MCQS of the WEEK with explanation

MCQS of the WEEK with explanation 

After being delivered following a benign gestation, a newborn infant is noted to have a platelet count of 35,000/μL, decreased fibrinogen, and elevated fibrin split products. On examination, you note a large cutaneous hemangioma on the left side of the face that is purple and firm. Which of the following anomalies might also be expected to explain this child’s condition?

a. Kaposiform hemangioendothelioma

b. Nevus simplex

c. Nevus flammeus

d. PHACE(S) syndrome

e. Infantile fibrosarcoma

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Answer to MCQS of the WEEK

Answer to MCQS of the WEEK

The child in the question likely has Kasabach-Merritt phenomenon, which is seen with large vascular anomalies (ie, Kaposiform hemangioendothelioma and tufted angioma). Platelet and RBC sequestration within the vascular tumor causes peripheral thrombocytopenia, coagulopathy, and microangiopathic hemolytic anemia. Treatment options include corticosteroids, α- interferon, and vincristine. Surgery frequently results in excessive bleeding.

Nevus simplex is a common minor vascular malformation seen on the glabella, eyelids, and nape of the neck in newborns; such lesions on the face are also called “angel or stork kiss,” while lesions on the back of the neck are called “stork bite.” 

Nevus flammeus, or port wine stain, is a large sharply demarcated pink to purple vascular malformation that can occur anywhere. Port wine stain involving the VI distribution of the trigeminal nerve should raise the suspicion of Sturge-Weber syndrome. 

PHACE(S) syndrome includes posterior fossa malformations, large facial hemangiomas, arterial abnormalities, coarctation of the aorta, eye abnormalities, and sternal defects. 

Infantile fibrosarcoma is a malignant congenital tumor that can be easily mistaken for an infantile hemangioma; a high index of suspicion is required to investigate further if a “hemangioma” is not resolving as expected.

Correct answer is 'a'

Hyperoxia test algorithm: How will you carry out and interpret this test?

Hyperoxia test algorithm: How will you carry out and interpret this test?

Persistent pulmonary hypertension in the newborn can be sometimes very difficult to distinguish from true cyanotic congenital heart disease. Response to oxygen may also be sluggish, simulating cyanotic CHD. There can be a transient right to left shunt across PFO and PDA. Shunt across PDA in

this baby produced a differential saturation (>5% difference between radial and femoral samples).

ECG will often show RVH with strain and qR in V1 or V3 R, indicating suprasystemic PA pressure.

The clinical picture may simulate obstructed TAPVC, but chest X-ray (CXR) in TAPVC will be most often characteristic—“white wash lung”. If echo is not available, a modified hyperoxia test may pick up PPHN (see the flow chart).

Management is essentially supportive, by using oxygen, IV diuretics, sildenafil (IV or oral) and inotropes. Both dobutamine and milrinone are useful. Mechanical ventilation, nitric oxide (NO) inhalation and extracorporeal membrane oxygenation (ECMO) may be the other advanced options, if available.

PEDIATRICS MCQS, TOACS, PEARLS & UPDATES: Cardiovascular System Examination Approach

PEDIATRICS MCQS, TOACS, PEARLS & UPDATES: Cardiovascular System Examination Approach: Cardiovascular System Examination Approach General Observation §   Look at the surroundings §   Things connected to the...

Cardiovascular System Examination Approach

Cardiovascular System Examination

Approach

General Observation

§  Look at the surroundings

§  Things connected to the patients

§  Observe any sounds “Prosthetic valve?”

§  Well or unwell (conscious, toxic, pain, …)

§  Respiratory distress: Count the RR “10Sec.X 6”

§  Growth & nutritional status

§  Dysmorphic features & Face

§  Colors (Cyanosis, Pallor, Jaundice)

 Hand

§  Clubbing (Test if in doubt) Examine the clubbing if present (angel, curvature, fluctuation & degree).

§  Cyanosis (Cold hand)

§  Pallor (Compare pt.’s hand with yours)

§  Perfusion (Capillary refill)

§  Pulse (Equality, rate, volume, character. Femoral “leave to the end)

§  BP (at the end)

§  Others (Hand anomaly, stigmata of Endocarditis & Xanthoma ..)

Head

§  Pallor & Cyanosis (Stick your tongue out)

§  Comment on Teeth

§  Sings of respiratory distress (Grunting & working Ala nasai)

Neck

§  Neck veins (Turn neck to your side & look to the other side)

§  Thrill (Suprasternal “Inform the child” & supraclavicular “Neck”)

Inspection chest

§  Scars (Raise arms up)

§  Precordial bulge

§  Visible pulsations

§  Dilated veins

Palpation chest

§  Apex (Both hands on the chest then, count the rib spaces & point the apex)

§  Thrill (in 4 areas & timing)

§  Parasternal heave (lift)

§  Palpable heart sound

Percussion chest

§  Upper border of the liver (if there is hepatomegaly)

Auscultation

§  Front basic 4 & total 6 areas (apex, Lt. LSB, Lt. Middle SB, Lt.USB, Rt. USB & Axillae) (Use the Bell for apex only & diaphragm for other areas)

§  Back "Below & in between scapula"

§  Change patient’s position

§  Lung bases for crackles

§  Comment (Heart sounds, splitting S2, added sounds & murmur)

§  Murmur (comment on 6 items)………… Timing (hand on pulse), character, site, radiation, grade & changeable

At the end

§  Growth charts

§  Femoral pulses “No or ↓ : Infant or Radiofemoral delay: elder child”

§  BP (4 limbs if suspect coarctation)

§  Other systems (Abdomen mainly for liver & leg edema … signs of heart failure, Rheumatic or endocarditis)

§  O2 Saturation

§  Offer to look at ECG & CXR

Pediatric Case 07.04.2020

Pediatric Case

A male infant, weighing 3.8 kg was born at full term by normal vaginal delivery. Two hours after delivery he started grunting and required oxygen to maintain his saturations at normal levels. A chest X-ray was taken.

1. What is the most likely primary diagnosis? 

A. Dextrocardia 

B. Staphylococcal bullae in the left side of the chest 

C. Congenital diaphragmatic hernia 

D. Tension pneumothorax 

E. Left sided chest infection 

2. Which of the following would you do next? 

A. Insert a nasogastric tube 

B. Perform an echocardiogram 

C. Do a full septic screen 

D. Perform a chest CT 

E. Give intravenous antibiotics 

3. Which of the following makes the prognosis worse? 

A. Late presentation after the neonatal period 

B. The presence of sepsis at delivery 

C. The size of the defect 

D. The presence of pulmonary hypertension 

E. The degree of respiratory distress at presentation

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Pediatric Cases- Answer

Pediatric Cases


Answer: 

1. C. 

2. A

3. D

Congenital diaphragmatic hernia (CDH) occurs in 1 of every 2000-3000 live births and accounts for 8% of all major congenital anomalies. It occurs more frequently on the left side and can be difficult to differentiate from a congenital cystic adenomatoid malformation. Mortality after live birth is generally reported to range from 40 to 62%. Factors leading to an adverse outcome include associated anomalies, prenatal diagnosis, prematurity, low birth weight and early pneumothorax. 

The outcome in patients with a late presentation of CDH (approx 10% present after the newborn period) is very good, with low or no mortality. 

The main risks associated with CDH affecting morbidity and mortality is of pulmonary hypertension and pulmonary hypoplasia. Treatment is aimed at mechanical ventilation avoiding high peak inspiratory pressures. 

High frequency ventilation is sometimes used to avoid this and in extreme circumstances ECMO is required. Fetal surgery has not as yet been shown to improve survival. A delayed surgical approach that enables preoperative stabilization is important in reducing morbidity and mortality.

Pediatric Lymphadenopathy; Causes according to the location, clinical approach and when to take biopsy

Pediatric Lymphadenopathy

Causes of lymphadenopathy according to location

•• Cervical

–– Oropharyngeal infections, for example, EBV

–– Mycobacterial lymphadenitis

–– Cat scratch disease

–– Kawasaki disease

•• Supraclavicular

–– Right side—Malignancy or infection in the mediastinum

–– Left side—Malignancy or infection from the abdomen

–– Lymphoma

–– Tuberculosis

•• Hilar

–– Tuberculosis

–– Leukemia

–– Lymphoma

–– Sarcoidosis

–– Histoplasmosis

•• Axillary

–– Cat scratch disease

–– Arm or chest infection

–– Leukemia

–– Lymphoma

•• Abdominal

–– Malignancy

–– Mesenteric adenitis

Clinical approach to lymphadenopathy

•• History

–– Associated other systemic symptoms

•• Age

–– Lymph node enlargement in children less than 5 years most likely infectious

–– Histiocytosis can cause lymphadenopathy in children < 3 years

–– Large lymph node in neonate most likely related to congenital infection

–– Likelihood of malignant lymphoma increases in adolescents

•• Location

–– Supraclavicular lymphadenopathy is always abnormal and the chances of malignancy are high

•• Size

–– Size of the enlarged lymph node aids in determining the need for further evaluation

–– Axillary and cervical > 1 cm

–– Inguinal > 1.5 cm

–– Epitrochlear > 0.5 cm

–– Anywhere > 2 cm

•• Characteristics

–– Usually develops over weeks or months.

–– Nontender, discrete, firm, rubbery, often immobile

Biopsy criteria

•• Size

–– > 2 cm

–– Increasing over 2 weeks

–– No decrease in size after 4 weeks

•• Location

–– Supraclavicular

•• Consistency

–– Hard

–– Matted

–– Rubbery

•• Associated features

–– Abnormal CXR

–– Fever

–– Weight loss

–– Hepatosplenomegaly

PEDIATRICS MCQS, TOACS, PEARLS & UPDATES: Tuberculosis (TB) Screening: Method of screening, ...

PEDIATRICS MCQS, TOACS, PEARLS & UPDATES: Tuberculosis (TB) Screening: Method of screening, ...: Tuberculosis (TB) Screening •• Routine screening for TB is no longer recommended. Method of screening •• The intradermal Mantoux tu...

Tuberculosis (TB) Screening: Method of screening, who should be investigated, what is positive Mantoux tuberculin skin test (TST)

Tuberculosis (TB) Screening

•• Routine screening for TB is no longer recommended.

Method of screening

•• The intradermal Mantoux tuberculin skin test (TST) is the most reliable diagnostic for TB.

•• The test consists of 0.1 mL of purified protein derivative (PPD) injected intradermally on the volar aspect of the forearm.

•• Forming a 6- to 10-mm wheal.

•• The area is inspected at 48–72 h; induration, not erythema.

•• It is measured transversely to the long axis of the forearm and the results recorded in millimeters.

•• The test is considered to be positive at specific sizes of the area of induration, depending on associated features.

Indication for initial TB screening

•• If active disease is suspected

•• Contacts of individuals who have confirmed or suspected active TB

•• Children who have clinical or radiographic findings suggestive of TB

•• Children emigrating from countries where TB is endemic, who visit these countries frequently, or who have frequent visitors from these countries

•• All children who will begin immunosuppressive therapy

•• Children infected with HIV

•• Incarcerated adolescents

•• Positive TST interpretation depends on the size of induration and associated risk factors (see infectious disease

chapter)

Critical to know

•• Positive TST result in a child or adolescent should be regarded as a marker for active disease within that community and should serve as a call to investigate contacts and to find and treat cases of latent TB.

IMMUNODEFICIENCY MCQS: MATCH THE CORRECT ANSWERS

Match each clinical condition with the most appropriate diagnostic laboratory test. Each lettered option may be used once, more than once, or not at all.

a. ESR

b. Serum immunoglobulin levels

c. Nitroblue tetrazolium (NBT) test

d. CH50 assay

e. CBC demonstrating Howell-Jolly bodies

f. Platelet count

g. Intradermal skin test using Candida albicans

Cases: 

01. A 1-year-old boy has been admitted three times in the past with abscess formation requiring incision and drainage. He is now admitted for surgical drainage of a hepatic abscess identified on ultrasound.

02.  A 5-month-old infant is admitted with severe varicella infection. The lesions cover the infant’s entire body, and the infant is beginning to show symptoms of respiratory distress. Past medical history is significant for a history of severe atopic dermatitis. The family also notes frequent epistaxis; the last episode required nasal packing in the ED.

03. A 3-year-old boy has had repeated episodes of sinusitis and otitis media. He was recently admitted for osteomyelitis of his femur with Staphylococcus aureus. The family notes that while his first 4 or 5 months of life were normal, he has been persistently ill with multiple infections in the ensuing months. The mother notes that her brother had similar problems with infections and died at the age of 3 years from a “lung infection.” Physical examination is significant for the absence of lymph nodes and tonsillar tissue.

04. A general practitioner refers to you for evaluation of a 3-year-old boy with frequent infections. You note the child to have a loud systolic murmur, posteriorly rotated ears that are small and low-set, down-slanting and widely spaced eyes, a small jaw, and an upturned nose. At birth the child spent 2 weeks in the nursery for “low calcium” and seizures, and he still receives calcium supplementation, but the mother does not know why. You would like to order a rapid diagnostic test for this child.

05. A 2-year-old girl has had two episodes of Neisseria meningitidis septicemia and is now admitted for Streptococcus pneumoniae septicemia.


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Answers: Immunodeficiency

The answers are 103-c, 104-f, 105-b, 106-g, 107-e.

The bulk of immunodeficiencies can be ruled out with little cost. The NBT or other respiratory burst

assay will help identify phagocytic-cell defects such as chronic granulomatous disease (resulting in the liver abscess in the child in question). A newer test for CGD is the dihydrorhodamine (DHR) flow cytometry study.

Wiskott-Aldrich syndrome must be considered in a patient with severe eczema and unusual infections, and is a strong possibility with this history if the platelet count is low (but is unlikely if the platelet count is normal). Other findings include eosinophilia and elevated IgE.

B-cell defects are likely to result in low immunoglobulin A, G, and M levels and result in multiple infections such as that described in the 3-year-old with otitis media and sinusitis.

An intradermal skin test using Candida albicans will result in no response in the patient with T-cell deficiencies, such as in the question of the dysmorphic child who possibly has DiGeorge syndrome. Asplenia results in Howell-Jolly bodies and also an increased risk for encapsulated organisms such as pneumococcus or meningococcus; a CBC with a peripheral smear can rule out this disease. Should any of these tests prove to be positive, more extensive, invasive, and expensive testing can be undertaken.

MCQS# 06.5.2020

MCQ# 6.5.2020

A baby on the post-natal ward developed jaundice at 32 h of age. She was born at term, weighing 3300 g, to a 25 year-old mother with a healthy 5 year-old daughter. Mother was breastfeeding. The membranes had ruptured 28 h before delivery. No antibiotics were given to mother or baby.

Examination of the baby was normal, apart from jaundice. The weight was 3100 g. The serum bilirubin level was 19.5mg/dL. Mother was blood group O Rhesus negative; baby A Rhesus negative The direct Coombs test was weakly positive Hb 15.4 g/dL, white count 16700/dL (60% neutrophils) and platelets 212000/L

1. What is the most likely diagnosis? 

    A. Rhesus haemolytic disease

    B. Dehydration jaundice

    C. Neonatal infection

    D. Breast milk jaundice

    E. ABO incompatibility

2. What other investigations are necessary? 

    A. Conjugated/unconjugated bilirubin levels

    B. Urea and electrolytes

    C. Glucose-6-phosphate dehydrogenase levels

    D. Osmotic fragility test

    E. None of above

3. What is the correct treatment? 

    A. Withdraw breast feeds

    B. Phototherapy and Penicillin and gentamicin

    C. Double-volume exchange blood transfusion

    D. Just phototherapy

    E. No need of any therapy

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