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.

MCQs In Pediatric Neurology For Medical Students.

Q1:

You suspect the diagnosis of Werdnig-Hoffman disease in an infant with severe hypotonia.

Which other finding will support this diagnosis?

(A) normal deep tendon reflexes

(B) seizures

(C) fasciculations of the tongue

(D) recurrent fevers

(E) atrophy of the optic nerve

MCQs In Pediatric Hematology - For Medical Students

A 2-year-old African-American child presents with painful swelling of the hands and feet.

Laboratory evaluation reveals hemoglobin of 9 g/dL with white blood cell count of 11,500

and platelet count of 250,000. Which additional laboratory test will support your diagnosis?

(A) skeletal survey

(B) VDRL testing

(C) bone marrow aspiration

(D) hemoglobin electrophoresis

(E) serum calcium measurement

Answer :

(D) The child described has the classic handfoot syndrome seen in infants and toddlers with sickle cell disease. Dactylitis, presumably secondary to infarction of the small bones, causes painful swelling of the hands and feet. Hemoglobin electrophoresis would show presence of high levels of HbS. 

In children younger than 5 years, the small bones of the hands and feet are frequently affected, and in contrast to most episodes of bone pain in older children, physical findings are common. 

This painful dactylitis (“hand-foot syndrome”) is typically the first clinical manifestation of SCD. A young child cries with pain; refuses to bear weight; and has puffy, tender, and warm feet or hands, or both. The child may appear acutely ill, be febrile, and have an impressive leukocytosis. At the onset of soft tissue swelling, bony changes are not generally apparent on radiographs. 

After 1 to 2 weeks, subperiosteal new bone, irregular areas of radiolucency, cortical thinning, or complete destruction of bone can be seen. All the bone changes are usually reversible but may persist for as long

as 8 months. A rare complication, permanent shortening of the digits after hand-foot crisis, has been

reported. Dactylitis before 1 year of age is a strong predictor of overall severity (stroke, death, high pain rate, or recurrent ACS) by 10 years of age, although recent single-institution evidence suggests that dactylitis is not a strong predictor of subsequent pain or ACS.

MCQs In Pediatric Infectious Diseases

Q 1:

A 2-year-old child was recently adopted from India. She appears to be healthy, and there are no abnormal symptoms. Her weight and height are at 25th percentile for age. Her examination is normal. On screening, you find a positive TB skin test using purified protein derivative (PPD) with 20 mm induration. She has a history of receiving a BCG vaccination at birth. Your management plan is to do which of the following?

(A) Obtain a chest x-ray and treat only if this is abnormal.

(B) Obtain a chest x-ray and initiate prophylactic treatment with isoniazid (INH).

(C) Repeat the test in 3–6 months.

(D) Attribute the positive PPD to the BCG vaccination and do serial yearly x-rays.

(E) Obtain sputum cultures.

Answer :

(B)

Generally, the interpretation of tuberculin skin test (TST) is the same regardless of BCG status.

 Induration >5 mm is considered positive in children in close contact with known or suspected cases of tuberculosis disease or children suspected to have tuberculosis disease.

Induration >10 mm is considered positive in children at greater risk of disseminated disease (age <4 years; other medical conditions such as lymphoma, diabetes, chronic renal failure, or malnutrition) or children at greater risk of exposure to tuberculosis disease (born in, or parents born in high-prevalence regions, travel to these regions, exposure to adults at high risk, such as HIV infected, homeless, or drug abusers).

Induration >15 mm is positive in children >4 years without any risk factors.

 Radiographic evaluation of all children with positive TST is recommended. Latent tuberculosis infection is
defined as an infection in a person with a positive TST, no physical findings of the disease, and a chest radiograph that is either normal or reveals only granulomas or calcifications in the
lungs or regional lymph nodes.

 Children with latent tuberculosis infection should receive prophylaxis, usually 9 months of INH. Those with
symptoms, signs, and/or radiographic manifestations are said to have tuberculosis disease.

There is no benefit to repeating the test in 3–6 months, and it will delay treatment. Sputum cultures are difficult to obtain in younger children.

 Gastric aspirate specimens obtained with a nasogastric tube are preferred. Culture material should be obtained in children with evidence of the disease in order to obtain information on drug susceptibility and resistance patterns.


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Q 2:

A parent brings in a 5-year-old boy being treated for acute lymphocytic leukemia (ALL). He states a friend who is staying with them at their home has just come down with chicken pox. Your patient has not had chicken pox or received immunization with varicella vaccine. What is the appropriate treatment?

(A) acyclovir given IV
(B) varicella vaccine
(C) varicella immune globulin (VZIG)
(D) varicella vaccine and VZIG
(E) acyclovir given IV for 7 days, varicella vaccine, and VZIG

Answer :


(E)

Children with chicken pox may be infectious for 1 or 2 days before the appearance of the rash.
Once skin lesions have crusted, the patient is no longer infectious. Susceptible individuals can
contract chicken pox from patients with zoster.

In the cases of both chicken pox and zoster, transmission is thought to occur by the respiratory
route rather than by direct contact. The virus can travel long distances in the air and remain viable.

Transmission from one hospital patient to other susceptible hospitalized patients has been reported to occur through air vents. VZIG should be given within 3 or 4 days of exposure to varicella-susceptible individuals who are immunocompromised.

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Q 3

A 3-month-old infant is brought to your office in the winter with a history of 1 day of vomiting, followed by 3 days of diarrhea. She has had six to eight stools per day, which are loose and foul smelling. On examination, she looks well. Which of the following viruses is the most likely cause of her illness?

(A) adenovirus
(B) enterovirus
(C) human herpesvirus, type 6
(D) respiratory syncytial virus
(E) rotavirus

Answer :

(E)

 Because many childhood viral illnesses have seasonal presentations, the etiologic agent may be suspected on the basis of clinical and seasonal presentation. Yearly winter outbreaks of bronchiolitis and pneumonia are associated with respiratory syncytial virus. Summer outbreaks of gastroenteritis are associated with
enterovirus, while winter outbreaks are associated with rotavirus. Although adenovirus can cause diarrhea, it more commonly causes respiratory symptoms. Human herpes virus type 6
is the etiologic agent in roseola infantum.

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Q 4:

A 10-year-old boy comes to your office in the winter with a sore throat he has had for 2 days. In addition, he has had fever, headache, and abdominal pain. He does not have any allergies to medications. On examination, he has a temperature of 38.6°C, an erythematous pharynx, and tender cervical adenopathy. Arapid screening test for group Astreptococcus is performed and is positive. Which of the following would
be the most appropriate antimicrobial agent?

(A) erythromycin
(B) penicillin
(C) trimethoprim-sulfamethoxazole
(D) azithromycin
(E) cefaclor

Answer:


(B)

Penicillin remains the drug of choice for treatment of streptococcal pharyngitis. Amoxicillin,
macrolides, and cephalosporins are acceptable alternatives.


Q 5:

 The same child returns to your office the next day. He has taken the medication you prescribed. He is feeling a little better. His fever has resolved, but he has developed a rash. His examination is unchanged, except that he is afebrile and has a fine, papular rash over his body, which is accentuated in his axilla and groin. Which of the following is the most likely cause of his rash?

(A) allergic reaction to the antibiotic
(B) rash from the antibiotic seen in patients with mononucleosis
(C) scarlet fever
(D) serum sickness
(E) viral exanthem typical of enterovirus

(C)

Scarlet fever is caused by toxins made by group A Streptococci. It is usually seen in patients with strep throat. The rash is papular and described as sandpaper like. Sometimes it is easier to feel it than to see it. An allergic rash would be urticarial. More than 80% of patients with EBV infection develop a maculopapular
rash if given amoxicillin.

 This patient’s clinical course is not typical for EBV which presents more gradually, and patients often have posterior cervical adenopathy and splenomegaly.

Patients with serum sickness often have urticarial rashes, sometimes progressing to angioedema. They may also have arthritis, myalgias, and lymphadenopathy. The rash in enteroviral infections is typically macular


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Q 6:

A 4-year-old child presents to your office in July with a history of a low-grade fever (38.1°C) and “sores” in his mouth for 2 days. He has been refusing to eat but has been drinking an adequate amount of liquids. On examination, he is afebrile and seems well hydrated. He has ulcers on his tongue and posterior pharynx,
which are 4 mm in diameter. You also note a few vesicles on his hands and feet, which are 3–4 mm in size and mildly tender. Which of the following is the most likely diagnosis?

(A) herpes simplex virus (HSV)
(B) coxsackie virus
(C) aphthous ulcers
(D) Behçet syndrome
(E) traumatic ulcers

Answer


(B)

Coxsackie A16 is the major cause of hand, foot, and mouth disease. This is a summer enteroviral illness presenting with classic lesions of the hand, feet, and mouth. Herpetic gingivostomatitis is the most common cause of stomatitis in children aged 1–3 years.

There is often a high fever, fetor oris, refusal to eat, and irritability. The lesions are initially vesicular, and soon form ulcers ranging from 2 to 10 mm in diameter. The tongue, cheek, and gums are usually involved, and there may be submaxillary lymphadenitis.

Aphthous ulcerations (canker sores) are painful ulcerations, which present as erythematous, indurated papules that erode to form circumscribed necrotic ulcers with gray fibrinous exudates and erythematous
halo. They are 2–10 mm in diameter, heal spontaneously, and often recur. Behçet syndrome is a multisystem disorder characterized by recurrent oral and genital ulceration, iritis or uveitis, as well as other cutaneous, arthritic, neurologic, vascular, and gastrointestinal (GI) manifestations. It is rare in children. Traumatic
oral ulcers may be seen in chronic cheek biters but do not involve extremities.

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Q 7:

A10-year-old boy comes to the office with fever and chills for 5 days and myalgia. He has recently returned from a 2-week vacation to New England with his family. On physical examination he has mild splenomegaly. Which of the following is the most likely cause of his symptoms?

(A) Kawasaki disease
(B) pneumococcus
(C) babesiosis
(D) leptospirosis
(E) psittacosis

Answer :

(C)

Kawasaki disease is an acute vasculitis of unknown etiology. Humans contract brucellosis by direct contact with infected animals or by drinking unpasteurized milk. Babesiosis is transmitted by ticks. Leptospirosis is
obtained from exposure to the urine of infected animals. Psittacosis is obtained from exposure to bird feces.

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Q 8:


A 6-year-old girl has a low-grade fever, headache, and nasal congestion. She has a flushed face and has developed a lacy reticular rash on the trunk and extensor surface of her arms and legs. Palms and soles are spared. Her mother has been ill with a low-grade fever and some joint stiffness and pain. Which of the following is the most likely diagnosis?

(A) rubella
(B) measles
(C) scarlet fever
(D) roseola infantum
(E) erythema infectiosum (fifth disease)

(E)

Erythema infectiosum is a common childhood viral exanthem caused by parvovirus B19.

It was the fifth in a classification system of childhood exanthems; the others were rubella, measles, scarlet fever, atypical scarlet fever, and roseola infantum. The rash classically presents early with flushed cheeks or a “slapped cheek” appearance. It is followed by development of a macular erythematous rash on trunk and
extremities, which then shows central clearing, developing a lacy, reticulated appearance.

 The infection is often not clinically apparent. Adult and older adolescents, especially females, may
develop arthropathy. The symptoms are usually self-limited. Parvovirus B19 is clinically significant
in people with hemolytic anemias because it may induce a transient aplastic crisis.

Immunocompromised individuals are also at risk for chronic infections accompanied by anemia, neutropenia, and thrombocytopenia. It may also induce fetal demise in case of primary infection of pregnant women.

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Q 9:

A 3-year-old boy was bitten while teasing a neighborhood cat. On examination, there are two puncture wounds on the right hand and some superficial scratch marks. There is erythema, warmth, and induration around the puncture sites. Which of the following organisms most likely caused the infection?

(A) Pasturella multicoda
(B) Bartonella henselae
(C) Eikenella corrodens
(D) Peptostreptococcus species
(E) alpha Streptococci


Answer:

(A)

P. multicoda and S. aureus are organisms commonly associated with cat bites. The cat’s sharp teeth and claws predispose the victim to puncture wounds. Wound infections are more common in cat bites than dog bites. E. corrodens,

Peptostreptococcus species, and alpha Streptococci are more common with human bites. B. henselae
causes cat-scratch disease, which presents with subacute lymphadenitis.

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Q 10:

A 7-year-old boy presents with a rash. His mother states that he was well until 3 days ago when he developed fever and malaise. The next day, the rash started as papules on the trunk, which rapidly changed to vesicles. The lesions have spread all over the body. On physical examination, he has no fever and seems well. You note numerous vesicles all over the body, some of which have crusted over. Which of the following is the most likely diagnosis?

(A) chicken pox
(B) Kawasaki disease
(C) measles
(D) rubella
(E) staphylococcal scalded skin syndrome


Answer

(A)

This is a typical presentation of chickenpox. A prodrome of fever and malaise is followed by the rapid eruption of papules that turn to vesicles and crust over. The rash in measles, rubella, and Kawasaki disease are macular or maculopapular. In staphylococcal scalded skin syndrome, a diffuse, tender erythroderma
develops.

Clinical Cases - Endocrinology

Q1:

A 13-year-old girl presented at clinic having been diagnosed as having hypothyroidism by her family

doctor who had confirmed the diagnosis with TFT’s. She also had a 2-year history of a limp in her left leg. On examination, she was short and obese with a goitre and other signs of hypothyroidism. She had

limitation of movement of her left hip and a limp.

Questions

1 What is the most likely diagnosis?

2 What investigations should be done?

3 What is the treatment?

Answers :

1 Slipped upper femoral epiphysis and Hashimoto’s disease.

2 Frontal and lateral hip X-rays (a frontal X-ray alone may not demonstrate the slipped epiphysis)
and thyroid autoantibodies.

3 In spite of the long history, urgent referral to an orthopaedic surgeon and urgent surgery are
necessary. An acute or chronic slip of the epiphysis may cause avascular necrosis of the femoral head.
Prophylactic pinning of the other femoral head is advocated by some surgeons. T4 treatment should
also be started.

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Case 2

A 13-year-old boy was referred to the regional endocrine clinic for consideration of growth hormone (GH) treatment. He also had delayed puberty and intermittent headaches. On examination, his height was > –4.0 SD with evidence of growth failure for at least 4 years. His weight was –1.0 SD and he was entirely prepubertal. A recent GH stimulation test at the referring hospital showed a maximum response to a diethylstilbestrol primed clonidine test of 5 mU/L. He was said to have had normal TFT’s 2 years previously with a FT4 = 9.2 pmol/L (9–24) and a TSH of 1.2 mU/L (0.4–4.0).

Questions

1 Are these TFT’s normal?
2 What is the likely overall diagnosis?
3 Is there a problem in interpreting his clonidine test?