PEDIATRIC MCQS: PEDIATRIC NEUROLOGY

A 12-year-old boy came to the emergency department with progressive weakness for 10-h while he was seated in his classroom. He described it as a stinging sensation in his arms that progressed to numbness

and weakness to the level of his upper chest. He has not urinated for several hours and he wakes only with assistance. He has moderate hypertonia in his upper extremities and his lower extremities are flaccid.

Formal strength testing reveals (R/L): biceps 4/4, triceps 3/3, and wrist extension 4/4, with all other muscle groups tested being grade 0. He has a sensory level at T2, and deep tendon reflexes are absent throughout.

MRI of the spine shows an ill-defined intramedullary hyperintensity extending from C5 to T2 without significant cord expansion or enhancement. MRI of the head is normal. CSF studies are normal, and no oligoclonal bands are detected.

What is the most appropriate treatment at this time?

A. IVIG 0.5 g/kg I.V. daily × 4 days

B. Methylprednisolone 500 mg I.V.B.I.D × 5 days

C. Prednisone 40 mg P.O. daily with a slow taper

D. Cyclophosphamide 800 mg/m² I.V. every 4 weeks

E. Interferon-β − 1a 30 μg I.M. every week

CHECK RESULT ON MONDAY

PEDIATRICS FCPS TOACS STATION

1. Describe the pedigree.

2. What is the mode of inheritance?

3. Give 4 examples.

ANSWER: FRIDAY 30/11/2018 AT 10 AM

PEDIATRIC MCQS: PEDIATRIC ENDOCRINOLOGY

You found a newborn having low total thyroxine (T4) level on newborn screening. The level was drawn 24 hours after a term, healthy female neonate was born. Pregnancy was uncomplicated, and there was no maternal history of thyroid disease. Repeat testing in your office at 7 days after birth shows a thyroid-stimulating hormone level of 200 mIU/L and a low free thyroxine (FT4) level of 0.2 ng/dL (2.57 pmol/L) in this otherwise healthy girl. Her weight is 3 kg. Findings on physical examination are unremarkable.

Of the following, the BEST next step in the management of this patient is to

A. Begin treatment with levothyroxine (LT4)

B. Begin treatment with liothyronine (LT3)

C. Measure serum thyroglobulin level

D. Order a thyroid radionuclide uptake and scan

E. Order thyroid ultrasonography

ANSWER: WEDNESDAY 28/11/2018 AT 10 AM.

PEDIATRICS FCPS TOACS STATION

A 6-month-old infant presented with fever, anorexia, and marked irritability. The skin overlying the shin and mandible is neither warm nor discolored. There is no soft tissue swelling, and palpation reveals bony-hard thickening below the subcutaneous tissues, which are adherent to the underlying bone.

1. What are the x-ray findings in A and B?

2. What is the most likely diagnosis?

ANSWER: WEDNESDAY 28/11/2018

PEDIATRIC TOP-UPS: GENERAL

A patient with fever and focal seizure: herpes encephalitis. 

Please remember, varicella causes generalized seizure and SSPE (subacute sclerosing panencephalitis) causes symmetric seizure activities.

How to adjust the dose of valproic acid in a child with seizure: Troph serum level seven days after the starting dose. The beginning dose is 10 mg/kg/day, then increase the doses by 5 -10 mg/kg/week until the usual dose of 30 -40 mg/kg/day.

A patient appears with Kawasaki disease and abdominal pain: Hydrops of the gallbladder.

Evans syndrome: a combination of autoimmune hemolytic anemia with immune thrombocytopenic purpura. Patients may develop chronic disease like SLE and have poor prognosis.

Glycogen storage disease type Ib and neutropenia: severe hepatomegaly and growth retardation are present; a defective neutrophil mobility and neutropenia can cause recurrent b acterial infections.

TREATMENT: antibiotic; rhG -CSF correct neutropenia.

PEDIATRIC MCQS: PEDIATRICS NEUROLOGY

QUESTION 01:

The port wine stain characteristic of Sturge-Weber syndrome is most commonly found:

A. In an upper motor neuron seventh nerve pattern

B. In a lower motor neuron seventh nerve pattern

C. In the first division of the trigeminal nerve, bilaterally

D. In the first division of the trigeminal nerve, unilaterally

E. In the distribution of the greater occipital nerve

QUESTION 02:

2-day-old, former full-term neonate has seizures that are difficult to control. Her mother reports that in utero the baby had significantly more “hiccups” than her other children did. On examination, the infant is encephalopathic and hypotonic. Labor and delivery were uneventful and the infant had Apgar scores of 8 and 9. 

What test or intervention would be most useful in identifying the etiology for her seizures?

A. Brain MRI

B. EEG

C. Lumbar puncture

D. EMG

E. Response to therapeutic hypothermia

QUESTION 03:

Which cranial nerve is most likely to be affected by Lyme disease?

A. Optic nerve

B. Oculomotor nerve

C. Trigeminal nerve

D. Facial nerve

E. Hypoglossal nerve

QUESTION 04:

A neonate is being loaded on phenobarbital for seizures. What is the most likely side effect the neonatology team should be prepared for?

A. Hyponatremia

B. Respiratory suppression

C. Anaphylaxis

D. Hypertension

E. Dystonic reaction

QUESTION 05:

What percentage of children with new-onset epilepsy  will eventually be able to discontinue medication and remain seizure-free?

A. 10%

B. 30%

C. 50%

D. 70%

E. 90%

ANSWER: MONDAY 10 AM.

PEDIATRICS SHOT: VIDEOS

WHAT TYPE OF SEIZURE THIS CHILD HAS?

PEDIATRICS PEARLS: NEONATOLOGY

1. 22-week-old female fetus appears with cystic hygroma.
Most likely diagnosis?

2. A 3.4 kg infant lost 200 gram s body weight in 3 days. Infant’s weight is 3.2 kg after 3 days. The infant is otherwise doing well.
Most likely cause?

3. How to examine muscle tone in newborn infants?

4. A newborn appears with broad toe or thumb.
Most likely diagnosis?


5. A newborn infant appears with hypoplastic nails, flattened nose, and hypertelorism. Mother was receiving anti-convulsant during pregnancy.
Name the anti-convulsant mother is taking?

ANSWER: SATURDAY 23/11/2018 10 am.

PEDIATRIC MCQS: PEDIATRIC HEPATOLOGY

A 13-year-old un-vaccinated CHILD brought by his parents approximately 3 weeks after exposure to hepatitis B from needle sharing with a known carrier. Following are the most likely laboratory findings indicating a hepatitis B infection if labs were taken the day of the visit:

A. HBV DNA negative, HBV core protein IgM negative, HBsAg negative

B. HBV DNA positive, HBV core protein IgM positive, HBsAg positive

C. HBV DNA positive, HBV core protein IgM positive, HBsAg negative

D. HBV DNA positive, HBV core protein IgM negative, HBsAg negative

E. HBV DNA positive, HBV core protein IgM negative, HBsAg positive

ANSWER: SATURDAY 23/11/2018 10 am.

PEDIATRIC MCQS: IMMUNODEFICIENCY

Of the following options, the best initial test for a workup for immunodeficiency is:

A. Serum levels of IgG, IgM, IgA, IgE

B. A complete blood count with differential

C. Peripheral T-cell phenotyping

D. Erythrocyte sedimentation rate

E. Post-immunization immunoglobulin levels

ANSWER: FRIDAY 23/11/2018 10 am. 

PEDIATRICS PEARLS: Dawn and Somogyi Phenomenons

Somogyi phenomenon, Dawn phenomenon, and Brittle diabetes:

Somogyi phenomenon: hypoglycemia precedes hyperglycemia. Hypoglycemia is due to insulin, while hyperglycemia is due to secretion of counter regulatory hormones. 

Hypoglycemia occurs in late night or early morning accompanied by sweating,

and terror. Within 4-5 hours, hyperglycemia, ketosis, glycosuria, and ketonuria develop.

Dawn phenomenon: Hyperglycemia in early morning (5-9 A.M.) without previous hypoglycemia. Blood sugar should be done at 3, 4, and 7 A.M .

Findings and management in Dawn phenomenon: 3 A.M. and 4 A.M. (Glucose level= 80 or above), 7 A.M. (Glucose level= 140 or above)= Increase intermediate acting insulin P.M. dose by 10-15%, or give PM injection 2-3 hours later.

Findings and management in Somogyi phenomenon: 3 and 4 A.M. (Glucose level= 60 or below), 7 A.M . (Glucose level= 140 or above)= Decrease intermediate insulin P.M . dose by 10 -15% or delay PM injection until 9 PM.

Brittle diabetes: blood glucose level fluctuates even with increase of insulin doses; often with recurrent DKA. They have normal insulin response in the hospital. Therefore, they have psycho-social or psychiatric problems including dysfunctional family and eating disorders. They need hospital admission, psycho-social or psychiatric evaluation.

PEDIATRICS SHOTS: BIRTH MARK

BIRTH MARK

You are seeing an 8-month-old boy for the first time. His parents are concerned about a birth mark on his chest that has enlarged slowly over the past 5 to 6 months.

Of the following, the MOST appropriate management of this lesion is

A. Interferon-alfa

B. Intralesional corticosteroid

C. Observation

D. Pulsed dye laser

E. Systemic corticosteroid

ANSWER: FRIDAY 23/11/2018 AT 10 AM

PEDIATRICS TOP-UPS: INVESTIGATING HYPOCALCEMIA IN LEVELS

INVESTIGATING HYPOCALCEMIA IN LEVELS

LEVEL 1:

1. SERUM PHOSPHATE, SERUM ALKALINE PHOSPHATE
2. LIVER FUNCTION TESTS
3. RENAL FUNCTION TESTS (BLOOD UREA, SERUM CREATININE)
4. X-RAYS WRIST (RICKETS/ALBRIGHTS HEREDITARY OSTEODYSTROPHY)

LEVEL 2:

1. PTH LEVEL (RANGE 12-72 ng/ml) (HIGH PHOSPHATE AND NORMAL RENAL FUNCTIONS)
2. MAGNESIUM LEVEL ( NORMAL OR LOW PHOSPHATE LEVELS)
3. MALABSORPTION STUDIES (FECAL FATS, TTG ETC)
4. 1, 25 HYDROXY D3 (LOW IN VDDR 1, HIGH IN VDDR II)
5. IN NEONATES, MOTHER X-RAYS FOR OSTEOMALACIA AND HYPERPARATHYROIDISM.

PEDIATRIC PEARLS: SIDE EFFECTS OF PROSTAGLANDIN 1

Most common complication of prostaglandin 1: Apnea. 

Please remember, elevated prostaglandin levels can cause hypertrophic pyloric stenosis. For patients who develop apnea, endotracheal intubation is indicated.

A newborn received prostaglandin therapy for 5 days. The newborn developed non-bilious vomiting. Most likely diagnosis:

hypertrophic pyloric stenosis secondary to prostaglandin.

Management: Discontinue prostaglandin. 

The vomiting stops and pyloric stenosis resolves slowly with the discontinuation of medication. 

The child should be operated for the underlying cardiac condition.

PEDIATRIC MCQS: PEDIATRIC CARDIOLOGY

A 1-week-old infant presents to the emergency department with a 1-day history of poor feeding, pallor, diaphoresis, and increasing somnolence. She was born at term, and the delivery was uncomplicated. On physical examination, her heart rate is 180 beats/min, respiratory rate is 90 breaths/min, and blood pressure is 50/30 mm Hg. Her breath sounds are shallow, and cardiac evaluation reveals no murmurs but a gallop rhythm. Her liver is palpable at 3 cm below the costal margin. Her extremities are cool, pale, and mottled, and she has poor distal pulses. After you administer normal saline at 20 mL/kg, her heart rate is 194 beats/min.

Of the following, the MOST appropriate next step is

A. Adenosine infusion at 50 mcg/kg

B. Computed tomography scan of the head

C. Dopamine infusion at 10 mcg/kg per minute

D. Lumbar puncture followed by antibiotics

E. Normal saline infusion at 20 mL/kg

ANSWER ON THURSDAY AT 10 AM

PEDIATRIC TOP-UPS: CONGENITAL HYPOTHYROIDISM FOLLOW-UP

CONGENITAL HYPOTHYROIDISM FOLLOW-UP

DRUG USED:             THYROXIN

DOSE:                         10-15 MICROGRAM/KG/DAY OD

FOLLOW-UP:

GOAL:                         FREE T4 LEVEL 10-15 MICROGRAM/dL

                                     02 WEEKS AFTER START OF THERAPY

                                     02 MONTHLY FOR 01 YEAR

                                     03 MONTHLY FOR NEXT 02 YEARS

                                     YEARLY AFTER 03 YEAS

DEVELOPMENTAL ASSESSMENT, BONE AGE YEARLY

PEDIATRIC SHOTS: PEDIATRIC DEMATOLOGY

What is the lesion?

PEDIATRIC TOP-UPS: TREATMENT PROTOCOL FOR CONTACT WITH MENINGOCOCCAL DISEASE

ACUTE MENINGOCOCCAL DISEASE: CHEMOPROPHYLAXIS

Who requires prophlylaxis?

1. Index Case (if treated only with penicillin)
2. All intimate, household or daycare contacts who have been exposed to Index Case within 10 days of onset.
3. Any person who gave mouth-to-mouth resuscitation to the Index Case.

Recommended prophylaxis:

Age	Drug	Dose and schedule
Infants <1 month	rifampicin*	Rifampicin 5mg/kg 12-hourly for 4 doses
Children > 1 month	rifampicin* OR ciprofloxacin	Rifampicin 10mg/kg (max 600mg) 12-hourly for 4 doses   Ciprofloxacin 125mg single dose ( <5yo) or 250mg single dose (5-12yo)
Adults	ciprofloxacin	500mg oral single dose
Pregnant or contraindication to rifampicin (e.g. severe liver or renal disease)	ceftriaxone	125mg ( <12 yo) or 250mg (>12yo) IM single dose

* Inform patients/carers that rifampicin causes orange/red discolouration of tears and urine and negates the effect of the oral contraceptive pill. 

PEDIATRIC MCQS: HEPATOLOGY

HEPATIC VEIN THROMBOSIS 

A 14-year-old male presents with sudden onset of left upper quadrant abdominal pain. Doppler ultrasound reveals a hepatic vein thrombosis. His past medical history is significant for aplastic anemia, which was diagnosed at age 10. He was treated with antithymocyte antiglobulin and cyclosporine, with good recovery of his counts. His current blood counts are all within normal ranges.

What laboratory test will be likely to reveal an etiology for his thrombosis?

A. Protein C

B. Factor V Leiden

C. Bone marrow biopsy

D. Homocysteine levels

E. Flow cytometry

ANSWER ON TUESDAY 10 AM

FCPS MCQS: PEDIATRIC CARDIOLOGY

You are evaluating a 13-year-old whose father recently drowned while swimming laps in a pool. Upon further inquiry, a couple of months ago, his father had had a fainting episode after running, but had attributed this to dehydration. Your patient admits that he has had some episodes of dizziness and palpitations during track practice, for which he took breaks, but he has never fainted or had any chest pain. He has a normal CXR and cardiovascular examination. 

What changes on his ECG would be most worrisome?

A. First-degree AV block (prolonged PR interval)
B. Premature atrial contractions
C. Prolonged QTc interval (>460 ms)
D. Sinus arrhythmia
E. Premature ventricular contractions



ANSWER ON MONDAY 10 AM

PEDIATRICS PEARL: Newborn's mother has recently tested positive for PPD and chest x-ray negative

Newborn's mother has recently tested positive for PPD and chest x-ray negative:

How do you manage child?

Don't do anything to child at birth; no isolation from mother is needed; follow-up in clinic when child is around 6 weeks of age and place PPD. If PPD is negative, do tuberculin test every 3 months for 1 year; if PPD is positive, do CXR; if CXR is negative, give INH for 6 months; if CXR is positive, give three antitubercular drugs for first 2 momths, then two drugs for next 4 months. Mother should be treated and other household members should be evaluated. H IV-infected patients should receive INH for 12 months. INH-resistant patients should receive rifampin.

FCPS MCQS ANSWER: WHICH NEONATE SHOULD RECEIVE HEPATITIS B IMMUNE GLOBULIN

Vertical transmission of hepatitis B infection can be prevented with appropriate antenatal serologic screening of pregnant women. For infants born to HBsAg seropositive mothers, appropriate immunoprophylaxis includes administration of hepatitis B vaccine and hepatitis B immune globulin.

For a variety of reasons, including inability to access maternal records, maternal hepatitis B serostatus may be unknown at the time of delivery. In these cases, HBsAg serology on the mother should be drawn immediately onadmission for delivery, and the hepatitis B vaccine should be administered to the neonate within 12 hours of age. Guidelines for administration of hepatitis B immune globulin are based on infant weight (using a weight cutoff of 2000 g) as well as the timing of determination of maternal serology status.

Because of the variable immune response to the hepatitis B vaccine in neonates born under 2000 g, hepatitis B immune globulin should be given to these infants if maternal serology status cannot be determined within 12 hours. For infants with a birth weight over 2000 g, immune globulin administration may be delayed if the maternal serology status can be determined within 7 days. Infants born to mothers who are HBsAg negative should only receive the hepatitis B vaccine.

Maternal chorioamnionitis and hepatitis C seropositive status are not indications for administration of hepatitis B immune globulin.

CORRECT OPTION IS 'E'

FCPS MCQS: WHICH NEONATE SHOULD RECEIVE HEPATITIS B IMMUNE GLOBULIN

Which of the following neonates should receive hepatitis B immune globulin within 12 hours after birth?

A. A 38 weeks’ gestation neonate (birth weight 3600 g) whose mother is hepatitis B surface antigen (HBsAg) negative

B. A 39 weeks’ gestation neonate (birth weight 3750 g) whose mother has HBsAg serology that is unknown, but will be confirmed within 24 hours after delivery

C. A 37 weeks’ gestation neonate (birth weight 3550 g) whose mother is positive for hepatitis C antibody only

D. A 34 weeks’ gestation neonate (birth weight 2500 g) whose mother is HBsAg negative but developed chorioamnionitis in labor

E. A 36 weeks’ gestation neonate (birth weight 1850 g) whose mother has HBsAg serology that cannot be resulted until 36 hours after delivery

ANSWER ON SATURDAY 10 AM

FCPS MCQS: ONE BEST OPTION

You are evaluating a 13-year-old girl who complains of malaise, fatigue, and occasional abdominal discomfort. You diagnosed hypothyroidism due to chronic lymphocytic thyroiditis (Hashimoto thyroiditis) 6 years ago. She has normal serum immunoglobulin A concentrations. A tissue transglutaminase antibody study was negative 1 month before this visit, and free thyroxine and thyroid-stimulating hormone (TSH) values were normal at that time. She has normal menses. She reports that she has been eating poorly and has lost 5 lb since you saw her at the beginning of the summer, but she obviously has had a good summer and has a tan.

Of the following, the MOST important laboratory studies to obtain at this time are

A. complete blood count and erythrocyte sedimentation rate

B. duodenal biopsy for cryptic celiac disease

C. measurement of cortisol and adrenocorticotropic hormone

D. measurement of free thyroxine and TSH

E. mononucleosis spot test and liver function study

ANSWER ON FRIDAY 10 AM

PEDIATRIC TOP-UP: SALMONELLA ENTERIC CARRIER

How to detect Salmonella enteric carrier: 

1. Positive stool culture, because such patients excrete a lot of Salmonella in stool. Sometimes urine culture may be positive.

2. If negative stool culture, then do duodenal aspirate culture to find out about biliary excretion of Salmonella or culture of duodenal string capsule, which should not be performed in very young or very ill children.


How to treat chronic carrier: 

1. High dose of ampicillin (or amoxicillin) plus probenecid or trimethoprim -sulfamethoxazole for 4-6 week.

2. Patients with cholelithiasis or cholecystitis: cholecystectomy within 14 days of antibiotic therapy.

PEDIATRIC TOP-UP: PPD AND MANAGEMENT

A child's TST (or PPD) result reveals induration which is 12 mm. 

HOW WILL YOU PROCEED?

Most likely diagnosis: recent converter of TB?

Management: 

chest x-ray (CXR) should be obtained.

1. Positive TST and negative CXR suggest latent tuberculosis infection:

    a. Isoniazid – susceptible: 9 months of IN H (isoniazid) once a day

    b. Isoniazid – resistant: 6 months of rifampin (RIF) once a day or 9 month of RIF therapy.

    c. Isoniazid – rifam pin resistant: consult a TB specialist

2. Positive TST and positive CXR suggest pulmonary TB:

   a. 6 months regimens: INH and RIF supplemented with PZA (pyrazinamide)   in first 2 months (10 0 % success rate) .

   b. 9 months regimens (for hilar adenopathy only): INH and RIF once a day

   c. Extrapulmonary (e.g., meningitis, military, bone or joint disease) TB: 2 months of INH, RIF, PZA, and streptomycin once a day, followed by 7-10 months of INH and RIF once a day (9 -12 months total)

  d. Other (or cervical lymphadenopathy): same as for pulmonary TB