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Child with fever and sore throat with lateral neck film taken in flexion and during expiration shows retropharyngeal prominence (prevertebral soft tissue swelling). Your next step: a. Repeat with inspiration & neck extension b. CT neck with contrast c. MR neck with contrast d. Fluoro the airway
Answer: Repeat film with inspiration and neck extension Filming the neck in flexion allows the child’s flexible retropharyngeal tissues to bow towards the airway. During exhalation in the young child, the pliable superior mediastinal structures transiently prolapse rostrad, causing temporary thickening of retropharyngeal tissues. Need to repeat film in inspiration and extension. If this is not an answer choice in combination, then CT would be next step.
Pancreatic pseudocyst in 1 yo child with nausea and vomiting likely related to: a. Child abuse b. Cystic fibrosis c. Henoch-Schonlein purpura d. Sickle cell anemia e. Tuberous sclerosis
Answer: Child abuse Common causes of acute pancreatitis in children include both accidental and nonaccidental trauma. Due to underdeveloped abdominal musculature, children are more prone to traumatic pancreatic injury than are adults. The predominant causes include abdominal trauma (23%), anomalies of the pancreaticobiliary system (15%), multisystem disease (14%), drugs and toxins (12%), viral infections (10%), hereditary disorders (2%), and metabolic disorders (2%). In addition, when associated with abdominal trauma, the frequency rate of pseudocyst identification is higher than 50%. Approximately 60% of pancreatic pseudocysts that are caused by blunt trauma require surgical intervention.
One-month old infant with breech delivery presents with painless torticollosis. MR shows diffuse thickening and low signal in sternocleidomastoid. Diagnosis? a. Infection b. Denervation injury c. Fibromatosis coli d. Rhabdomyosarcoma
Answer: Fibromatosis coli This rare, benign condition presents in neonatal period as a mass in the SCM muscle. Microscopically, muscle is replaced by dense fibrous tissue. A history of birth trauma and resulting torticollis is common. The clinical course is spontaneous resolution over a period of 4–8 months, with no treatment or with stretching exercises. US shows an isoechoic or hypoechoic mass within the muscle. The mass can be seen to move with the muscle on real time ultrasound.
Physiologic herniation of bowel occurs at what maternal age? a. 6-8 wks b. 8-12 wks c. 12-16 wks d. 16-20 wks e. 20-24 wks
Answer: 8-12 weeks The bowel re-enters the abdominal cavity at about week 10. There is a physiologic hernia during the time the fetus measures 23mm-60mm in length corresponding to approx 45-70 days. Herniation was detected in 64% of the cases at 8 weeks, in 100% during weeks 9 and 10, and in 25% at 11 weeks\' gestation. Elongation of gut occurs faster than elongation of body. This results in the formation of a ventral midgut loop which herniates into umbilical cord. The midgut initially develops outside of abdominal cavity. During 10th week of development, the midgut returns to the abdomen, and then undergoes further rotation.
Neonate/child with chunky calcifications in enlarged scrotum is suggestive of what? a. neuroblastoma b. meconium peritonitis c. tuberculous peritonitis d. hemangiomatosis e. teratoma
Answer: Meconium peritonitis Meconium peritonitis – sterile chemical peritonitis due to perforation of bowel after third month of gestation due to high-grade or complete obstruction (atresia, meconium ileus, volvulus). On plain film, meconium peritonitis is characterized by intraabdominal calcifications, which may manifest as a peripherally-calcified pseudocyst, small scattered calcifications, large calcifications along the inferior surface of the liver and along the flanks, processus vaginalis, and in the scrotum. If the perforation event occurs close to birth, mortality is higher due to active leak from the perforation. Generally prognosis is good if the perforation site is completely healed, surgery may not be required.
Plaque-like calcification in the abdomen of a neonate is most likely seen in which: A. Neuroblastoma B. Intrauterine perforation of the bowel C. Multicystic dysplastic kidney D. Congenital megacalyces E. PCP
Answer: Intrauterine perforation of bowel (meconium peritonitis) The most common cause is meconium peritonitis. This occurs when there is antenatal bowel perforation with spillage of meconium into the peritoneal cavity. There is a sterile chemical peritonitis with resultant dystrophic calcifications. 50% of cases are secondary to webs or atresias. Usually found incidentally on an abdominal radiograph. The appearance of the calcification varies and it can be anywhere in the abdominal cavity including along the diaphragm and in the scrotum. The calcifications are more common on the right.
FALSE about vascular malformations? a. Lymphocele (lymphangiomas) grow rapidly in first year b. Venous malformations enlarge during puberty c. (Capillary) hemangiomas involute rapidly during the first year d. AV malformation can grow with age
Answer: Hemangiomas involute rapidly during the first year (FALSE) Hemangiomas of infancy always have a period of growth (proliferative phase) followed by a period of shrinkage (involutive phase). Most hemangiomas begin their proliferative (growth) phase shortly after birth. This phase usually lasts for 4 to 6 months, but can be longer or shorter. The involutive phase is much slower and can take up to ten years. It is difficult to predict how long this shrinkage process will last. Lesions that involute slowly, over a long period of time, are much less likely to shrink completely. In some children, even those hemangiomas that do shrink completely may leave residual fatty tissue and telangiectasias (tiny dilated blood vessels) of the skin.
TRUE regarding venous malformation size: a regresses in childhood b parallels the child’s growth c involutes at birth
Answer: Parallel\'s the child\'s growth
9-year-old boy with intramuscular vascular malformation in his thigh mass containing phleboliths. This most likely reprsents: A) Capillary hemangioma B) Venous malformation C) Arteriovenous malformation D) Lymphatic malformation CAVERNOUS hemangioma was an option in some years but not others
Answer: Venous malformation Phleboliths are pathognomonic for venous malformation (emedicine, Vascular, Venous malformations). Venous malformations are congenital, but they may not become clinically apparent until late infancy or early childhood. Venous malformations do not regress or involute but rather grow with the child. Rapid enlargement may occur during puberty or pregnancy or with trauma. Potential complications include pain, compression or invasion of adjacent structures, decreased range of motion, bleeding, consumptive coagulopathy, and cosmetic deformity. Phleboliths are common. Cavernous hemangiomas (more often seen in adults) can have punctate calcifications. Cavernous hemangiomas are larger and deeper and occur later in life. Often intramuscular. Do not spontaneously involute and therefore may require surgical intervention. Phleboliths are associated with cavernous hemangiomas in approximately 50% of cases. Capillary hemangiomas are one of the most common benign orbital tumors of infancy. Benign endothelial cell neoplasms typically absent at birth and characteristically have rapid growth in infancy with spontaneous involution later in life. Capillary hemangiomas are present in approximately 1-2% of neonates. All patients that eventually develop hemangiomas have them by age 6 months. Vascular malformations, such as lymphangiomas and arteriovenous malformations, are present at birth and are characterized by very slow growth with persistence into adult life. Females outnumber males with hemangiomas by ratio of 3:1. Arteriovenous hemangiomas are deep or superficial, are abnormal communication between arteries and veins, and cause a variable degree of shunting. Vascular malformations further differentiated into low-flow and high-flow lesions, which is an important distinction having clinical and therapeutic implications. The time-resolved contrast-enhanced 3-D MR angiography permits the most accurate classification of vascular malformations with visualization of the dynamic enhancement profile. Sclerotherapy is the treatment of choice for low-flow lesions.
Atresia of which portion of bowel is most associated with other congenital anomalies? a. duodenal atresia b. jejunal atresia c. ileal atresia d. colonic atresia e. R colon atresia f. L colon atresia
Answer: Duodenal atresia Duodenal atresia has the highest association with other anomalies. 50% of patients with duodenal atresia will show other congenital anomalies. Common associations are Trisomy 21, malrotation, congenital heart disease, and VACTERL associated anomalies. Most sites of duodenal atresia are around the ampulla of Vater, either just proximal or just distal to it. The radiographic sign is the “double bubble” sign created by a dilated stomach and proximal duodenum. This can be seen as early as 24 weeks on ultrasound. The pylorus usually demonstrates hypertrophy secondary to the downstream obstruction. Emesis can be bilious or not, depending on whether the site of atresia is proximal or distal to the ampulla. Jejunal, ileal, and colonic atresias are rare and are secondary to in utero vascular accident.
Most likely to cause cavitary/necrotizing PNA in a child? a. Staphyloccocus aureus b. Streptococcus pneumoniae c. Chlamydia d. Mycoplasma e. Viral
Answer: Staphyloccocus aureus (Bacertoides fragilis if this is a choice) The bacteria produced necrotizing pneumonia include S. aureus, Gram-negative enterics, and anaerobes. Prior to the advent of good anaerobic culture techniques, S. Aureus was the most frequently recovered organism. A review of the literature since then reveals that Bacteroides fragilis is the most common pathogen, followed by staph aureus, and hemolytic streptococci. E coli and Klebsiella at are the most common Gram-negative organisms to form lung abscesses. Pneumococcus, H influenza, and M pneumonia are reported as rare causes of cavitary pneumonia.
Appropriate mA to use in a 2 y.o child during a chest CT? a. 20 mA b. 80 mA c. 160 mA d. 300 mA
Answer: 20 vs 80 mA 1. < 15 kg: kV:120, mAs: 17 2. 15-24 kg : kV: 120, mAs: 20-40 3. 25-34 kg : kV: 120, mAs: 30-50 4. 35-44 kg: kV: 120, mAs: 50-80 5. 45-54 kg: kV: 120, mAs: 70-100
Which is most characteristic of coxa valga deformity of the hips with dislocation? a. Cerebral palsy b. Legg-Calve-Perthe disease c. Osteogenesis Imperfecta d. Metaphyseal dysplasia e. Tibial torsion
Answer: Cerebral palsy Coxa valga = increased angle between the head and neck of the femur and the shaft, > 140° in AP projection, neutral position. Reflects persistence of neonatal alignment of proximal femur, usually from weakness of abductor muscles and lack of normal weight-bearing forces. Most commonly associated with neuromuscular disorders such as cerebral palsy, spinal dysraphism, and poliomyelitis, but is also seen in some skeletal dysplasias and juvenile idiopathic arthritis. If severe, then there may be associated lateral subluxation or even dislocation of the femoral head. CP – coxa valga LCP – coxa magna and plana OI – coxa vara Metaphyseal chondrodysplasia – coxa vara Tibial torsion - coxa valga
Most commonly associated w/ microcolon: a. meconium plug b. meconium peritonitis c. meconium ileus d. Hirschprung\'s e. anal atresia
Answer: Meconium ileus Meconium ileus causes 10-25% of bowel obstruction in newborns, and occurs in 6-20% of children with cystic fibrosis. Contrast enema shows a microcolon. Hirschsprung\'s - absence of ganglion cells that innervate colon; usually focal segment. Meconium plug syndrome - functional immaturity of ganglion cells; it is a temporary phenomenon that resolves.
Microcolon is NOT associated with which of the following? a. Meconium ileus b. Meconium plug c. Meconium peritonitis d. Hirshprung’s disease
Answer: Meconium plug (NOT associated) Meconium plug syndrome = functional colonic obstruction in the full-term neonate. Plug of thick meconium lodges in the distal colon, probably caused by poor peristalsis as a result of neuronal underdevelopment. Radiographs may reveal low obstruction with bowel distension. Contrast enemas usually reveal a normal-caliber left colon. Meconium ileus occurs when meconium obstructs the distal ileum (microcolon always present, 99% a/w CF). Differential for microcolon is MI MCA: Meconium ileus/ peritonitis (cystic fibrosis), Ileal/ jejunal atresia, Megacystic-microcolon-hypoperistalsis syndrome, Colonic atresia, Aganglionosis (Hirschsprung dz).
A child presents with progressive lower extremity weakness, leg length discepancy, limp, scoliosis, sacral dimple/tuft of hair. Most likely associated with: A. Tethered cord B. Sacrococcygeal teratoma C. Myelomeningocele D. Idiopathic scoliosis E. Chordoma
Answer: Tethered cord Tethered cord syndrome is associated with a variety of conditions: thickened filum terminale, intradural lipoma, myelomeningocele, diastematomyelia, lipomyelomeningocele, trauma, and infection. Presents with cutaneous findings: present in 80-100% of childhood tethered cord, and <50% of adult tethered cord, hypertrichosis (tuft of hair), subcutaneous lipoma, and/or dermal sinus. Difficulty with walking with lower limb weakness. Muscle atrophy, short limb. Foot deformity: common in children, not seen in adults. Sensory deficit (numbness). Bladder dysfunction: dribbling, delayed toilet training, recurrent urinary infection and bed-wetting. Frequency, urgency, sensation of incomplete emptying, incontinence. Pain in the back, legs, or foot arches. Scoliosis or kyphosis: common in children, uncommon in adults (<5%). In children symptoms are aggravated by growth spurts. In adults symptoms are aggravated by trauma, maneuvers associated with stretching of the spine (flexion), disc herniation, spinal stenosis. Note that a meningomyelocele could cause similar symptoms but would present at birth. Idiopathic scoliosis (orthopedic problem) does not give rise to leg weakness, and is not associated with a sacral dimple.
Most specific finding in tethered cord: a. Scoliosis b. Lower extremity paralysis c. Diarrhea d. Chronic UTI e. Limp
Answer: Scoliosis Lower extremity weakness is more likel than paralysis.
Diabetic mothers are more prone to have children with: a) Caudal regression (syndrome) b) Syringohydromyelia c) Myelomeningocele d) Lymphoma e) Tethered cord f) Filum lipoma Sacral teratoma
Answer: Caudal regression syndrome Caudal regression syndrome is hypoplastic/absent distal spine, sacrum due to mesodermal insult during 4th week of gestation. Caudal regression syndrome = sacral agenesis. Infants of diabetic mothers are predisposed (16-22% of children with sacral agenesis have diabetic mothers). Also seen with greater incidence in infants of diabetic mothers: meconium plug syndrome, subvalvular aortic stenosis (hypertrophic obstructive cardiomyopathy), hyaline membrane disease, adrenal hemorrhage, MCDK, renal vein thrombosis. Dähnert CD-ROM
An 8 year-old develops fever, elevated WBC, flank pain, and positive UA. First imaging test? a. cystogram to check for reflux b. kidney and bladder US c. CT abdomen/pelvis
Answer: Kidney and bladder US The question refers to a diagnosis of pyelonephritis. A kidney and bladder ultrasound should be performed first, looking for complications such as abscess, etc.
3 month old baby with a solid renal mass. Most common neonatal renal mass? a. Wilms tumor b. Mesoblastic nephroma c. RCC d. Neuroblastoma
Answer: Mesoblastic nephroma Mesoblastic nephroma is the most common solid renal tumor in children less than 6 months. It is a mesenchymal neoplasm consisting of connective tissue,islands of immature tubules and glomeruli,muscle,cartilage,cystic spaces. US demonstrates a large predominantly solid complex renal mass. Prognosis is good post-nephrectomy except for the more aggressive cellular histologies. On CT it appears as a large uniform mass of soft tissue attenuation, replacing the majority of the renal parenchyma. It may extend beyond the capsule but does not invade the renal vein. Post-contrast, tumor generally enhances less than the renal parenchyma, although focal areas of strong enhancement may present then becoming indistinguishable from a Wilms\' tumor. Wilms has it peak incidence at 3 ½. RCC is rare before age 5.
Which disease does Down’s syndrome have the same incidence as in the general population? (Down\'s syndrome is NOT associated with:) A Duodenal atresia B Pancreatic divisum C Obstructive sleep apnea D Hirschsprung\'s E Annular pancreas
Answer: Pancreatic divisum (NOT associated) Bony changes: flattened acetabular angles, outward flaring of iliac wings, hypoplasia of ischial rami, increase in number of ossification centers of sternum, only 11 ribs, short in-curved fifth finger with a hypoplastic middle phalanx, atlantoaxial and atlantoccipital instability, clinodactyly. CV: AV canal defect, VSD, PDA. Pulmonary: Obstructive sleep apnea. GI: duodenal atresia, duodenal bands, annular pancreas, TEF, anorectal anomalies, Hirchsprung. Higher incidence of leukemia.
Down’s syndrome is NOT associated with: a Increased atlanto-axial distance b Hypertrophic pyloric stenosis c Glossoptosis d Trident hands e Duodenal atresia f Echogenic bowel
Answer: Trident hands (NOT associated) Trident hands are associated with achondroplasia - short, stubby fingers, separation between middle and ring fingers. Abnormalities assosciated with Down’s syndrome include: Glossoptosis (abnormal downward or posterior placement of the tongue) Duodenal web or atresia Hirschprung Atlantoaxial instability Other ultrasonographic abnormalities include cystic hygroma, duodenal atresia or stenosis (double-bubble sign), cardiac defects (endocardial cushion defect, ASD, VSD, and abnormal MV,TV), and echogenic bowel and renal pyelectasis.
Down\'s syndrome is NOT associated with: A. Scaphocephaly B. Duodenal atresia C. Clinodactyly D. Hypotelorism E. Flat acetabulum F. Under development of second tooth G. Echogenic bowel H. Multiple manubrial ossification centers I. Flattened acetabular roof
Answer: Scaphocephaly (NOT associated) Down\'s patients have brachycephaly - WIDE head in lat to medial direction (synostosis of coronal sutures). Scaphocephaly = dolichocephaly - LONG head in AP diameter (early closeure of sagittal sutures). Down Syndrome also characterized by MR, hypotonia, characteristic facies, Simian crease. More common associations: Persistent metopic suture (40-79%) after age 10, atlantoaxial subluxation (25%) hypersegmentation of manubrium = 2-3 ossification centers (90%), 11 pairs of ribs (25%), clinodactyly (50%). Congenital heart disease (40%): endocardial cushion defect, VSD, tetralogy of Fallot Duodenal atresia (8-10%) – “double bubble sign”
Acute reason for imaging an infant w/ UTI: a. to evaluate for scarring b. to evaluate cortical thickness c. to detect associated congenital anomalies d. to determine renal function
Answer: To detect associated congenital anomalies The following recommendations for imaging in setting of acute UTI: An US performed at the time of acute illness is of limited value. A voiding cystourethrogram for the identification of reflux is useful only if antimicrobial prophylaxis is effective in reducing reinfections and renal scarring. Renal scans obtained at presentation identify children with acute pyelonephritis, and scans obtained six months later identify those with renal scarring. Routine performance of urinalysis and urine culture during subsequent febrile UTI with a previous febrile UTI will probably obviate need of US scans.
Work up of UTI in a 8 yo female would be: a. VCUG b. MRI of the pelvis c. Cystogram d. Ultrasound
Answer: Ultrasound In children > 3-4 yrs of age who have only signs of lower UTI, VCUG is not recommended if renal U/S is normal. However, if renal U/S is abnormal, then VCUG or radionuclide cytography is recommended. Kirks
2 year old girl develops flank pain, burning micturation, fever and pyuria. What is the next most appropriate study? a. Ultrasound of the kidneys and bladder b. Contrast-enhanced CT c. IVP d. VCUG e. excretory urogram
Answer: VCUG In a child presenting with symptoms of UTI, the main question is “Is there an underlying anatomic abnormality (VUR, UPJ or UVJ obstruction, ureterocele or posterior urethral valve)?” Under age 5, the child should undergo a VCUG. If the VCUG is normal, the next appropriate study is an ultrasound. If the VCUG is abnormal, an excretory urogram or radionuclide renogram are appropriate. Hans Blickman. The Requisites: Pediatric Radiology, 1998]
Earliest sign of necrotizing enterocolitis? (a) Diffuse bowel dilatation (b) Bowel wall thickening (c) Portal venous gas (d) Free air (e) Pneumatosis
Answer: Diffuse bowel dilatation 1st: Dilated loops of bowel consistent with ileus typically is seen in the early stages of NEC. 2nd: Separated loops (thickened walls), edema of the bowel wall, ascites, or gas in the portal vein may be present. 3rd: Pneumatosis intestinalis, the hallmark of NEC, appears as bubbles of gas in the bowel wall. Pneumoperitoneum appears when bowel perforation occurs. Substantial intraperitoneal air may result in \"football\" sign on supine film. In absence of intraperitoneal air, a loop of bowel remains in a fixed position on serial films (sentinel loop) indicating necrotic bowel.
All are associated with NEC EXCEPT: A. Most commonly involves the right colon and ileum B. Late finding is right sided stricture C. Associated with bacterial infection
Answer: Late finding is right sided stricture (NOT associated) Necrotizing enterocolitis may occur secondary to hypoxia, stress, infection/endotoxin, or congenital heart disease. It usually develops 2-3 days after birth, and 90% of cases develop within first ten days of life. Predisposed by prematurity, low-birth-weight, Hirschsprung disease, and any type of bowel obstruction. Symptoms include abdominal distention, bilious emesis, diarrhea, bloody stools, and sepsis. On plain film, signs include small bowel distention, a disorganized bowel gas pattern, tubular bowel loops, thumbprinting (bowel wall edema), pneumatosis intestinalis/portal venous gas, pneumoperitoneum, and ascites. NEC usually involves the terminal ileum, cecum, and right colon. It rarely involves the stomach or proximal small bowel. Complications include bowel perforation in 10-30%, which is treated by surgical resection. If large amounts of bowel resected, short bowel syndrome (diarrhea, malnutrition) may result. Inflammatory strictures develop in 80% of patients, characteristically in the left colon.
XRT in children will more likely results in which when compared with XRT in adults: a. scoliosis b. osteonecrosis c. sarcoma d. cartilage damage
Answer: Scoliosis Late effects in children treated with radiation therapy for Wilms’ tumor, found that scoliosis with or without kyphosis was the most common late toxicity in 18 of 42 children (42.9%). Median time to develop scoliosis was 102 months. Radiation-induced sarcoma is a grave late effect but fortunately is uncommon. The probability of sarcoma is not directly related to local radiation dose and may increase with chemotherapy. Most second malignancies that arise in bone are osteosarcomas, although fibrosarcomas, malignant fibrous histiocytomas, and sarcomas may occur. Bilateral or familial retinoblastoma are at high risk for the development of osteosarcoma as a second tumor; especially in the radiation site.
Best way to differentiate hyaline membrane disease (RDS) from meconium aspiration: a. Lung volumes b. Pleural effusion c. Interstitial pattern d. Heart size e. Pneumothorax/pneumomediastinum
Answer: Lung volumes Meconium aspiration is most common cause of respiratory distress in full term infants. It produces hyperinflation with areas of emphysema. Diffuse, bilateral patchy opacities are seen. Rapid clearing in 48 hours. Small pleural effusions are sometimes present (20%). Physical obstruction of small airways is associated with subsegmental collapse and compensatory hyperinflation. The coarse patchy infiltrates are due to atelectasis and inflammatory changes. Rupture of hyperinflated air spaces may lead to pneumothorax and pneumomediastinum in 25%. Hyaline membrane disease (RDS of the premature newborn) is an acute disease with hypoinflation (stiff lungs), immature surfactant production, atelectasis, reticulogranular pattern, and prominent air bronchograms. Low lung volumes are seen (if not on ventilator). In severe cases, diffuse consolidation may reflect edema and hemorrhage.
Large mass between bladder and rectum on neonatal ultrasound is most likely: A. Sacrococcygeal teratoma B. Rhabdomyosarcoma C. Neuroblastoma D. Hydrometrocolpos E. Duplicated rectum F. Anterior meningocele
Answer: Hydrometrocolopos Large tubular fluid filled midline mass between bladder and rectum is a dilated fluid filled vagina/uterus. Sacrococcygeal teratoma occurs in the presacral space and may extend into the pelvis or protruding from the sacral area. Present as palpable gluteal mass. Cystic indicates benignity and solid is more likely malignant. If diagnosed prenatally, sacrococcygeal teratoma may be associated with polyhydramnios and tumor hemorrhage, which may result in anemia and hydrops. Delivery is recommended as soon as lung maturity is documented. The coccyx should be included in surgical resection, as failure to resect the coccyx results in a 35-40% recurrence rate. Rhabdomyosarcomas (GU) - present in children between 2-6 years of age, typically as a painless mass or with bowel or bladder problems. Sarcoma botryoides = grapelike cluster of tumor masses that occur in the bladder or vagina. Hydrometrocolpos - imperforate hymen in neonates; obstruction of flow of mucoid secretions, which are under the influence of maternal estrogens. The retention of secretions (hydro) in the uterus (metro) and vagina (colpos) can cause mass effect, may be discovered as a bulging hymen or palpable abdominal mass. Usually adolescent female. Duplicated rectum (5% of GI duplications) - occurs in presacral space and symptoms include constipation, bleeding, abscess, and fistula formation. GI tract duplications are characterized by a coat of smooth muscle, an epithelial lining, and an attachment to the GI tract. The most common site for GI duplication is the small intestine.
1 day old girl with mass between bladder and rectum. Most likely cause? a) hydrometrocolpos b) saccrococcygeal teratoma c) neuroblastoma d) rhabdomyosarcoma e) duplicated rectum
Answer: Hydrometrocolpos
Which is TRUE of Meckel\'s diverticulum? A. urachal remnant B. omphalomesenteric remnant C. arises on the mesenteric side of the bowel D. cloacal remnant
Answer: Omphalomesenteric remnant The diverticulum is a blind pouch that is a remnant of the omphalomesenteric duct or yolk sac that nourished the early embryo. It contains all layers of the intestine and may have ectopic tissue present from the pancreas or stomach. 50% ectopic gastric mucosa (this increases to 95% in pts presenting w/ GI bleed); located within 2 feet of ileocecal valve/2 % of population/ symptomatic before age of 2/ 2 inches in length; usually located on ANTImesenteric border. REMEMBER: in nucs study: pentagastrin stimulates uptake of pertechnetate & cimetidine inhibits its secretion.
MOST specific fracture for child abuse? a. Skull b. Long bone c. Scapula d. Clavicle e. Vertebral body
Answer: Scapula High likelihood of nonaccidental trauma: metaphyseal lesion, posterior rib fracture, scapular fracture, spinous process fracture, and sternal fracture. Moderate likelihood: multiple fractures, epiphyseal separation, vertebral body fx, digital fracture, complex skull fx. Low likelihood: clavicular fracture, long bone shaft fracture, linear skull fracture.
All are associated with SCFE EXCEPT: a. Obesity b. Hypothyroidism c. Growth hormone d. Spondyloepiphysealis dysplasia e. Renal osteodystrophy
Answer: Spondyloepiphysealis dysplasia (NOT associated) SCFE is associated with hypothyroidism, panhypopituitaryism, gonadal conditions, renal osteodystrophy, and during growth hormone therapy.
Primary defect in osteogenesis imperfecta? A. Decreased mineralization B. Decreased conversion of woven to lamellated bone C. Decreased formation of matrix Increased resorption
Answer: Decreased formation of matrix Osteogenesis imperfecta is characterized by low production and abnormal production of type I collagen. The primary defect is in the extracellular bone matrix. The clinical deficits of osteogenesis imperfecta involve tissues with high type I collagen content including bones, ligaments, tendons, fascia, sclera, and teeth.
What is the most common cause for a limp in a child without history of trauma? A. Osteomyelitis B. AVN C. Toxic synovitis D. Hip dislocation E. Malignancy
Answer: Toxic synovitis Toxic synovitis (transient synovitis of hip) is a nonspecific inflammatory reaction and the most common nontraumatic cause of acute limp in a child. Etiology is unknown and diagnosis is by exclusion. Average age is 5-10 with a male predominance of 2:1. Patients develop a limp over 1-2 days with pain in the hip, thigh and knee. There is a history of recent viral illness in 65% and mild fever in 25%. Radiographs are usually normal. Joint effusion and regional osteoporosis may be present. Complete resolution within a few weeks is seen with non-weightbearing treatment.
Most common mediastinal mass in 6-12 year old child: A Neuroblastoma B Lymphoma C Thymoma D Germ cell neoplasm E Bronchogenic cyst
Answer: Lymphoma Neuroblastoma is most common in children two years of age or younger. Ganglioneuroblastoma is the second most common. Mediastinal masses in young infants are within the posterior mediastinum 50-60%, with neuroblastoma as the most common (
this age group is too old for neuroblastoma). In older children, mediastinal lymphadenopathy is most commonly due to lymphoma. Hodgkin\'s disease has been reported to cause 33-56% of pediatric mediastinal lymphomas. 80%-90% are nodular sclerosing. Neurogenic tumors are reported to be the second most common pediatric mediastinal malignancy seen in 21%-44%.
CXR of non-symptomatic child with HIV shows reticulonodular infiltrates. Most likely cause of these findings? a. PCP b. LIP (Lymphocytic interstitial pneumonia) c. Parainfluenza
Answer: Lymphocytic interstitial pneumonia (LIP) Lymphoid interstitial pneumonitis (LIP) is the second most common AIDS-defining illness in children. Typically occurs in children with relatively high CD4 counts. CXR demonstrates reticulonodular opacities +/- hilar lymphadenopathy that persists for two months despite adequate treatment. Patients are usually asymptomatic initially, but may develop cough and shortness of breath as the disease progresses. LIP increases susceptibility to bacterial pneumonia pathogens, especially Haemophilus influenzae and pneumococcus. PCP is most common opportunistic infection in children before universal prophylaxis. Pneumocystis carinii pneumonia typically presents with fever and tachypnea. CXR may show reticulonodular infiltrates or may be normal. Diagnosis is made by sputum or BAL antigen detection. Infants between 6 weeks and 1 year of age require prophylaxis regardless of CD4 count; otherwise, recommendations for prophylaxis are based on CD4 count and history of prior PCP infection.
Infant presents with peribronchial infiltrates, FTT, and may have all of following EXCEPT: a sterility b intussusceptions c pansinusitis d intestinal polyposis e meconium ileus equivalent
Answer: Intestinal polyposis (NOT associated) Cystic fibrosis is associated with pulmonary conditions such as recurrent pulmonary infections (staph/pseudomonas), progressive respiratory failure, finger clubbing (hypertrophic osteoarthropathy from hypoxemia); GI tract conditions such as pancreatic insufficiency, steatorrhea, malabsorption, liver cirrhosis, rectal prolapse, meconium ileus [meconium ileus equivalent in older children], meconium peritonitis, intussusception, and other conditions such as hypoplastic frontal sinus, opacification of other sinuses, infertility in males. Radiographic features include bronchiectasis, mucus plugging reticular, cystic pattern of lung fibrosis, prominent hila (pulmonary hypertension, adenopathy), recurrent pneumonias. Early complications include lobar atelectasis (especially RUL), pneumonia. Late complications include respiratory insufficiency, hypertrophic osteoarthropathy, recurrent pneumothorax (rupture of bullae and blebs), cor pulmonale and PAH, hemoptysis, aspergillus superinfection. Cystic fibrosis correct answer on 2002 exam (nonvisualization of gallbladder on HIDA scan).
Afebrile 2 month old child presents with stridor. AP and lateral XRs demonstrate eccentric narrowing of the trachea. Which of the following is most likely? a. Thyroglossal duct cyst b. Papilloma c. Subglottic hemangioma d. Rhabdomyosarcoma
Answer: Subglottic hemangioma Subglottic hemangiomas (= infantile laryngeal hemangiomas) are most common subglottic soft-tissue mass causing upper respiratory tract obstruction and croup-like symptoms in neonates (age < 6 months). Radiographic finding: eccentric thickening of subglottic portion of trachea (AP view), these arise from the posterior wall below true cords (on lateral). Epiglottis is a supraglottic mass. Laryngeal papillomatosis is the most common benign tumor of the larynx, and might present with similar symptoms (inspiratory stridor, cough, respiratory distress). But the age of onset is older (1-54 years). Laryngomalacia (immaturity of cartilage) is most common cause of stridor in neonate + young infant, and is only cause of stridor to get worse at rest. This involves the supraglottic portion of the larynx.
Most common cause of round pneumonia in children is: a. Staphylococcus aureus b. Streptococcus c. Psudomonas d. Klebsiella
Answer: Streptococcus Streptococcus and Staphlococcus both cause round pneumonia. Streptococcus is more common from age 1-3. S. aureus is more common in infancy. Round pneumonia appears round because of poorly developed collateral pathways (pores of Kohn and channels of Lambert). With time the initially round pneumonia develops into a more typical consolidation.
Two brothers with pneumonia, liver abscesses, and other infections. Which of the following do they have? a. DiGeorge syndrome b. Chronic granulomatous disease c. Agammaglobulinemia d. Cystic fibrosis
Answer: Chronic granulomatous disease Chronic granulomatous disease of childhood is a recessive X-linked (60%) / autosomal (40%) immunodeficiency disorder resulting in purulent infections and granuloma formation primarily involving lymph nodes, skin and lungs. Onset of symptoms is at childhood with recurrent chronic infections. Hepatic abscess is the most common abdominal process associated with this disease. Caused by abnormal leukocyte function.
6 year old with a pustule on the hand, then develops swollen, painful epitrochlear and axillary nodes as well as forearm swelling. What is the most likely diagnosis? a. Lyme disease b. Cat-scratch disease c. Mycosis fungoides d. Lymphoma e. RMSF f. Kawasaki dz. g. Eosinophilic fascitis
Answer: Cat-scratch disease 60% of cases of cat scratch disease occurs in kids. 3-5 days after a cat scratch, clinical symptoms include a localized papule progressing to a pustule that crusts over. Tender regional adenopathy develops within 1-2 weeks. Scratches are most often sustained over the hands or face producing epitrochlear, axillary, pectoral and cervical adenopathy. Rocky Mountain Spotted Fever is caused by Rickettsia ricketsii. The classic clinical triad includes fever, rash and history of tick exposure. Macules first appear on the wrist and ankles and progress to involve the trunk. More severe sequelae include CNS involvement, renal failure, hepatic injury and bleeding. I found no mention of adenopathy. Kawasaki’s disease is an acute febrile multisystem disease of children. It is characterized by nonsuppurative cervical adenitis and changes in the skin and mucous membrane (congested conjunctivae, erythema of the oral cavity, lips and palms), and desquamation of the palms and soles.
Which places a pediatric patient at high risk for latex hypersensitivity? a. Tetrology of Fallot b. Bladder exstrophy c. Unilateral renal agensis d. Allergy to PCN
Answer: Bladder exstrophy Patients with spina bifida have a high risk of clinical latex hypersensitivity. Since exposure appears to increase the probability of latex hypersensitivity, children with other conditions requiring frequent surgery may also be at risk. These conditions include bladder exstrophy, cerebral palsy, myelomeningocele, and spinal cord injury.
Contraindication to intussusception reduction in pediatric patient: a. symptoms for 48 hrs b. peritonitis c. heme positive stool d. age < 2 or 3mo or age > 3 yr e. symptoms >12hr or > 24 hr f. intestinal obstruction
Answer: Peritonitis Absolute contraindications to BE for intussusception include perforation or peritonitis (Peds Requisites 69). Contraindications for attempting pressure reduction of an intussuseption include peritonitis on physical exam or pneumoperitoneum on radiography. Ref: fundamental of pediatric radiology pg 116
Most common type of esophageal atresia: a. EA with proximal TEF b. EA without TEF c. EA with proximal and distal TEF d. EA with distal TEF
Answer: EA with distal TEF The most common type is esophageal atresia, with a fistula between the distal esophageal segment and the trachea (85%); the next common is esophageal atresia with no fistula (10%). The other types are an “H” fistula (1%), EA with proximal and distal TEF (1%) and EA with proximal TEF (1%). Dähnert p. 807
6-week-old afebrile infant with hyperinflated lung and peribronchial cuffing and peri-hillar infiltrates, what is the most likely cause? a. Chlamydia b. Parainfluenza c. RSV d. E. coli e. Kleisbella f. Streptococcus g. Staphylococcus h. Mycoplasma
Answer: Parainfluenza Viral pneumonia (parainfluenza) tends to present with hyperinflation, atelectasis and perihilar peribronchial cuffing. Chlamydia pneumonia - average age of onset is 6 weeks. Presents with cough, rhinitis, and conjunctivitis (30%). The findings on chest radiographs are far worse than would be predicted on physical exam. Radiographic findings can vary from perihilar/interstitial process to a focal alveolar infiltrate with generalized hyperinflation. Effusions may occur; consolidation is rare. Mycoplasma causes bronchopneumonia.
Membranous croup is caused by: a. Staphyloccocus aureus b. Haemophilus flu c. Parainfluenza d. Streptococcus e. Ecoli
Answer: Staphyloccocus aureus Membranous croup (exudative tracheitis) is caused by a bacterial infection, most commonly Staphylococcus. Donnelly CXR shows irregularity fo the tracheal walls due to membranes in the subglottic airway. (Kirks 3e p.654) Noncontagious croup is caused by diphtheria. Viral croup, AKA croup or laryngeotracheobronchitis, is caused by a virus, commonly parainfluenza. Donnelly p. 5
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