presents with postprandial
 mesis.

 Necrotizing enterocolitis is a gastrointestinal disease associated with systemic decompensation and an acute abdomen. Tracheoesophageal fistula (TEF) is associated with respiratory distress and secretion control problems during intervals between feeding; the rare H type fistula with an intact esophagus (accounting for <5% of all TEFs) typically does not present in the newborn period.

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Q 3

You admitted a 2,000-g term newborn to the neonatal intensive care unit. Her Apgar scores
were 4 and 6 at 1 and 5 minutes, respectively. She exhibits seizure activity at 24 hours of age.
Physical examination reveals microcephaly , respiratory distress requiring assisted
ventilation, hepatosplenomegaly, cutaneous petechiae, and lethargy. Laboratory tests
demonstrate thrombocytopenia, anemia, elevated liver transaminases, and hyperbilirubinemia.
Of the following, the viral agent MOST likely to cause these findings is

A. adenovirus
B. Coxsackievirus B
C. cytomegalovirus
D. hepatitis C virus
E. herpes simplex virus

Answer:

C


The infant described in the vignette has findings consistent with symptomatic congenital
CMV infection: intrauterine growth restriction; seizures, which are common in association with
microcephaly; and intracranial calcifications. Respiratory distress may be due to
pneumonitis, and hepatopathy may include elevated serum transaminase concentrations,
coagulopathy, and persistent jaundice. Bone marrow suppression is not uncommon, with
thrombocytopenia resulting in petechiae . If anemia is profound, extramedullary
hematopoiesis may manifest with hepatomegaly, splenomegaly , and cutaneous
nodules (“blueberry muffin” spots).


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Q 4


You are evaluating a newborn who has complete heart block and several 1.5-cm erythematous
macules and annuli located on the forehead, behind the ears, and in the scalp.
Of the following, the test MOST likely to confirm the infant’s diagnosis is

A. anti-Ro (SSA) antibodies
B. creatine kinase
C. hepatic function profile
D. platelet count
E. urinalysis

Answer

A




The infant described in the vignette has complete heart block and erythematous annular plaques
on sun-exposed areas, suggesting a diagnosis of neonatal lupus erythematosus (NLE). NLE is
a rare disorder caused by transplacental passage of maternal autoantibodies. In the majority of
cases (95%), the antibodies responsible are anti-Ro (SSA) antibodies alone or in association
with anti-La (SSB) antibodies. A small proportion of patients and their mothers exhibit anti-
U1RNP antibodies. Performance of these antibody studies on the infant and mother (if she has
not been evaluated previously) help confirm the diagnosis.

MCQs In Pediatric Pharmacotherpy

Q1:

Q 1:

A 12-year-old girl who has a history of juvenile idiopathic arthritis is brought to the emergency department with severe epigastric abdominal pain. She has been taking ibuprofen to control her joint pains. Physical examination demonstrates a well-developed, well-nourished girl in moderate distress from pain. The remainder of the general physical examination shows direct tenderness in the epigastrium without rebound. The rectal examination shows normal sphincter tone and a scant amount of dark brown, hemoccult-positive stool in the rectal vault. Initial laboratory data include the following:

White blood cell count, 10,500/µL (10.5 × 109/L)

Hemoglobin, 11.7 g/dL (117 g/L)

Erythrocyte sedimentation rate, 32 mm/h

Serum electrolytes, normal

Blood urea nitrogen, normal

Creatinine, normal

Of the following, the MOST likely mechanism responsible for her symptoms is

A.  decreased pepsinogen production

B.  duodenal stress ulceration

C.  gastritis induced by peptidoglycans

D.  hypersecretion of gastric acid

E.  inhibition of prostaglandin synthesis

Answer :

E

The girl described in the vignette presents with abdominal pain, hemoccult-positive stools, and anemia. These findings indicate chronic gastrointestinal blood loss, and the presence of epigastric tenderness strongly suggests a lesion in the upper gastrointestinal tract (ie, proximal to the ligament of Treitz). Although the differential diagnosis of chronic upper gastrointestinal bleeding is broad and includes erosive esophagitis, Helicobacter pylori infection, and Crohn Disease, the most likely diagnosis is gastritis or peptic ulcer disease caused by her use of ibuprofen. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, inhibit prostaglandin synthesis. Prostaglandin E stimulates gastric mucus production and helps maintain the protective mucin glycoprotein-bicaA rbonate layer, without which gastric mucosa is exposed to the deleterious effects of gastric acid as well as to the proteolytic effects of chief cell-produced pepsin, which can result in gastritis or peptic ulcers.

NSAIDs are highly effective anti-inflammatory agents that act via inhibition of the enzymes cyclooxygenase-1 (COX-1) or cyclooxygenase-2 (COX-2) or both. The NSAIDS that inhibit both COX-1 and COX-2 are termed nonselective cyclooxygenase inhibitors and include aspirin, ibuprofen, and naproxen. These agents are associated with a significantly higher risk for both gastrointestinal and renal toxicity when compared with selective COX-2 inhibitors (eg, celecoxib). However, the COX-2 inhibitors have been associated with an increased incidence of deleterious cardiovascular effects in adults.

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Q 2:


You are talking to a group of medical students about the antibiotic vancomycin and its
associated adverse effects. One of the students asks you to explain “red man syndrome.”
Of the following, the MOST appropriate response is that “red man syndrome” is

A. a manifestation of a life-threatening anaphylactic reaction
B. a manifestation of the development of ototoxicity
C. related to cytokine release from cells
D. related to endotoxin release from cells
E. related to histamine release from cells

Answer

E



A reaction that is peculiar to vancomycin and occurs in 3.4% to 11.2% of infusions is referred to
as “red man” or “red neck” syndrome. It consists of pruritus; an erythematous rash that
involves the face, neck, and upper torso; and occasionally hypotension. The manifestations of
the reaction are due to the nonimmunologically mediated release of histamine from basophils and
mast cells. This complication can be avoided by slowing the infusion rate, decreasing the dose,
and administering antihistamines prior to the infusion. Red man syndrome is not a manifestation
of a life-threatening anaphylactic reaction or the development of ototoxicity.

MCQs in pediatric infectious diseases

Q 1:

A 12-year-old girl presents to the emergency department for evaluation of severe headache, fever, and lethargy. The parents note that she first became ill with an acute upper respiratory illness with congestion and low-grade fever. The parents also report that over the past few days the girl has had an elevated temperature of 39.1°C, complaints of increasing frontal headaches (greater on the left side), and increased sleepiness. On physical examination, the girl is uncomfortable and awake but sleepy. On examination of head, eyes, ears, nose, and throat, there is tenderness over the frontal sinuses. Her neck is supple. Neurologic examination reveals a left sixth cranial nerve palsy. The remainder of her examination is unremarkable. Computed tomography scan with contrast reveals pansinusitis with meningeal enhancement over the left frontoparietal lobe and an epidural collection of approximately 2 cm.

Of the following, the BEST choice for empirical antibiotic therapy, pending neurosurgical evaluation, is

A. ampicillin and gentamicin

B. cefazolin and gentamicin

C. ceftriaxone and vancomycin

D. metronidazole and vancomycin

E. nafcillin and vancomycin

Answer:

C

The child described in the vignette has a brain abscess documented on computed tomography scan. Brain abscesses can arise as a complication of a number of infections through direct extension (eg, sinusitis, mastoiditis, and odontogenic infections) or hematogenous spread (eg, endocarditis), especially in children with cyanotic congenital heart disease. Trauma and surgical procedures are other predisposing factors for development of brain abscesses. These infections are frequently polymicrobial. Treatment generally involves a combination of antimicrobial therapy and surgical drainage. Initial empiric antibiotic therapy depends on the focus of origin and the likely associated infectious agents.

In this case, the epidural abscess arose as a direct extension from frontal sinusitis, so the likely organisms reflect the pathogens of sinusitis: Streptococcus pneumoniae, Haemophilus influenzae, other streptococcal species, anaerobes, and, less likely, Staphylococcus aureus. Of the listed regimens, ceftriaxone and vancomycin provides coverage for these organisms, and these drugs adequately cross the blood-brain barrier.

Ampicillin and gentamicin would not provide adequate coverage for ß-lactamase positive H influenzae, S aureus, or penicillin-resistant S pneumoniae. Additionally, gentamicin does not adequately cross the blood-brain barrier. Similarly, first-generation cephalosporins such as cefazolin do not adequately cover H influenzae and do not cross the blood-brain barrier. The combination of metronidazole and vancomycin or nafcillin and vancomycin does not provide adequate coverage, especially for H influenzae.

The duration of antibiotic therapy for brain abscesses is typically 6 to 8 weeks according to clinical response. In addition to antibiotic therapy, treatment for brain abscesses includes consultation with the appropriate specialists and surgical drainage if indicated.

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Q 2:

An 18-month-old boy is brought to your clinic because of redness of his left cheek that his mother noticed yesterday. He has been otherwise well and has had no fever. Physical examination findings reveal a tender, erythematous area of slight induration on his left cheek . His mother tells you that the boy recently started sucking ice chips.

Of the following, the MOST likely diagnosis is

A. cellulitis

B.  cold panniculitis

C.  dental abscess

D.   juvenile xanthogranuloma

E.   lipoma

Answer

B

Cold panniculitis, also known as “popsicle panniculitis,” is a lesion of the skin caused by prolonged exposure to cold objects. Sucking on popsicles or ice chips results in the most common presentation on the cheeks, but any area of the body exposed to cold can be affected. The mechanism of pathogenesis is similar to that of fat necrosis and likely occurs because in infants the subcutaneous fat is more apt to solidify than in adults.

Typical lesions are bluish red nodules that may be painful. They usually arise within 1 to 2 days of cold exposure, and they may persist for several weeks. Although rarely required for diagnosis, histologic examination reveals histiocytic and lymphoid cells within fat lobules. Because the lesions resolve within weeks, no treatment is necessary. However, it is advisable to avoid cold exposure if possible.

Cellulitis is suppurative inflammation of the skin caused by bacteria, such as Streptococcus pyogenes and Staphylococcus aureus. A child who has cellulitis is often febrile, and his skin is very tender, erythematous, and warm to the touch. A dental abscess could cause painful swelling of the cheek, but fever and tenderness over the gingiva and affected tooth would be expected. Juvenile xanthogranuloma is characterized by yellowish or brownish nodules on the skin, and the lesions are typically present from birth or early infancy. A lipoma, a benign tumor of fat cells, may be found anywhere on the body but typically does not cause tenderness or skin discoloration.

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Q 3:

A 6-year-old girl who has corrected congenital heart disease and a history of furunculosis presents to the emergency department with fever and increased work of breathing. Physical examination reveals a temperature of 39.5°C, heart rate of 130 beats/min, respiratory rate of 30 breaths/min, and blood pressure of 85/55 mm Hg. Her oxygen saturation is 90% in room air. A new blowing murmur is noted on cardiac examination, and auscultation of the chest reveals diffuse crackles bilaterally. She has hepatosplenomegaly and a capillary refill of 3 to 4 seconds. Her skin examination yields normal results. Her white blood cell count is 30.0 × 103/µL (30.0 × 109/L), with 71% polymorphonuclear leukocytes, 23% lymphocytes, and 6% monocytes. Chest radiograph shows diffuse pulmonary interstitial edema.

Of the following, the MOST appropriate initial antibiotic therapy for this patient is

A.  ampicillin-sulbactam

B. ceftazidime

C. doxycycline

D. trimethoprim-sulfamethoxazole

E. vancomycin

Answer

E

The patient described in the vignette presents with clinical sepsis, and her history of corrected congenital heart disease and furunculosis in conjunction with fever and a new murmur on physical examination strongly suggests acute infectious endocarditis (IE). In children with a fulminant presentation of IE, Staphylococcus aureus is the most common cause. Therefore, prompt initiation of antimicrobial therapy with a bactericidal agent such as vancomycin is warranted.

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Q 3:


A 3-year-old patient who has acute lymphoblastic leukemia is admitted to the pediatric intensive
care unit after developing severe sepsis due to Pseudomonas aeruginosa. She is intubated,
ventilated, and requires intensive vasopressor support.
Of the following, the MOST appropriate antibiotic regimen for the treatment of this patient is an
aminoglycoside plus

A. cefazolin
B. cefdinir
C. ceftazidime
D. ceftriaxone
E. cefuroxime

Answer

C


Serious P aeruginosa infections, such as bacteremia, sepsis, and pneumonia, are more
likely in patients who have underlying conditions, especially cystic fibrosis. Initial therapy usually
consists of two antipseudomonal agents, such as a beta-lactam antibiotic (piperacillin, piperacillintazobactam,
or ceftazidime) plus an aminoglycoside (gentamicin, tobramycin, or amikacin) until
results of susceptibility tests are available

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Q 4 :

A 10-year-old boy presents with a 1-day history of fever and a swollen leg. According to his
mother, the boy developed a small abrasion on his leg while playing outside 3 days ago. Last
night he began to complain of pain in the area and had a low-grade fever. This morning his
temperature was 102.4°F (39.1°C) and the area around the abrasion looked very red and was
tender to palpation. About 2 hours later, the swelling had increased. Physical examination
reveals a boy in no apparent distress who has a temperature of 101.4°F (38.6°C), a heart rate of
93 beats/min, a respiratory rate of 23 breaths/min, and a blood pressure of 95/65 mm Hg. All
other findings are normal, except for a small erythematous abrasion just above the medial
malleolus that has no discharge. Erythema from this area extends to a well-demarcated region
of the mid-calf and is tender to touch .
Of the following, the MOST likely pathogen is

A. Pseudomonas aeruginosa
B. Staphylococcus aureus
C. Streptococcus pneumoniae
D. Streptococcus pyogenes
E. Vibrio vulnificans


.Answer:

D

Cellulitis is an infection and inflammation of the connective tissue that involves the dermis and often is preceded by a break in the skin. Cellulitis also can be seen in patients who have an underlying condition that predisposes them to such an illness (eg, lymphatic stasis, diabetes mellitus).

Streptococcus pyogenes and Staphylococcus aureus are the two most common bacterial agents responsible for the development of this infection. 

Although distinction between the two pathogens is difficult, the rapidly spreading erythema without purulence described for patient in the vignette is most consistent with S pyogenes infection .

 Infections caused by S aureus tend to be more localized and produce purulent material. Confirmation of the
etiologic agent requires recovery of the organism from an aspirate of the most erythematous area or a culture from purulent exudates or from the blood.

For most patients, initial empiric therapy is with an antimicrobial agent that has activity
against both of these gram-positive cocci. Empiric treatment courses have changed recently,
with the increased prevalence of methicillin-resistant S aureus (MRSA). Mild forms of cellulitis
may be treated with a topical antimicrobial ointment (eg, mupirocin). More advanced cases
require the addition of an oral antimicrobial agent such as clindamycin, trimethoprimsulfamethoxazole,

or doxycycline in geographic areas that are highly endemic for MRSA.

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Q 5:

You are evaluating a previously healthy 3-year-old boy for a 3-day history of nausea; vomiting;
and profuse watery, nonbloody diarrhea that has worsened over the last 24 hours. He can keep
down water and an oral electrolyte maintenance solution but has no interest in eating solid food.

On physical examination, the tired-appearing little boy has a temperature of 100.8°F (38.3°C), moist
mucous membranes, and a soft abdomen with mild diffuse tenderness to palpation. Laboratory
tests document a peripheral white blood cell count of 6.7x103/mcL (6.7x109/L); hemoglobin of
12.0 g/dL (120.0 g/L); platelet count of 230.0x103/mcL (230.0x109/L); and a differential count of
50% neutrophils, 40% lymphocytes, and 10% monocytes.
Of the following, the MOST likely pathogen causing this patient’s condition is

A. Campylobacter jejuni
B. Escherichia coli
C. Giardia lamblia
D. Salmonella sp
E. Shigella sp