rheum

Question 1

You see a child with fever, arthralgias, and a rash on his lower limbs (see picture below). What test needs to be done now?

a) Abdominal ultrasound
b) Urinalysis
c) IgA

Answer 1

urinalysis
HSP diagnosis
Palpable purpura
\+ one of the following:
1) abdo pain 2) arthritis/arthralgia
3) bx of tissue showing IgA deposition

• recommends no lab work as its clinical diagnosis but RECCOMEND BP and urinalysis for 6 months after diagnosis, especially those who had HTN/urine abn at presentation as 1-2% can have renal disease and 8% that have HSP nephritis get ESRD

Question 2

A 3 year old has a history of recurrent fevers for the past year. They occur every 4-12 weeks for 1-4 days each. He has been treated for numerous otitis media and pharyngitis. She is growing well. The likely underlying cause is:

a. multiple viral infections
b. familial med fever
c. CVID
d. Ig deficiency (

Answer 2

viral infxn
The onset of fever and pain (due to serositis at one or more sites) is usually abrupt, peaking soon after onset. Some patients have a stereotypic prodrome before their attacks [2]. Episodes last for one to three days and then resolve spontaneously. Patients are asymptomatic between attacks. The frequency of attacks is highly variable, even in a given patient. The intervals between episodes are irregular, ranging from one week to several months or years.

Question 3

2 year old child with fever for the past 2-3 weeks (up to 39 C), lymphadenopathy and mild hepatosplenomegaly presents complaining of joint pain. There is no true arthritis, but complains of pain with movement of joints. Hgb 91, WBC 9 (45% lymp, 55% PMN), platelets of 110. What is your next step in establishing diagnosis?

a. BMA
b. Blood culture
c. ANCA, ESR and RF
d. EBV serologies

Answer 3

BMA
the combination of two abnormal parameters on complete blood count (WBC count <4000/microL; platelet count 150,000 to 250,000/microL; hemoglobin <11 g/dL) was 96 percent sensitive and 88 percent specific for ALL.

Question 4

Criteria for JIA

Answer 4

age onset <16yo
arhtirits
duration for more then 6w
onset type (poly more then 5, oligo 4 or less, systemic if rash and fever)

Question 5

10 year old girl with migratory arthritis for last 10 days, now affecting left wrist. She is febrile, and has an ESR of 40. Most LIKELY diagnosis is

a. SLE
b. Rheumatic fever
c. JIA
d. Septic arthritis

Answer 5

RF (need GAS)
Jones criteria for RF

JONES CAFE PAL
major
Joint, O =mycarditis, N nodule, E erythema marginatum, Sydenham chorea
MINOR : CRP inc, Arthalria, Fever, elevated ESR, prolonged PR, anamess of rheumatism, leulocutosis
NEED
GAS/ASOT+ 2 major, OR 1 major 2 minor

Question 6

Rhuematic fever diagnosis

Answer 6

JONES CAFE PAL
major
Joint, O =mycarditis, N nodule, E erythema marginatum, Sydenham chorea
MINOR : CRP inc, Arthalria, Fever, elevated ESR, prolonged PR, anamess of rheumatism, leulocutosis
NEED
GAS/ASOT+ 2 major, OR 1 major 2 minor

Question 7

2 year old with mild metatarsus adductus and tibial torsion who has had intoeing since birth. There has been no improvement. They are presenting to your office today. The best advice is:

1. Reassurance
2. Hip, knee, tibia, foot x-rays
3. Referral to orthopedics
4. Advise them not sit in W position (common in femoral anteversion)

Answer 7

reassurance
INTOEING caused by the following (all, or seperate) 1) metatarsus adductus, tibial torsion and femoral anteversion
Increased femoral anteversion — The natural history of in-toeing secondary to increased femoral anteversion is that of spontaneous resolution, usually by 11 years of age.
TIbial torsion should go by 5yo
-metatarsus adductus - goes away by itself

Question 8

You are treating a teenage boy with pericarditis. You suspect that his pericarditis might be secondary to SLE. Which of the following is most supportive of this diagnosis?

a. Positive RPR
b. Positive ANCA (
c. Positive HLAB27
d. Thrombocytosis

Answer 8

RPR - (test for syphillis, falsely elevated/positive in pt who have lupus due to elevated antintiphospholipid antibodies (lupus anticoagulant [LA], IgG and IgM anticardiolipin [aCL] antibodies; and IgG and IgM anti-beta2-glycoprotein [GP] I)

ANCA=usually GPA - granulomatosis polyangitis, can also be positive with lupus)

Question 9

SLE diagnosis

Answer 9

SLE “SOAP BRAIN MD” need 4/11
Serositis – Pleurisy, pericarditis
Oral ulcers
Arthritis
Photosensitivity
Blood disorders
Renal involvement
Antinuclear antibodies (positive in <95%)
Immunologic phenomena
Neurologic disorder
Malar rash
Discoid rash

Question 10

17 year old male with history of enthesis related JIA comes to your office. Just had a new baby girl with his girlfriend and would like to quit smoking for her sake. What puts him MOST at risk of not being able to quit

1) Chronic illness
2) Male gender
3) Older adolescent
4) Parenthood

Answer 10

chronic illness

Question 11

5yo M with intermittent abdominal pain and purpuric rash on thighs. He has joint pains and hematuria. Which of the following lab abnormalities would likely be present?

a. Thrombocytopenia
b. Schistocytes
c. Elevated IgA

Answer 11

elevated IgA

Question 12

4yo F with one very inflamed joint for over 1 month, ANA negative, no uveitis. What is the first line treatment for her condition?

a. Methotrexate
b. Systemic steroids
c. NSAIDs
d. IVIg

Answer 12

NSAID
Oligoarthritis defined as involving ≤4 joints within first 6 months of disease onset, often only single joint involved. Predominantly large joints of lower extremities such as knees and ankles.
Positive ANA = increased risk for asymptomatic anterior uveitis, requires periodic slit-lamp exam.
Positive ANA correlated with younger age at onset, female, asymmetric arthritis, and lower number of joints over time.
try injection of intraarticular steroids. Next line would be DMARDs, MTX, and last resort is TNF inhibitors.
NSAIDs rarely induce remission in polyarthritis or systemic JIA.

Question 13

A 7 year old girl has oligoarticular JIA and has been on methotrexate as maintenance therapy for her disease. She has sudden onset high fever, anemia, thrombocytopenia, and hepatomegaly with elevated liver enzymes. Which of the following is the cause of her current condition?

a. Methotrexate toxicity
b. Macrophage activation syndrome

Answer 13

MAS

dec fibrinogen
dec counts plt/WBC
inc lfts

Question 14

6-year-old with clinical and laboratory evidence consistent with systemic JIA develops persistent fever, extensive and fixed rash, thrombocytopenia and hyponatremia. What is most likely to decrease:

a) Triglyceride
b) Fibrinogen
c) LDH
d) Ferritin

Answer 14

fibrinogen

Question 15

You want to start an 11 year old boy with JIA on Infliximab. Which is most important prior to starting this medication?

a) VZV vaccine
b) MMR vaccine
c) Checking for Mycobacterium Tuberculosis

Answer 15

check for mycobacterium
Do not initiate TNF blockade in subjects with history of chronic or frequent recurrent infections. TB should be tested for prior to initiation of therapy with TNF antagonists. If test results are positive, anti-TB treatment must be administered before starting anti-TNF therapy.

Question 16

Child with recurrent fever, cervical adenitis, aphthous ulcers, pharyngitis. Normal immune work-up. Best treatment

a) oral colchicine x 5 days (FMF treatment)
b) oral prednisone x 1 day

Answer 16

oral predx1 day
PFAPA = periodic fever, aphthous stomatitis, pharyngitis, adenitis
Most common recurrent fever syndrome in children. Recurring episodes of fever, malaise, exudative tonsillitis with negative throat cultures, cervical lymphadenopathy, oral aphthae, and less commonly headache, abdo pain, and arthralgia. Episodes last 4-6 days regardless of treatment (antipyretic/antibiotic), occur regularly on 3-6 week cycles. During episode - mild HSM, mild leukocytosis, elevated acute-phase reactants.

Majority of patients show dramatic response to single oral dose of prednisone (0.6-2.0 mg/kg) although does not prevent recurrent and may shorten interval between flares.. Cimetidine (20-40 mg/kg/day) prevents recurrence in ⅓ of cases. Resolution possible after tonsillectomy.

Question 17

Girl had fever then swollen extremities, cracked lips. Treated with IVig and ASA then developed anemia and hematuria.
a) Kawasaki IVIG hemolytic reaction

Answer 17

kawasaki IVIG hemolytic

Question 18

Kid with fevers, salmon rash, HSM (no joint pain).

a) Systemic JIA
b) ALL

Answer 18

systemic JIA
Systemic JIA characterized by:
arthritis - classically polyarticular and destructive
fever - spiking to >39 1-2X/day and returning to normal quickly, often in evenings
rash - classic evanescent salmon-colored lesions which are linear/circular and on trunk and proximal extremities
visceral involvement - HSM, lymphadenopathy, and serositis (pericarditis)

Question 19

Girl walked and tripped on a curb now has cold, extremity painful to touch

a) CRPS
b) osteomyelitis

Answer 19

CRPS complex regional painn syndrome
noxious event/immbilization with continued pain,allodynia, hyperalgesia, out of proprtion to event

evidence of edema, skin blood flow abnormality, atrophy of hair and weakness

treat with OT/PT

Question 20

Ankle injury-when to XR

a) Posterior tip of medial malleolus tenderness for XR
b) Anterior tip of lateral malleolus
c) Cant weight bare right after injury

Answer 20

ankle x-ray - if there is pain in the malleolar zone and any of the following:
1 Bone tenderness at the posterior edge or tip of the lateral malleolus, or
2 Bone tenderness at the posterior edge or tip of the medical malleolus, or
3 Inability to weight bear both immediately and in the emergency department

A foot x-ray series is only necessary if there is pain in the midfoot zone and any of the following:
1 Bone tenderness at base of fifth metatarsal, or
2 Bone tenderness at the navicular bone, or
3 Inability to bear weight both immediately and in the emergency department

Question 21

Girl with JDM, what is the best diagnostic test

a) EMG
b) CK

Answer 21

EMG
Diagnostic criteria:
classic rash (heliotrope rash of eyelids or gottron papules)
plus 3 of the following:
weakness: symmetric, proximal
muscle enzyme elevation (≥1): CK, AST, LDH, aldolase
EMG changes: short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre high frequency repetitive discharges
muscle biopsy: necrosis, inflammation

Question 22

JDM criteria

Answer 22

Diagnostic criteria:
classic rash (heliotrope rash of eyelids or gottron papules)
plus 3 of the following:

weakness: symmetric, proximal
muscle enzyme elevation (≥1): CK, AST, LDH, aldolase
EMG changes: short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre high frequency repetitive discharges
muscle biopsy: necrosis, inflammation

Question 23

1.     Boy with lupus. Most likely test consistent with this Dx
A.     ANCA+ 
B.     Thrombocytosis 
C.     HLAB27+ 
D.     positive RPR

Answer 23

D. positive RPR

Question 24

Child in rhythmic gymnastics. Has back pain that is worse on extension. On exam has exaggerated lumbar lordosis, hamstring tightness. Bone scan is positive. What does she have?
Spondylolysis
Posterior overuse sydnrome
Herniated disc
ring apophositis

Answer 24

Spondylolysis

Question 25

``` 14 year old female gymnasts presents with a 2months history of lower back pain on extension. She has tight hamstrings, spasm of her paraspinal muscles, normal sensations and motor function. A bone scan lights up her lumber vertebrae. What is the diagnosis? Spondylosis Posterior Element Overuse syndrome Disk herniation Vertebral body avulsion fracture ```

Answer 25

spondyloysis

Question 26

treamtnet with JDM

Answer 26

MUSCLE ENZYMES -elevated alanine aminotransferase most commonly elevated on initial presentation and CK may be normal. Usually ANA positive in 80% of patients MRI T2 = can be used to help with EMG and muscle biopsy location determination Treatmentet- steroids and MTX +/- IVIG

Question 27

. A term baby is born to a mother with maternal lupus. He is noted to have congenital heart block. a) Name the 2 most common antibodies in congenital heart block.

Answer 27

Anti-Ro (SSA) | Anti-La (SSB)

Question 28

Name 3 other manifestations of neonatal lupus.

Answer 28

characteristic annular/macular rash affecting face (especially periorbital area), trunk, scalp hematologic manifestations: anemia, neutropenia, thrombocytopenia hepatic manifestations: asymptomatic elevated LFTs, mild HSM, cholestasis, hepatitis neurologic manifestations: hydrocephalus, macrocephaly, neuropsychiatric dysfunction stippling of epiphyses (chondrodysplasia punctata) on radiographs

Question 29

18 month old with missed developmental dysplasia of the hip: a) Name two clinical features of this diagnosis (not sure exact wording) b) Name one physical exam finding.

Answer 29

``` Breech presentation Female First born Family history of DDH Any condition that leads to tighter intrauterine space and consequently less room for normal fetal motion: oligohydramnios large birth weight multiples (twins/triplets/etc) Tight swaddling ```

Question 30

which ECG change is characteristic of acute rheumatic fever? A. Peaked T waves B. Prolonged PR interval C. Sinus tachycardia

Answer 30

Prolonged PR interval

Question 31

A 3 year old girl presents with 7 day history of fever. She has bony pain but no arthritis on exam, but she has HSM and diffuse generalized lymphadenopathy. Her blood work shows WBC 18, Plt 110 and anemia. What is the next best step? A. Bone Marrow Aspirate B. EBV Serology C. Work up for systemic JIA

Answer 31

bma

Question 32

A kid has had 6 days of fever despite treatment with amoxicillin, with no response. He also has cracked lips, nonpurulent bilateral conjunctivitis, and a polymorphous rash. What would you expect to see on his labs? a. Neutropenia b. Hypoalbuminemia c. Elevated ASOT d. Elevated EBV titres

Answer 32

Hypoalbuminemia KD- Fever persisting at least 5 days † Presence of at least 4 principal features: Changes in extremities: Acute: Erythema of palms, soles; edema of hands, feet Subacute: Periungual peeling of fingers, toes in weeks 2 and 3 Polymorphous exanthem Bilateral bulbar conjunctival injection without exudate Changes in lips and oral cavity: erythema, lip cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosa Cervical lymphadenopathy (>1.5 cm diameter), usually unilateral

Question 33

``` Toddler comes to the ED refusing to weight bear. Xray of leg shows non-displaced spiral fracture of left tibia. Which is most likely? NAI Ricketts Toddler’s fracture Osteogenesis Imperfecta ```

Answer 33

Toddler’s fracture

Question 34

8y boy had URTI two weeks ago; now presents with fever >40, unable to weight bear on right leg. WBC is 18, ESR 40 (? I think) and CRP 80. What is next step in management? Admit and start IV abx Nsaids Urgent orthopedic consultation

Answer 34

Urgent orthopedic consultation

Question 35

13 y.o. Girl presents with antalgic gait and pain for 2 weeks. She has difficulty with rotation and adduction of her leg. X-ray was similar to the one below. What is the diagnosis? a) Septic joint b) Calve-Perthes c) SCFE d) Fracture e) Post-infectious

Answer 35

SCFE

Question 36

``` 14 year old adolescent girl who you haven’t seen in the last 2 years comes in for routine check-up. When she bends forward, you note a large thoracic asymmetry. Spine X-ray shows a Cobb angle of 50 degrees. What do you do next? Repeat X-ray in 3 months Custom thoracolumbar spine brace Spinal fusion Electro-something stimulation ```

Answer 36

spinal fusion 40 – 50 degrees or more: Surgery may be required to correct the curve. There are several surgical procedures. A frequent recurring procedure is the “spinal fusion”, to link the vertebrae together so that the spine cannot longer continue to curve Those with Cobb angle of more than 60° usually have respiratory complications

Question 37

6 yo girl with diagnosis of JIA and pain in one knee. CRP 58. Sedimentation 25. ANA negative. No uveitis. What is the next step in management a. NSAIDS b. Methotrexate c. Intra-articular corticosteroids d. Oral steroids

Answer 37

nsaids

Question 38

``` Girl with systemic JIA well-controlled on methotrexate then re-presents with fever, unwell, rash, liver 3 cm below costal margin. What is the most likely diagnosis MAS Sepsis Methotrexate toxicity Autoimmune hepatitis ```

Answer 38

MAS

Question 39

17. Kid with JIA and MAS features, what is it? a. MAS b. Sepsis

Answer 39

mas

Question 40

Picture of a 7y boy with completely erythematous face. He’s on fluticasone and phenytoin. What is the most likely diagnosis? a. Drug hypersensitivity b. SLE c. JDM d. JIA

Answer 40

a. Drug hypersensitivity

Question 41

. Ankle injury. Indication for xray: [CPS] a. posterior malleolus tenderness b. can’t wt bear immediately c. anterior medial malleolus

Answer 41

posterior mallelos

Question 42

Kid with FMF, what to give? | a. Colchicine

Answer 42

colc FMF attacks can last between 12 and 72 hours and consist of inflammation involving the peritoneum, pleura, joints, or skin; sometimes in combination. Between episodes, patients usually feel completely well and remain so for a few days to a few months. In children, fever may be the only sign of FMF, although other symptoms typically develop progressively with time Colchicine therapy is highly effective for most patients in preventing febrile episodes and systemic amyloidosis.

Question 43

A 6y girl presents with arthritis of 3-4 joints at a time. Her ANA is positive. Which is the most likely associated finding? a. Eye pain b. Photophobia c. Unequal pupil

Answer 43

unequal pupil Synechiae - iris adheres to the cornea. Patients presenting with synechiae typically have an underlying inflammatory disease process such as uveitis

Question 44

12y gymnast presents with 2mo of lower back pain. The pain is worse for 2-3 days after practice. Her sleep is ok. She gets spasms in her paraspinal muscles. On exam, she has tight hamstrings, normal sensation and motor function in her legs with normal anal tone and sensation. A bone scan lights up in her lumbar vertebra over the location of her pain. What is the diagnosis? a. Spondylolysis b. Posterior element overuse c. Disk herniation d. Vertebral body avulsion fracture

Answer 44

a. Spondylolysis

Question 45

1. Kid w knee pain | a. Patellofemoral syndrome

Answer 45

Most common symptom - pain beneath or near patella Classically walking up/down stairs aggravates it Pain after prolonged sitting with the knee in flexion (“theatre sign”)

Question 46

(repeat) 148. 5 year old child with Kawasaki disease. What lab finding would you expect a. Hypoalbuminemia b. Thrombocyotpenia c. Low liver enzymes d. Leukopenia

Answer 46

hypoalbunimiea

Question 47

A 10 yr old girl presents with 10 days of fever and a migratory arthritis. On exam, she has a swollen left wrist. Her WBC is 18 and her ESR is 75. Diagnosis: a. SLE b. JRA c. Rheumatic fever d. Septic arthritis

Answer 47

RF

Question 48

14 year old boy with Duchenne’s, who is in a wheelchair, has recently seen his FVC fall from 30% to 21% predicted. What symptom will he MOST likely complain of? a. Headache early in morning b. Headaches in the afternoon c. Tingling of his fingers d. Dyspnea with exertion

Answer 48

h/a Headache early in morning (due to carbon dioxide retention with ineffective ventilation while sleeping) DMD - progressive weakness, intellectual impairment, hypertrophy of calves, proliferation of connective tissues in muscles. X-linked recessive. Abnormal gene at Xp21 locus. Most patients walk with increasing difficulty until age 10 Respiratory involvement weak ineffective cough, frequent pulmonary infections, decreasing respiratory reserve. Progression to severe hypotonia, chest wall muscles shorten and lose elasticity. Lung volumes decrease = becomes restrictive. Chronic hypercapnea

Question 49

Boy with recurrent pharyngitis. Episodic jerking of shoulders and head over past 6 weeks. Most likely diagnosis? a. Rheumatic fever b. Transient tic disorder c. Tourettes d. Some sort of seizure disorder

Answer 49

RF PANDAS: pediatric autoimmune neuropsychiatric disorders associated with strep pyogenes neuropsychiatric disorders: OCD, tic disorder, Tourette syndrome hypothesized relationship with GAS infections but not proven autoimmune antibodies in response to GAS infection cross-react with brain tissue similar to autoimmune response responsible for sydenham chorea

Question 50

JDM question, what most likely to make dx. a. CK b. EMG

Answer 50

emg Diagnostic criteria: Rash: heliotrope rash of eyelids (blue-violet discoloration of eyelids), Gottron papules (bright pink or pale, shiny thickened atrophic plaques for PIPs, DIPs, and sometimes knees, elbows and small joints) PLUS 3 of Weakness: symmetric, proximal Muscle enzyme elevation (>1): CK, AST, LD, aldolase EMG changes: short, small, polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre, high-frequency, repetitive discharges Muscle biopsy: necrosis, inflammation *nerve conduction studies typically normal unless severe necrosis ESR typically normal, ANA positive in >80%, RF negative

Question 51

. What is the most common childhood wrist fracture? a. Colles fracture b. Greenstick c. Buckle fracture d. Salter Harris

Answer 51

buckle #

Question 52

A 7 year old boy has a history of recurrent fevers, evanescent pink rash, lymphadenopathy, and hepatomegaly. His MSK exam is normal. What’s the diagnosis? a. Leukemia b. Scarlet fever c. Lyme disease d. Systemic JIA

Answer 52

systemic jia

Question 53

Evanescent rash, lymphadenopathy, hepatomegaly without joint pain in 6 yo boy. What is your diagnosis? a. systemic JIA b. ALL

Answer 53

Definition of systemic JIA (Table 155-2): Arthritis in 1+ joint, with or preceded by, fever of at least 2 weeks in duration that is documented to be daily (“quotidien”) for at least 3 days, accompanied by 1+ of: Evanescent (nonfixed) erythamtous rash Generalized lymph node enlargement Hepatomegaly, or splenomegaly, or both Serositis (pericarditis, pleuritis, or peritonitis)

Question 54

14 yo girl with scoliosis. Measurements of Cobb angle = 50 degrees. What is management of choice? a. spinal fusion b. electrical muscular stimulation c. molded brace

Answer 54

spinal fusion

Question 55

14 yr old who hasn’t been to see you in 2 yrs. She has scoliosis with Cobb angle of 50 degrees. What is the most appropriate management? a. observe b. refer for brace/ orthosis c. refer for posterior spinal fusion d. electrical muscle stimulation

Answer 55

refer for post spine fusion

Question 56

. 4 yr old boy with fever of 40 degrees despite amoxcil. Maculopapular rash, bilateral conjunctivitis,dry cracked lips. What is the most likely lab finding? a. hypoalbuminemia b. neutropenia c. EBV monospot + d. + ASOT

Answer 56

hypoalbuminia

Question 57

5 yo with fever 40 degress x 6days, bilateral conjunctivitis, cervical lymphadenopathy, cracked lips. Has not responded to 3 days of amoxicillin. What finding is most consistent with this diagnosis? a. Hypoalbuminemia b. neutropenia c. positive ASOT d. positive monospot

Answer 57

hypoalbuminmia

Question 58

Kid with >=6 day of fever, non purulent conjuctiviits, MP rash. Clinical picture c/w Kawaski’s dx. Most likely lab abnormality? a. Low albumin b. Neutropenia c. Monospot + d. Positive ASOT

Answer 58

low albuminia

Question 59

14 yr old with fevers, polyarthralgia, wt loss. Appears pale. No arthritis on exam. Urine + for protein and blood. Decreased WBC and lymphs. Normal platelets. What is the most likely diagnosis. a. SLE b. Systemic JIA

Answer 59

sle

Question 60

Child with wt loss anemia, normal plts, low WBC, protein/blood in urine. Dx? a. SLE b. RF c. PSGN

Answer 60

SLE

Question 61

6 days post scoliosis surgery. Presents with bilious vx. Etiology? a. SMA b. Small bowel adhesions c. Pancreatitis

Answer 61

SMA

Question 62

Boy with proximal muscle weakness, difficulty climbing stairs, easily fatiguable and scaly rash on dorsum of hands. What is the diagnosis: a. JIA b. SLE c. JDM d. Myesthenia gravis

Answer 62

``` JDM Classic rash Heliotrope rash of eyelids Gottron papules Plus 3 of the following: Weakness (symmetric, proximal) Muscle enzyme elevation (1+ of CPK, AST, LDH, aldolase) EMG changes (short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability) Muscle biopsy (necrosis, inflammation) ``` *Fever, dysphagia or dysphonia, arthritis, muscle tenderness and fatigue are also commonly reported at diagnosis

Question 63

3 year old with refusal to walk for 3 days. Temp 38.1C, mildly tachycardic, very irritable when you examine right leg which is held in slight abduction and external rotation. Right hip has decreased ROM and he is in pain when you move his hip. He refuses to walk. Bloodwork shows ESR 48, CRP 20, WBC 14, normal Hgb and platelets. Most likely diagnosis: a. transient synovitis b. osteomyelitis c. septic arthritis d. Legg-Calve-Perthes disease

Answer 63

septic arhtritis

Question 64

5 year old fever 38.5 degrees, had a recent URTI. Hip was externally rotated and child not weight-bearing. ESR was 40. Diagnosis? a. transient synovitis b. JIA c. septic arthritis

Answer 64

septic arthritis

Question 65

marked facial erythema pic ? dx a. Drug hypersensitivity b. Dermatomyositis c. SLE

Answer 65

drug hypersensitivty

Question 66

(Picture of a kid with a malar rash). Has fever, joint pain, diffuse rash. Only meds are fluticasone and phenytoin for a seizure disorder. What is the most likely? a. drug hypersensitivity reaction b. Juvenile dermatomyositis c. Systemic lupus erythematosus d. Juvenile idiopathic arthritis

Answer 66

drug hypersentivity drug-induced lupus Classically triggered by anticonvulsants, minocycline, hydralazine, anti-TNF Tx is to stop drug and symptoms go away

Question 67

23. Patient with ankle injury. Can wt bear in er. Reason to x-ray? a. swollen ankle b. tenderness anterior to medial malleolus c. tenderness posterior to lateral malleolus d. inability to wt bear immediately after injury

Answer 67

c. tenderness posterior to lateral malleolus

Question 68

A 10 year boy hurts his ankle while playing soccer. He is able to weight bear in the emergency with significant pain. Which of the following would make you more inclined to do an ankle x-ray? a. Inability to weight bear immediately after the injury b. Pain at the anterior edge of the lateral malleolus c. Pain at the posterior edge of the medial malleolus d. Swelling

Answer 68

pain at posteror edge of medial malleolos

Question 69

8 year old girl tripped over a curb two weeks ago. She now complains of left leg pain. On exam the leg is cool and pale and she complains of pain even with light touch. Her X-ray is normal. What is the likely diagnosis? a. Fracture b. Conversion disorder c. Reflex sympathetic dystrophy (now called complex regional pain syndrome)

Answer 69

reflex sympathetic dystrophy AKA CPRS Diagnosis requires the following: An initiating noxious event or immobilization Continued pain, allodynia and hyperalgesia out of proportion to the inciting event Evidence of edema, skin blood flow abnormalities or sudomotor activity Exclusion of other disorders

Question 70

13 yo boy presents with intermittent and recurrent hip and heel pain. What is likely to be found on review of family history? a. psoriasis b. ankylosing spondylitis c. SCFE

Answer 70

ankylosis spondylitis ILAR Criteria for Enthesitis Related Arthritis Arthritis and enthesitis OR Arthritis, or enthesitis and at least 2 of: Presence or history of SI joint tenderness and/or inflammatory back pain HLA B27 positive Onset arthritis in male >6 years old Acute (symptomatic) anterior uveitis Hx ankylosing spondylitis, enthesitis-related arthritis, sacroiliitis with IBD or acute anterior uveitis in first degree family member Exclusions: Presence of systemic JIA, psoriasis or hx of psoriasis in the patient or 1st degree relative, presence of IgM rheumatoid factor on at least 2 occasions

Question 71

12 year old athletic girl complains of knee pain that she notices when walking down the stairs. On exam you note pain on palpation behind her patella. What is her most likely diagnosis a. Osgoode Schlatter b. Patella fracture c. Patellofemoral syndrome

Answer 71

patellorfemoral syndrome

Question 72

6. Child with spiking fevers and evanescent pink rash, lymphadenopathy, hepatomegaly, splenomegaly, and MSK exam normal, for about 3 weeks Diagnosis. a. Scarlet fever b. Lyme disease c. Systemic onset JIA d. Leukemia

Answer 72

systemic onset JIA

Question 73

A 2 year old boy with 2 days fever, now irritable, elevated inflammatory markers, and refusing to move right leg. Tender area over right tibia. Which of the following investigations will most likely make the diagnosis? a. x ray tibia b. x ray hip c. bone scan d. blood culture

Answer 73

bone scan MRI is the imaging modality of choice when imaging other than plain radiography is needed to establish the diagnosis of osteomyelitis. We suggest scintigraphy (also known as radionuclide scanning or bone scan) when MRI is not available a

Question 74

Teenager presents with left sided hip pain and decreased range of motion, and right sided heel pain; what question on family hx would most likely be positive? a. Rheumatoid arthritis b. Ankylosing spondylitis c. Psoriasis d. LCP disease

Answer 74

ankylosing spondylitis

Question 75

Boy comes in to your office with left hip pain for 8 months, decreased and painful range of motion, with pain in the left heel. What disease is most likely in his family medical history: a. rheumatoid arthritis b. ankylosing spondylitis c. psoriasis d. inflammatory bowel disease

Answer 75

ankylosing spondylitis

Question 76

Teen boy with pain to the right knee, above the joint. No effusion. No trauma. X-ray shows mottling in bone, and periosteal reaction. The likely diagnosis: a. osteosarcoma b. osteoid osteoma c. osteochondroma d. Ewings sarcoma

Answer 76

osteosarcoma The classic radiographic appearance of osteosarcoma is the sunburst pattern, night awakening ewing - primarily lytic bone lesion with periosteal reaction, the characteristic onion-skinnin osteochondroma- stalks or broad-based projections from the surface of the bone, osteoid osteoma oval metaphyseal or diaphyseal lucency (0.5-1.0 cm diameter) surrounded by sclerotic bone.

Question 77

Child with 6 wk history of severe ankle pain. Unable to weight bear. Unable to do physiotherapy. The foot is swollen, red, and warm. What is the most likely cause? (1 or 2 depending on stem) a. Reflex sympathetic dystrophy b. Osteomyelitis c. Manchaussen

Answer 77

reflex sympathetic dystrophy

Question 78

A 3 yo child develops left hip pain following URTI. What is the best way to rule out osteomyelitis? a. Lack of fever b. Normal WBC c. Negative blood culture d. Bone scan

Answer 78

bone scan

Question 79

12 yo girl with arthritis, some blood in the urine | diagnostic criteria

Answer 79

``` S - serositis O - oral ulcers A - arthritis P - photosensitivity B - blood disorders (leukopenia, thrombocytopenia, hemolytic anemia) R - renal (proteinuria, cellular casts) A - ANA I - immunologic (antibodies - ENA) N - neuro (sz, psychosis) M - malar rash D - discoid rash ```

Question 80

What is the position of the septic hip in a patient with septic arthritis? a. Abducted and internally rotated b. Abducted and externally rotated c. Adducted and internally rotated d. Adducted and externally rotated

Answer 80

Abducted and externally rotated

Question 81

2 year old has fever of 40 degrees and is irritable. He refuses to move his left hip. What is the first thing you do? a. Aspirate the left hip with needle b. X-ray c. Bone scan d. Admit, do blood culture and start antibiotics

Answer 81

xray FIRST | aspirate most important

Question 82

10yo Lebanese girl with recurrent self limited abdominal pain and fever for one day. During an episode you do some labs and find increased ESR (60-80 range), AST and ALT slightly elevated, increased CRP and decreased albumin. What is a likely diagnosis? a. Paroxysmal nocturnal hemoglobinuria b. Familial Mediterranean fever c. SLE d. Cyclic neutropenia

Answer 82

FMF | The hallmark cutaneous finding is an erysipeloid erythematous rash that overlies the ankle or foot dosrum

Question 83

Best determinant of scoliosis on physical exam a. Leg length discrepancy b. Asymmetric shoulder height c. Asymmetric rib cage on bending over

Answer 83

asx shoulder height

Question 84

Kawasaki disease and parents refuse treatment with IVIG. Which of the following is an acceptable alternative treatment? a. ASA b. ASA + steroids c. ASA + cyclophosphamide d. Steroids alone

Answer 84

ASA and steroid ASA - IVIG with aspirin is more effective than aspirin alone in decreasing the risk of CA aneurysms (UTD)

Question 85

2 year old M with intoeing present since walking 1 year ago and not improving. On exam the big toe is deviated medially, tibial torsion and mild metatarsus adductus on both sides. What to do? a. Reassurance/observation b. Refer to Ortho for for special shoes c. X-rays

Answer 85

reassruance If tibial torsion will correct by age 8

Question 86

Child has a history of recurrent fevers, evanescent pink rash, lymphadenopathy, hepatomegaly. His musculoskeletal exam is normal. What’s the diagnosis? a. Leukemia b. Scarlet fever c. Lyme disease d. Systemic JIA

Answer 86

``` systemic JIA Systemic JIA diagnostic criteria: Arthritis in >/=1 joint with or preceded by fever x 2 week duration, that is daily (quotidian) for at least 3 days PLUS >/= 1 of the following: Evanescent erythematous rash Generalized lymphadenopathy Hepatomegaly, splenomegaly or HSM Serositis Initial symptoms [of arthritis] may be subtle or acute, and often include morning stiffness with a limp or gelling after inactivity ```

Question 87

10 yo female with 3 weeks of antalgic gait. On exam she has decreased internal rotation and pain. There is an XR of a hip. (we think it showed scfe but it was VERY ambiguous with no other side to compare it too – but ? SCFE). What is your initial management? a. NSAIDS b. nail it c. cast it d. arthrocentesis

Answer 87

nail it The classic patient presenting with a SCFE is an obese, African-American boy between the ages of 11 and 16 yr. Girls present earlier, usually between 10 and 14 yr of age. Patients with chronic and stable SCFEs tend to present after weeks to months of symptoms. Patients usually limp to some degree and have an externally rotated lower extremity. Physical examination of the affected hip reveals a restriction of internal rotation, abduction, and flexion.

Question 88

28 week baby currently ventilated for severe RDS. Also has associated anomaly (picture of club foot). What to do: a. Refer to ortho immediately for serial plastic (did not say plaster) casting b. Refer to ortho once off ventilator c. Refer to ortho at discharge d. Refer to ortho at 3 months of age

Answer 88

``` Refer to ortho once off ventilator Talipes equinovarus (also known as clubfoot) describes a deformity involving malalignment of the calcaneotalar-navicular complex. Components of this deformity may be best understood using the mnemonic CAVE (cavus, adductus, varus, equinus). ```

Question 89

2 y/o child with in-toeing. Father reports having had the same problem as a child for which he was fitted with immobilization boots. On exam, child has a searching toe, metatarsus adductus, and internal tibial torsion. What to do: a. Observe b. Discourage W sitting c. Cast d. Refer to ortho

Answer 89

obserev

Question 90

. 3 y/o with mono arthritis for a few weeks. What is the most likely test result: a. Positive RF b. Positive ANA c. Increased WBC d. Increased ESR e. Decreased Hgb

Answer 90

positive ANA Elevated ANA titers are present in 40-85% of children with oligoarticular or polyarticular JIA but are rare with systemic onset JIA. ANA seropositivity is associated with increased risk of chronic uveitis in JIA.

Question 91

14 yo girl with , pain above knee to palpation, radiograph shows lesion in the distal femur with periosteal elevation. What is the likely cause? a. osteoid osteoma b. ewing's sarcoma c. osteogenic sarcoma d. aneurismal bone cyst

Answer 91

osteogenic sarcoma

Question 92

Child presents to ER with fever, sore hip what do you do? a. aspirate joint b. Xray hip c. order CBC

Answer 92

CBC a. aspirate joint -? Yes but Ortho not us **if this was right, would need to do U/S first, consult ortho to drain b. Xray hip -? x-ray doesn’t r/o septic arthritis c. order CBC - part of the criteria to differentiate septic hip from transient synovitis ``` Kocher criteria to differentiate septic hip vs transient synovitis Non-weight-bearing on affected side Erythrocyte sedimentation rate > 40 Fever > 38.5 °C White blood cell count > 12,000 ```

Question 93

15yo with generalized malaise, violaceous rash on knuckles. You order? a. CK b. ANA c. urinalysis d. ESR

Answer 93

CK

Question 94

Description of a child with Osgood Schlatter. What is the management? a. temporary restriction of physical activities b. ice c. NSAIDs prn d. when feeling better, do quad strengthening exercises e. cylindrical casts for 3-4 wk

Answer 94

NSAID PRN temporary restrict exercise then quad exercise 9 to 14 years of age who have undergone a rapid growth spurt -occurs most frequently in participants of sports that involve running, cutting, and jumping -overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center (apophysis) of the tibial tubercle -The most common presenting complaint is anterior knee pain that increases gradually over time, from a low-grade ache to pain that causes a limp and/or impairs activity

Question 95

A 3mo old with tender swelling over the mandible bilaterally for one week, with fever and irritability. There is hyperostosis on x-ray. Diagnosis? a. parotitis b. osteomyelitis c. hypervitaminosis A d. Caffey’s disease

Answer 95

Caffey’s disease: - Infantile cortical hyperostosis (Caffey disease, Caffey-Silverman disease) is characterized by fever (sometimes as high as 40°C [104ºF]), irritability, subperiosteal bone hyperplasia, and swelling of overlying soft tissues. - The bone changes typically begin before six months of age and resolve by two years. - Leukocytosis, elevated ESR, and elevated alkaline phosphatase are common laboratory findings.

Question 96

What is correct about IVIG in Kawasaki disease? a. decreases cytokine release b. interacts with antibodies causing vasculitis c. monthly IVIG regresses giant coronary artery aneurysm

Answer 96

decreases cytokine release

Question 97

3yo girl well, has 3 weeks of right knee swelling, best initial treatment: a. steroids b. methotrexate c. NSAIDS

Answer 97

nsaid

Question 98

Which of the following is the best confirmatory test for juvenile dermatomyositis a. EMG b. CK c. ANA

Answer 98

EMG | nerve conduction studies are typically normal, but this is part of the diagnostic

Question 99

. 14y old with leg pain, radiograph shows lesion in the distal femur with sunburst appearance. What is the likely cause? a. Osteoid osteoma b. Ewing’s c. Osteogenic sarcoma d. Aneurismal bone cyst

Answer 99

osteogenic sarcoma aggressive lesions Poor definition ●Cortical destruction ("moth-eaten" or permeative pattern) ●Spiculated or interrupted periosteal reaction; however, the absence of these findings does not exclude an aggressive lesion [8] ●Extension into the soft tissue ●Large size

Question 100

12y female with 2w hx of fever, arthralgia and myalgia. She is pale but otherwise looks well. She has blood and protein in the urine.WBC 18. Plat : normal a. Acute rheumatic fever b. Wegners granulomatosis c. SLE d. JIA

Answer 100

SLE

Question 101

In a child with myopathy, which of the following could help distinguish dermatomyositis from duchenne’s MD? a. Proximal muscle weakness b. rash on face and knuckles c. abnormal muscle enzymes d. onset before age 5 e. more commonly affect girls than boys

Answer 101

. rash on face and knuckles See above about JDM. Heliotrope and Gottron’s papules are characteristic of JDM. DMD typically presents 2-3 years of age, JDM presents 5-10 years of age. DMD is X-linked, JDM is more common in girls.

Question 102

Which of the following statement is true about Kawasaki: a. Coronary artery thrombosis is a rare complication b. serologic tests are helpful c. Iv gamma globulin increase the acute phase of illness d. Initial manifestation of KS shares many similarities with scarlet fever

Answer 102

coronary artery thrombous nad scarlet fever if it said coronary artery aneurysm that is not THAT rare, up to 25%; but thrombosis is definitely rare) Dr. Schneider says thrombosis is rare especially when treated but can also have features in common with Scarlet fever.

Question 103

4y old male adolescent is referred for evaluation because of pain and swelling below his right knee. He is very active in sports. PE: reveals point tenderness over the anterior tubercle of the right knee. Diagnosis : a. Osgood schlatter disease b. patellar tendonitis c. tear of the collateral ligament d. tear of the medial meniscus

Answer 103

osgoode schlatter

Question 104

Which of the following statements is true about osteomyelitis in children? a. the most common site is proximal humerus b. most infections are cause by H.Flue c. The epiphyseal growth plate limits the spread of metaphyseal infection d. radiologic examination is useful to confirm a diagnosis

Answer 104

radiologic examination is useful to confirm a diagnosis

Question 105

A 2 yo boy is brought in by mom not moving left arm. He’s holding it pronated. Mom admits she pulled on Left wrist during horseplay. Pt not cooperative with exam. Next test: a. sling with xray b. sling then orthopedics referral c. orthopedics referral d. skeletal survey e. manipulate at elbow until arm function restored

Answer 105

e. manipulate at elbow until arm function restored radial head sublux Children with RHS may hold the affected arm close to the body with the elbow either fully extended or slightly flexed and the forearm pronated

Question 106

2-year-old child with flexible flat feet. Father and aunt had the same abnormality. You suggest: a. no intervention is necessary b. must wear shoes all the time c. needs orthotics d. foot exercises e. orthopedics referral

Answer 106

no internvetion necesary

Question 107

An 8-year-old boy has a 6 month history of right hip pain. Hip x-ray shown = AVN a. slipped capital femoral epiphysis b. avascular necrosis of the capital femoral epiphysis c. juvenile rheumatoid arthritis d. hip dysplasia

Answer 107

avascular necrosis of the capital femoral epiphysis

Question 108

What is true in this child. Hip x-ray shown = SCFE a. sports-related trauma b. more frequent in females c. associated with steroid use d. subsequent bone necrosis

Answer 108

subsequent bone necrosis

Question 109

A child has been receiving IV Penicillin for meningococcemia for the past 7 days. He has now developed a warm swollen right knee. What should be done: a. provide NSAIDs b. add a second antibiotic c. change to a different antibiotic d. aspirate and culture e. bone scan

Answer 109

d. aspirate and culture Primary purulent arthritis caused by N. meningitidis is a rare event when compared with arthritis due to immune complexes. I

Question 110

A 3-month-old child has had tender swelling over the mandible bilaterally for 1 week, along with fever and irritability. There is hyperostosis on x-ray. Most likely diagnosis: [REPEAT] a. Caffey’s b. parotitis c. cherubism d. osteomyelitis e. hypervitaminosis A

Answer 110

caffey

Question 111

A 12-year old female presents with a two-week history of fevers, arthralgias, and myalgias. She is pale but otherwise looks well. She has blood and protein in her urine. WBC 18. Platelets normal. [REPEAT] a. acute rheumatic fever b. Wegener's granulomatosis c. systemic lupus erythematosus d. juvenile rheumatoid arthritis

Answer 111

systemic lupus erythematosus

Question 112

Features of Kawasaki disease include all EXCEPT: a. elevated WBC b. ANA negative c. platelet count 75 d. urine with 10-15 WBC/hpf

Answer 112

plt 75 this more consistent with MAS

Question 113

Parents bring 3 year old for intoeing gait. You find tibial torsion and flexible metatarsus adductus. His father had a similar condition. Neurologic examination is normal. You advise: a. stop W sitting b. ortho referral for in shoe prosthesis c. no treatment necessary as this invariably resolves d. Dennis splint e. x-ray of lower limbs

Answer 113

no treatment necessary as this invariably resolves

Question 114

. In an adolescent with pain below the knee after running, the x-ray shows changes compatible with Osgoode-Schlater's disease. All are done except: a. Protective gear b. Ice may be used to reduce swelling c. Only stop activities which cause pain d. Quadriceps strengthening exercises when pain resolves e. Cast for 3-4 weeks

Answer 114

cast 3-4w

Question 115

14 year old female presents with pain above the right knee which is worse at night and with activity. On exam there is no fever, but there is tenderness to palpation above the knee. X-ray shows periosteal elevation and mottling of the distal femur. The most likely diagnosis is: a. osteomyelitis b. osteosarcoma c. osteoid osteoma d. subperiosteal hematoma

Answer 115

osteosarcoma | Sunburst appearance

Question 116

Mg't of LCP - legg calge perthes

Answer 116

Legg-Calve-Perthes (LCP) AVN of the hip that occurs in children between 3-12 years. Peak incidence is 5-7y. Bilateral in 10-20% Male: Female 4:1 Present with limp of insidious onset and a trendelenburg gait. Pain is mild and often referred to the anteromedial thigh or knee. May have limited internal ROM and abduction of the hip Treatment: non weight-bearing and referred to orthopedics

Question 117

Caffey disease age of onset treatment prognosis

Answer 117

5 months can have high alp - plt, anemia. pge indomethacin, steroids self resolve - if have fusion of ribs can have scoliosis DOES NOT involve vertebrae and phalanges