Dev. Milestones
A child presents to clinic with his mom, he is doing well developmentally. He can draw a square, hop on one foot, speak a 4-word sentence and loves to be a little helper. Which milestone is he meeting?
Meeting 4-year milestones
A child developed a rash that is scaly and pruritic with plaques in the palm of his hand. He recently started playing with homemade slime without gloves. What is the diagnosis?
a) Contact dermatitis
b) Atopic dermatitis
c) Scabies
d) Seborrheic dermatitis
Correct ans: a) Contact dermatitis
Contact dermatitis presents with itchy, erythematous, scaly patches and plaques in the area where the skin encountered the potential allergen. This is an acute reaction.
Atopic dermatitis (choice B) is characterized by chronic dry skin which is pruitic.
Scabies (choice C) is a papular, itchy rash seen on the finger webs, axillae, belt line, and genital areas.
Seborrheic dermatitis (choice D) primarily affects the scalp and intertriginous areas. It is most common in the first 6 weeks of life, but can occur in children up to 12 months of age. Involvement of the scalp is frequently termed "cradle cap", and manifests as greasy, yellow plaques on the scalp. Other commonly affected areas include the forehead and eyebrows, nasolabial folds, and external ears. Involvement of skin creases, such as the nappy area, can lead to secondary Candidal infection and maceration.
A 6-year-old girl, previously healthy, presents to the ED with a facial rash (cheek and eyelids, erythematous), fatigue, and muscle pain. You note heliotrope discolouration over the eyelids and papules over her knuckles. Her muscles are tender to palpation, grip strength is normal, but her strength seems diminished on shoulder abduction. She also has difficulty standing from a seated position. Of the following, the MOST likely cause for this child's symptoms is?
a) Dermatomyositis
b) Polymyositis
c) Duchenne muscular dystrophy
d) Systemic lupus erythematosus
e) Viral myositis
Correct ans: a) Dermatomyositis
Explanation:
Dermatomyositis tends to present in a slow, progressive fashion, with insidious onset of fatigue, malaise, and progressive muscle weakness, accompanied by low-grade fevers and rash. The muscle disease of JDM primarily affects the proximal muscles. Children may have a positive Gower sign. A classic poikilodermal rash occurs on the face and across the cheeks but also can be found on the shoulders and back (shawl sign). Patients may have heliotrope discoloration of the eyelids. Scaly, red plaques (Gottron papules) classically are found across the knuckles but can be found on the extensor surfaces of any joint. Patients may have dilated nail-fold capillaries.
A 5-year-old boy came to the clinic for follow-up. Mom mentions that he has episodes of seizures during sleep (not on any treatment). EEG done shows there's one type of focal seizure, benign, with good prognosis, and expected to disappear in childhood. Normal developmental history. Normal neurological exam.
a) West Syndrome
b) Benign Rolandic Epilepsy
c) Infantile spasms
d) Absence seizures
e) Febrile seizures
Correct ans: b) Benign Rolandic Epilepsy
Explanation:
Benign Rolandic Epilepsy: Usually noticed during sleep, normal neurological and developmental history. Good prognosis with spontaneous seizure remission prior to adulthood. EEG shows centrotemporal spikes.
Infantile spasms are characterized by sudden flexion of the arms, forward flexion of the trunk, and extension of the legs. Seizures last a few seconds and recur many times a day. They occur only in the 1st 5 years of life, then are replaced by other types of seizures. Developmental defects are usually present. Absence seizures do not present until age 1-8 years. Febrile seizures would occur when the child has a fever.
West syndrome is usually seen in 3-8 months of age and it has the infantile spasms, developmental regression, and abnormal EEG (hypsarrythmia) triad.
A child born at 32 weeks gestation is brought to your office at 2 months of age for a routine check-up. The child has an upper respiratory tract infection but is afebrile. What decision would you make regarding the child's today's vaccination?
a) Wait until the child is two months older to administer the vaccination
b) Wait until the child is clinically well and then vaccinate
c) Administer the vaccination
d) Consult a pediatrician
e) Skip the vaccination
Correct ans: c) Administer the vaccination
Explanation:
Acute illness is not a contraindication to immunization. The only indications to post-pone this vaccine would be due to: fever associated with moderate or severe illness or in an immunocompromised child. OR hypersensitivity reaction to the vaccine or its constituents.
At 2 months of age this child should receive the following shots: DTaP: Diphtheria, tetanus, and acellular pertussis vaccine Hib: Haemophilus influenzae type b vaccine IPV: Inactivated poliovirus vaccine Pneu-C-13: Pneumococcal conjugate 13 vaccine Rot-1: Rotavirus vaccine
An infant is experiencing stranger anxiety. What is the typical age for appearance of stranger anxiety?
a) 6–9 months
b) 18–24 months
c) 4–6 months
d) 15–18 months
Correct ans is: a) 6–9 months
Separation protest or “anxiety” typically surfaces between 6 and 9 months, and is marked by an infant’s crying when his parent or caregiver leaves his presence. Most separation anxiety resolves naturally, as the infant develops cognitively and learns that absences are followed by reunions when parents return
A 6-month-old female has had itching and irritability for 4-5 weeks. There is a family history of atopy and asthma. Physical examination reveals an excoriated dry rash bilaterally over the elbows and knees, as well as some involvement of the face (cheeks). Which one of the following is the most likely diagnosis?
a) Contact dermatitis
b) Herpes zoster dermatitis
c) Atopic dermatitis
d) Scabies
Correct ans: c) Atopic dermatitis
Explanation:
This child has atopic dermatitis (eczema). The infantile stage may present with pruritic, red, scaly, and crusted lesions on the extensor surfaces and cheeks or scalp. The childhood stage is characterized by less exudation and often demonstrates lichenified plaques in a flexural distribution, especially of the antecubital and popliteal fossae, volar aspect of the wrists, ankles, and neck. There often is a family history of atopy or allergies.
A 10-year-old child who presented to your clinic with history of spiking high grade fever every day reaching 39 degrees C for 3 days, weight loss, hepatosplenomegaly, and salmon-colored lesions. The child has been complaining of joint pain for 6 weeks. What is the most likely diagnosis in this child?
a) Non Hodgkin lymphoma
b) Systemic juvenile arthritis
c) Leukemia
d) Kikuchi disease
Correct ans: b) Systemic juvenile arthritis
Explanation:
Systemic JIA is characterized by arthritis for 6 weeks or more, high fever, rash, and prominent visceral involvement, including hepatosplenomegaly, lymphadenopathy, and serositis (pericarditis). The characteristic fever, defined as spiking temperatures to ≥39°C (102.2°F), occurs on a daily or twice-daily basis for at least 2 wk, with a rapid return to normal or subnormal temperatures. The evanescent salmon-colored lesions, classic for sJIA, are linear or circular and are most commonly distributed over the trunk and proximal extremities. The classic rash is non-pruritic and migratory with lesions lasting <1 hr. Fever, rash, hepatosplenomegaly, and lymphadenopathy are present in >70% of a effected children.
Without arthritis, the differential diagnosis includes the episodic fever syndromes, infection, and malignancy. Some children initially present with only systemic features, and evolve over time, but definitive diagnosis requires presence of arthritis. Arthritis may affect any number of joints, but the course is classically polyarticular, may be very destructive, and can include hip, cervical spine, and temporomandibular joint involvement.
Classification Criteria for Systemic JIA
1. Fever 2 or more weeks, with high grade fever at least once a day (and should be documented daily for 3 or more days)
2. Arthritis in 1 or more joint for 6 or more weeks
3. At least one of the following: Evanescent erythematous rash, Generalized lymphadenopathy, Hepatomegaly/splenomegaly or Serositis (pericarditis, pleuritis, peritonitis)
Which of the following genetic diseases is incorrectly linked with its transmission pattern?
a) Duchenne muscular dystrophy - X-linked recessive
b) Achondroplasia - autosomal dominant
c) Cystic fibrosis - autosomal recessive
d) Hemophilia - X-linked dominant
e) Neurofibromatosis type 1 - autosomal dominant
Correct ans: d) Hemophilia - X-linked dominant (it's X-linked recessive!)
A 6-year-old boy who had received the MMR, oral polio, and DTaP vaccines 2 weeks ago came to you for the varicella vaccine. When should you administer the varicella vaccine?
a) Wait for one week
b) Wait for two additional weeks
c) Proceed and give the vaccine
d) The boy does not require the vaccine at all
Correct ans b) Wait for two additional weeks
Explanation:
We need 4 weeks between 2 live vaccines or we give them all together simultaneously
A toddler is able to say 50 words, speak 2-word sentences, runs, can climb up and down the stairs one step at a time, and can stack up to 6 blocks. Guess the milestone?
a) 3-year-old
b) 4-year-old
c) 18 months old
d) 2-year-old
e) 15 months old
Correct ans is d) Meeting 2-year milestones!
An 8-year-old female comes in with an asymptomatic erythematous eruption characterized by oval patches with collarette scaling. It is distributed as a "Christmas tree" pattern on the back. The father states that there was originally one lesion on the trunk (Herald patch) a few weeks prior. What is the most likely diagnosis?
a) Pityriasis rosea
b) Tinea corporis
c) Lichen planus
d) Psoriasis
e) Seborrheic dermatitis
Correct answer is a) Pityriasis rosea
Pityriasis rosea (PR) is a condition that classically begins with a single, primary, 2- to 10-cm “herald” patch that appears on the trunk or proximal limbs. A general centripetal eruption of 0.5- to 2-cm rose- or fawn-colored oval papules and plaques follows within 7 to 14 days. The lesions have a scaly, slightly raised border (collarette) and resemble ringworm (tinea corporis). Most patients itch, occasionally severely. Classically, lesions orient along skin lines, giving PR a Christmas tree-like distribution when multiple lesions appear on the back. A prodrome of malaise and headache precedes the lesions in a minority of patients. Diagnosis is based on clinical appearance and distribution. Sunlight or UVB phototherapy may help the lesions disappear faster. Condition resolves spontaneously in about 6 weeks.
A 12-year-old girl known to have systemic lupus (SLE) presents to your the emergency department with a complaint of worsening chest pain that increases when she takes a deep breath. On physical examination, the girls heart rate was 150 beats/min, respiratory rate was 36 breaths/min, blood pressure was 92/48 mm Hg, and oxygen saturation was 98% in room air. You examined her in a sitting leaning forward position and heard clear normal breath sounds. Cardiac examination was significant for a loud intermittent friction rub and no murmur, electrocardiography show no specific abnormality apart of low voltage QRS. Of the following, the MOST likely cause of this girl's signs and symptoms is?
a) Pleural effusion
b) Pericardial effusion
c) Pulmonary embolism
d) Pneumothorax
Correct ans: b) Pericardial effusion
Explanation:
The girl in the question presents with symptoms of positional chest pain and has signs of a left pulmonary process, as well as a friction rub, suggesting a pericardial effusion. The first presentation for SLE may be with a pericardial effusion.
Low voltage is because of either small heart compared to the rest of body or barrier between the heart and the skin like effusion
A 3-month-old presents to clinic with recurrent right focal seizures now generalized in nature. Birth history is normal. Neurological examination is normal. Skin lesion noted on left side of the face going up to the forehead. Brain MRI showed tram track calcification on the left side. What is the diagnosis?
a) Tuberous sclerosus
b) Neurofibromatosis
c) Sturge Weber syndrome
d) Congenital Rubella syndrome
Correct ans: c) Sturge Weber syndrome
Explanation:
STURGE - sporadic, tram track calcification on Brain MRI on the ipsilateral side of the lesion, unilateral port-wine stain in the trigeminal nerve distribution, intellectual disability, glaucoma on the same side of the lesion/stain, epilepsy on the contralateral side of the stain
A 14-month-old infant boy was brought in by his mother for required (routine and non-routine) vaccination before they leave the country to go to Peru for Easter. The mother tells you that last week, he tried a small amount of scrambled eggs and developed hives, wheezing and swelling. He was treated in the emergency room. She has read some stories about possible immunization complications in children with egg allergy. Which of the following contains the highest amount of egg protein and should not be given to persons hypersensitive to eggs?
a) Flu vaccine
b) MMR vaccine
c) DTaP vaccine
d) Yellow fever vaccine
e) Varicella
Correct ans is: d) Yellow fever vaccine
Explanation:
Children with egg allergy present the biggest concern when receiving childhood vaccines. The following routine childhood immunizations may contain egg or egg-related proteins: influenza (flu) and measles-mumps-rubella (MMR) vaccines. In addition, the following non-routine vaccines contain egg protein: yellow fever and typhoid vaccines. Yellow fever vaccine contains the highest amount of egg protein of all the egg-based vaccines. Live yellow fever vaccine is produced in chick embryos and should not be given to persons hypersensitive to eggs. Diphtheria, tetanus, and pertussis, or DTaP, vaccine does not contain egg proteins (some contain bovine proteins).
A child can say up to 6 words including mama, walk alone, build a bridge of 2 cubes, use a pen but can not draw a circle. What is his/her age?
a) 24 months
b) 15 months
c) 12 months
d) 36 months
Correct Ans is b) 15 months
12 months pincer grip
15 months 2 blocks
18 months 3 blocks
24 months (2x3 = 6 blocks)
A 2-month-old baby presents with an erythematous, scaling, crusting eruption of the scalp, face and diaper area. It is greasy yellow in appearance. What is the most likely diagnosis?
a) Psoriasis
b) Eczema
c) Seborrheic dermatitis
d) Atopic dermatitis
Correct ans: c) Seborrheic dermatitis
Seborrhoeic dermatitis primarily affects the scalp and intertriginous areas. It is most common in the first 6 weeks of life, but can occur in children up to 12 months of age. Involvement of the scalp is frequently termed "cradle cap", and manifests as greasy, yellow plaques on the scalp. Other commonly affected areas include the forehead and eyebrows, nasolabial folds, and external ears. Involvement of skin creases, such as the nappy area, can lead to secondary Candidal infection and maceration. Although this condition usually resolves without treatment, it may require treatment in some cases. Suggestions for treatment include: -Shampoo frequently with baby shampoo and gently remove scaly skin with a soft brush or fine-tooth comb after shampooing. -Apply a small amount of an emollient (white petroleum jelly, vegetable oil, mineral oil, baby oil) to the scalp (overnight, if necessary) to loosen the scaly patches, followed by gentle scalp massage with a soft brush (to lift the scale), then shampoo with a non-medicated baby shampoo. If it persists despite these measures, mild topical corticosteroids or a prescription anti-fungal (not antibacterial) shampoo may be used. Abx: Erythromycin ointment
Which of the following is true about congenital heart block in neonatal lupus erythematosus?
a) It is associated with maternal anti-Ku autoantibodies
b) It is transient
c) The majority of patients will require a pacemaker
d) Neonatal lupus is a much more common cause of heart block presenting after the neonatal period
e) The risk of mortality is small
Correct ans: c) The majority of patients will require a pacemaker
Correct ans: c) The majority of patients will require a pacemaker
Explanation:
In severe cases, surgical implantation of a pacemaker, along with the correction of structural abnormalities in the heart, may be necessary. Congenital heart block, an important manifestation of neonatal lupus erythematosus (NLE) that carries a poor prognosis, may merit preventive therapy in pregnancy during fetal cardiac development. It should be considered in pregnant women with systemic lupus erythematosus who are anti-SSA/Ro antibody positive and have previous children with congenital heart block. Congenital complete heart block is the most serious manifestation of NLE. A general management plan of pregnancy in mothers with systemic lupus erythematosus includes treatment of disease flares using drugs that are effective but also safe for the fetus. Such an approach may diminish or reduce the prevalence of complete heart block associated with NLE. Corticosteroids and some immunosuppressive drugs are sometimes used, but long-term outcome data in children exposed to immunosuppressive drugs in utero is lacking.
An 8-year-old boy is brought to your office by his mother for evaluation. She is concerned about his poor school performance as he is much “slower” to learn than the other children in his class. She has noted several raised lesions on his face, and his “acne” seems to be getting worse. You note that he has several flat, hypopigmented macules on his back. What is his diagnosis?
a) Sturge-Weber syndrome
b) Von Hippel-Lindau disease
c) Neurofibromatosis
d) Tuberous sclerosis
Correct ans: d) Tuberous sclerosis
Explanation:
The clinical description of the child above most closely fits the neurocutaneous disorder known as tuberous sclerosis (choice D). This is a progressive, autosomal dominant disorder characterized by ash-leaf spots (flat, hypopigmented macules), shagreen patches (areas of abnormal skin thickening), sebaceous adenomas (sometimes confused with acne), and facial angiofibromas. Intellectual disability and seizures usually accompany the cutaneous manifestations, and neuroimaging demonstrates distinctive periventricular “tubers”.
Sturge-Weber syndrome (choice A) is characterized by tram track calcification on Brain MRI on the ipsilateral side of the lesion, unilateral port-wine stain in the trigeminal nerve distribution, intellectual disability, glaucoma on the same side of the lesion/stain, epilepsy on the contralateral side of the stain
Von Hippel-Lindau disease (choice B) is characterized by vascular hamartomas in the eye and brain and is associated with renal cell tumors and pheochromocytoma.
Neurofibromatosis (choice C) is characterized by multiple café-au-lait macules on the skin as well as the development of fibromas. It is also associated with hypertension secondary to renal artery stenosis.
A 5-year-old is brought in to the emergency department. His parents report that he stepped on a rusty nail in their kitchen about two hours ago. His immunization card reveals that he had his DTaP vaccinations at 2, 4, 6 months and 18 months of age and a booster DT vaccination one year ago. What would you recommend for management of this patient?
a) Tetanus immune globulin, 250 units intramuscularly b) Tetanus toxoid, 0.5 mL intramuscularly
c) Vaccination with tetanus and diphtheria toxoids
d) Amoxicillin
e) No further immunization is required
Correct ans: e) No further immunization is required
According to the Tetanus Prophylyaxis guidelines:
6 weeks to 6 years old
1. Clean minor wounds: If they received unknown or less than 3 doses of tetanus toxoid, then they should get the DTaP but no need to get Tetanus immune globulin. If they got 3 or more doses of Tetanus toxoid, we can give a 4th dose for only 3 doses, but no need to give DTaP or Tetanus immune globulin.
2. All other wounds: If less than 3 doses or unknown received of tetanus toxoid, then should receive DTap and tetanus immune globulin at this age group. If 3 or more doses received, then no need to receive DTap or Tetanus immune globulin.
A mother is concerned that her 12 month old son is not developing normally. “My son doesn’t walk on his own yet and he only speaks a few words”. At this stage of development, the child should be able to:
a) Walk with support, throw objects, speak in single words, have pincer grasp
b) Walk without support, create a tower of 3 cubes, speak in 3 word phrases
c) Climb stairs with support, copy a square, speak in single words
d) Crawl, pincer grasp, babble
e) Walk with support, put on shoes, speak in 3 word phrases
Correct ans is A) Walk with support, throw objects, speak in single words, have pincer grasp
6 months: tripod sit, object transfer from hand to hand, babble, stranger anxiety (some texts say 9 months) 2 years: 2 word sentences, understands 2 step commands, up/down steps with one feet 3 years: 3 word combos, 3 digit repeat, rides tricycle 4 years: Counts 4 objects, knows 4 colours, draws 4 sided object (square), hops on one foot, 5-year old, and at 5-years of age: skips, rides a bicycle, draws a triangle, sings and dances
A 10-year-old female presents with a mildly itchy rash of 10 days duration. She had streptococcal pharyngitis 2 weeks ago. A red, papular rash with scaling is present on the trunk and proximal extremities. The lesions are 5-10 mm in diameter. This presentation is most consistent with:
a) Scarlet fever
b) Guttate psoriasis
c) Atopic dermatitis
d) Scabies
e) Erythema marginatum
Correct ans: b) Guttate psoriasis
Explanation:
Guttate psoriasis occurs predominantly in children and is characterized by a distinctive, acute eruption of small, droplike, 1-10 mm in diameter, salmon-pink papules, usually with a fine scale on the trunk and proximal extremities. The onset frequently follows a streptococcal respiratory infection.
→ Scarlet fever (choice A) usually accompanies streptococcal paryngitis and the rash is red, punctate, and often felt more readily than seen
→ Atopic dermatitis (choice C) is characterized by chronic dry skin which is pruitic
→ Scabies (choice D) is not related to streptococcal infection and is a papular, itchy rash seen on the finger webs, axillae, belt line, and genital areas
→ Erythema marginatum (choice E) is a manifestation of rheumatic fever and is a nonspecific macular lesion of the trunk with central blanching that appears serpiginous.
What is the major criteria for Rheumatic Fever?
Correct ans:
JONES
Joint involvement
Myocarditis
Nodules (subcutaneous)
Erythema Marginatum
Syndenham chorea
Minor: CRP, ESR elevated, Arthalgia, Fever (CAFE)
PAL (prolonged PR interval, anemesis of rheumatism, leukocytosis)
An 8-year-old boy presents to the physician for a routine health maintenance visit. His mother states that he has had difficulty reading and concentrating in his second-grade class. On examination, you see seven hyperpigmented spots on his body, as well as two small, soft masses above his orbit. He also has axillary freckling. His mother has café-au-lait spots on her arms. Which of the following is the most likely diagnosis?
a) Congenital hypothyroidism
b) Marfan syndrome
c) Neurofibromatosis
d) Osteogenesis imperfecta
e) Tuberous sclerosis
Correct ans: c) Neurofibromatosis
Explanation:
Neurofibromatosis is a multisystem genetic disorder. The features of this condition are more than six café-au-lait spots, two or more neurofibromas, axillary freckling, optic gliomas, iris hamartomas (Lisch nodules), and osseous lesions. There is almost always a first-degree relative with neurofibromatosis.
Congenital hypothyroidism is associated with poor feeding, an enlarged fontanelle, an enlarged tongue, and an umbilical hernia in the neonatal period. It would not go undetected until 8 years of age.
Marfan syndrome is a connective tissue disorder characterized by long fingers, hypermobile joints, subluxation of the lenses, pectus carinatum, and aortic aneurysms.
Osteogenesis imperfecta is a rare connective tissue disease characterized by recurrent fractures, blue sclera, thin skin, and hyperextensibility of ligaments.
Tuberous sclerosis is associated with facial angiofibromas (adenoma sebaceum), retinal hamartomas, seizures, and intellectual disability. Seizures are the most common presenting symptom. It is an autosomal-dominant inherited disease.
A 4-month-old baby has developed a fever of 40.2°C and become very irritable within 8 hours of receiving his second dose of routine immunization. Which one of the following options would you consider for completing the immunization of this baby?
a) Next time omit pertussis vaccine from the schedule
b) Give DTP instead of acellular pertussis
c) Omit Hib and administer DTaP and IPV
d) Reassure the mother and proceed with DTaP, IPV, Hib
e) Omit diphtheria toxoid from the combination
The correct answer is d) Explanation:
Short-term, mild reactions to immunizations are common. Immunizations that may cause a fever include: Diphtheria, tetanus, acellular pertussis (DTaP) or diphtheria, pertussis, tetanus (DPT). Babies can have a fever of up to 40°C (104°F) within 2 to 3 hours of getting the DTaP or DPT shot. Children may be fussy and have other mild symptoms such as poor appetite, sleepiness, or redness and swelling at the shot site for a few days. With Measles, mumps, and rubella (MMR), the shot site may become red, swollen, hard, and slightly warm within the first 24 to 48 hours. Fever also may occur 1 to 2 weeks after the shot. A mild rash may develop up to 3 weeks after the shot. Fever is a common clinical complaint in adults and children and a frequently reported adverse event following immunization. It is a generally benign and common clinical sign.