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.