MSK - Ortho and Rheum - 2019 Updated! Flashcards
1
Q
You are seeing an 18 month old baby with a femur fracture. The baby has not had any previous long bone fractures, but there is a history of rib fractures in the past. You are concerned about non-accidental trauma, but feel that you should rule our Osteogenesis Imperfecta.
a. Name 3 physical features that would support a diagnosis of OI.
A
Blue sclera Conductive hearing loss Short stature Wormian bones Poor dentition Easy bruising Joint laxity Bowing of long bones Hernia Thin skin Scoliosis
2
Q
Child presents with abdominal pain and arthritis. Picture of purpura on buttocks.
A) What is the diagnosis?
B) What is the MOST likely cause of long-term morbidity?
A
A) Henoch-Schonlein purpura
B) Renal disease and hypertension (needs to be monitored for 1 year after episode)
3
Q
Child with monoarticular JRA involving one knee. List 3 long-term orthopedic complications of arthritis.
A
- leg length discrepancy
- Short stature
- Joint destruction
- flexion contractures
- osteoporosis (from glucocorticoid use)
Other jt problems : TMJ
4
Q
A 13 year old girl comes to you with a complaint of hip pain for the last month and a slight limp. You do the following hip XR. What is the diagnosis (shows dislocation of femoral head):
a. SCFE
b. AVN
c. JIA
A
a. SCFE
Classic presentation is limp with externally rotated, adducted leg - external rotation increases as hip is flexed
5
Q
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
A
d) subsequent bone necrosis
(AVN); other complication is chondrolysis (acute dissolution of articular cartilage in hip) ● Classic: obese, African American boy btwn 11-16 y.o. ● RF/ Trends o Black o Obesity o Male o Left > Right o Bilateral in 60% of cases
6
Q
How do you classify a SCFE as stable vs unstable?
A
If they can walk on it, it is stable - but they should not walk on it because this can cause it to become unstable
7
Q
28 week baby currently ventilated for severe RDS. Also has associated anomaly (picture of club foot). What to do:
- Refer to ortho immediately for serial plastic (did not say plaster) casting
- Refer to ortho once off ventilator
- Refer to ortho at discharge
- Refer to ortho at 3 months of age
A
- Refer to ortho at discharge
- ideally casting should be started within the first month of life
- One article stated not to start in the NICU
? Consider referral once off ventilator
8
Q
What are the components of a club foot and what is it’s medical name?
A
Talipes equinovarus
Cavus - plantar flexion of first metarsal
Adductus - of forefoot and midfoot
Varus - hindfoot
Equinus - hindfoot
CAVE is also the order it is corrected in
9
Q
Child with achondroplasia. Which is true:
a. decreased life expectancy
b. despite small foramen magnum, they rarely get cord compression
c. borderline to mild developmental delay
d. spinal stenosis commonly occurs in childhood
A
b. despite small foramen magnum, they rarely get cord compression
- intelligence is normal unless CNS complications develop (e.g. hydrocephalus)
- with appropriate intervention and monitoring risk of cord compression at foramen magnum can be minimized
10
Q
Babe with clubfoot - name ONE part of the treatment.
A
Weekly casting using Ponsetti technique
Most need tenotomy for equinus at end of casting
Then bracing (boots and bars)
11
Q
Which feature is typical for achondroplasia?
a. proximal limb shortening
b. distal limb shortening
c. short mid-portion of the bone
d. non-specific shortening
A
a. proximal limb shortening aka rhizomelic shortening of the arms and leg
12
Q
A 12 year old boy comes to you with a complaint of left knee pain and swelling for the past month. He has also had pain over the right heel. Which of the following would you expect to find on family history:
a. Psoriasis
b. Ankylosing spondylitis
c. Rheumatoid arthritis
A
b. Ankylosing spondylitis
- enthesitis (inflammation at tendon insertion point) common
- juvenile ankylosing spondylitis:
- boys > girls
- begins often with oligoarthritis and enthesitis
- arthritis commonly in lower extremities and often hips
13
Q
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
a. Only stop activities which cause pain
c. Quadriceps strengthening exercises when pain resolves
d. Cast for 3-4 weeks
A
d. Cast for 3-4 weeks
- mgmt:
- rest and gradual reintroduction of activity (maintain activity level for 1-2 weeks before advancing)
- activity modification to avoid exacerbating symptoms (avoid squats)
- if more severe, can use knee immobilizer or crutches until pain resolves
- stretching quads and hamstrings while resting can help prevent recurrence once exercising again
14
Q
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?
a) Reflex sympathetic dystrophy (now called CRPS)
b) Osteomyelitis
c) Munchaussen
A
b) Osteomyelitis (no hx of fever, systemic unwell? BUT WARM joint is not CRPS and most likely osteo > CRPS epidemiology wise)
?chronic osteo?
15
Q
14 year old boy presents with groin discomfort. X-ray shown shows femoral neck and femoral head not aligned in the middle. What is your diagnosis (1)? What are two steps in management ?
What are two risk factors
for this disease (2)?
A
- SCFE (slipped capital femoral epiphysis)
- admit and put on bed rest - no weight bearing
- consult ortho (who will pin in the OR) - RF: obesity, male, pubertal, endocrine disease (hypothyroid, hypopituitary, renal osteodystrophy)
16
Q
What child with a SCFE would need further investigation for an underlying cause? What causes would you worry about?
A
Child under age 10 years - r/o endocrinopathy -hypothyroid, hypopituitarism, renal osteodystrophy)
17
Q
What are risk factors for Legg-Calve-Perthes?
A
AKA AVN - trauma, family history, low birth weight
18
Q
Description of a 4 yr old girl who refuses to weight bear. On exam, the only finding is there is tenderness over the proximal tibia (on both sides), What are
your two differential diagnoses.
A
- leukemia
- tibial stress fractures
- toddler’s fracture (9months - 3 years, and distal tibia)
- enthesitis/arthritis
19
Q
AOM on Amox for 7 days. Presents with joint pain, anemia, rash, hematuria, edema. Management:
a) Pulse pred
b) IVIG
c) high dose NSAIDS
d) plasmapheresis
e) Hydroxyzine + Ibuprofen
A
Serum Sickness Like reaction:
a) Pulse pred - appropriate for severe reaction (severe jt / extensive rash)
or
e) Hydroxyzine + Ibuprofen
- manifests as annular, urticarial, sharply marginated, coalescing plaques, often with a lavender hue to the center
- acral erythema/edema, arthritis/arthralgia, lymphadenopathy, and fever are often present
20
Q
Picture of SCFE, how to treat:
a. trial of NSAIDS
b. “nail the hip”
c. traction
d. casting
e. arthrocentesis
A
b. “nail the hip”
21
Q
1 year old child presents with a metaphyseal femur fracture. What is the next step?
a) calcium, phosphate and alkaline phosphatase levels
b) full skeletal survey
c) bone scan
d) no further investigations
A
b) full skeletal survey
CML’s= classic metaphyseal lesions= chip or corner #; bucket handle (high specificity for abuse)
o Looks like chip off corner of long one
o Thought to happen when pulled or swung violently and relatively weaker
growing point of bones break
- skeletal survey should be done in any child under 2 years with suspicion for abuse or under 5 years with suspicious fracture
22
Q
A 6-month-old child has not been moving her left leg. An x-ray demonstrates a fracture at the corner of her distal tibia (metaphyseal bucket-handle fracture). What
should be done:
a) calcium, phosphate, and alkaline phosphatase levels
b) screen for osteogenesis imperfecta
c) skeletal survey
d) bone scan
e) no further investigations
A
c) skeletal survey
23
Q
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
A
d) Bone scan
- WBC may be increased or normal
- ESR and CRP are usually elevated
- 50% of cases have positive blood culture
- sensitivity of bone scan 90%, MRI more specific
24
Q
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
A
e) manipulate at elbow until arm function restored
- rotate arm into supination while maintaining pressure over radial head until click is felt
25
Xray of a child/infant’s elbow…story goes that it is painful, but there is no swelling and the parents brought the child in (I think he was 10 months old?) no hx of trauma. No fever.
1. What is your diagnosis?
2. What could have caused
this?
3. How do you correct this?
1. Pulled elbow (Nursemaid elbow) ( annular ligament slips proximally between radial head and distal humerus).
2. Caused by longitudinal traction force applied at elbow (e.g. someone pulling on child's arm to stop them from falling)
3. Rotate into supination and flexion with pressure over radial head
26
Dad brings toddler to ED for shoulder pain, xray shows spiral fracture. List the next three things you do.
Assuming there is no clear mechanism of injury...
1. skeletal survey
2. contact child protective services
3. immobilize fracture, consider advice from ortho if needed
4. pain control
27
9 month old boy who has come in with a story of an accident. Nurse mentions he has been in her 5 times previously with other injuries. He is a well child
otherwise. . Picture of Xray of bones with bony chip off the distal humerus.
(1) What does the xray show
(2) What could have caused this
1. classic metaphysical lesion of distal humerus
2. physical abuse
- accidental trauma
- this type of fracture is caused by accumulation of multiple micro fractures across the metaphysics perpendicular to the axis of the long bone (from shaking/shearing forces)
28
What is the most common childhood wrist fracture
a. Colles fracture
b. Greenstick
c. Buckle fracture
d. Salter Harris
b. Greenstick
c. Buckle fracture - unclear which is correct
● 80% of forearm fractures involve the distal radius and ulna
● majority of forearm fractures are buckle or greenstick fractures
- buckle (or torus): compression fracture
- greenstick: bone bends, but only breaks on the convex side, not all the way through
29
You are seeing an 8 month old female with a femur fracture and are concerned about non-accidental trauma:
a. What are the next 3 investigations that you will do to support your diagnosis?
1. skeletal survey
2. liver enzymes (screen for abdominal trauma)
3. 25-OH-vitamin D, serum calcium, phosphorus, alkaline phosphatase (may be elevated with healing fractures), parathyroid hormone
4. U/A (for hematuria)
30
Young girl who has flat feet. Mum is concerned. When she stands the feet are flat and you note that they are valgus and that her forefoot is abducted. When she sits down with her feet in the air, her arches look normal.
What is her diagnosis (1) ?
What kind of intervention is needed for her (1)?
1. Dx: flexible pes planus
2. generally no treatment needed - common in young children and they generally outgrow it
- if pain, abnormal wearing down of shoes, or fatigue after walking can consider treatment with non prescription orthotics (will help symptoms but not correct pes planus)
31
Child presents to ER with fever, sore hip what do you do?
a. aspirate joint
b. Xray hip
c. order CBC
a. aspirate joint (concern for septic arthritis)
dx: blood culture
- aspiration of joint for gram stain and culture
- WBC, CRP and ESR generally elevated but non specific and normal tests do not rule out septic arthritis
- imaging - X-ray at least
- surgical emergency
32
14 year old being treated for osteomyelitis. Severe pain despite naproxen and tylenol. Best analgesic:
a. narcotic
b. tricyclic
c. higher dose of NSAID
a. narcotic
| - follow pain ladder - if giving regular tylenol and NSAID and not achieving good control then escalate to narcotic
33
A 14-year-old girl with spina bifida at the T12 level presents with a one-day history of a swollen leg and foot with erythema over the anterior tibia. Temp 37.8. WBC 16. ESR 22. Most likely:**
a) fracture
b) cellulitis
c) osteomyelitis
d) deep venous thrombosis
e) erythema nodosum
b) cellulitis
- sounds most like cellulitis - may have decreased sensation so less aware of developing infection
- other thought was DVT as may be immobilized from spina bifida
34
18 mo M high fever, irritable, not moving hip. Next management issue?
a. IV ABx and blood culture
b. Needle aspiration
c. X-ray
b. Needle aspiration
35
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
b) Abducted and externally rotated
36
You are seeing a 19 month old boy who has a swollen right knee. A joint aspirate is positive on C&S for S. Aureus. He also has a history of a pneumococcal meningitis
at 9 months of age. You order a CBCd, blood C&S and CT scan of the knee, and start him on IV antibiotics.
a. What 4 further tests will you order?
Concern for immunodeficiency:
- recurrent bacterial infections - think B cell, phagocytic and complement defects
1. immunoglobulins (IgG, IgM, IgA, IgE)
2. C3, C4, CH50
3. vaccine titres for antibody responsiveness
4. Lymphocyte subsets
5. Mitogen stimulation assay
6. Delayed skin testing (candida)
5. Neutrophil oxidative burst index
37
Child with hip pain for 3 days. Today fever to 39, significant increase in pain. He is sitting with leg flexed and ext rotated. What are the 2 most important diseases on your differential diagnosis. List 3 investigations you would do to differentiate.
1. septic arthritis of hip
- osteomyelitis
- abscess (deep pelvic)
2. MRI of hip
- joint aspirate
- U/S (for effusion and fluid collection)
- Xray HIp
38
Child presents with 6 week history of pain after mild ankle injury – now won’t bear weight, hurt to touch, hot, no objective signs of arthritis. What is the diagnosis? Treatment?
Dx: osteomyelitis
Tx: IV antibiotics - depends on age but cefazolin a general good choice
- tx duration 3-4 weeks - depends on clinical response
39
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
```
c) Septic arthritis
Kocher Criteria For septic arthritis
● T >38.5
● WBC >12
● ESR >40
● Inability to weight bear
● CRP >23
```
40
A 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:
1. Observe
2. Discourage W sitting
3. Cast
4. Refer to ortho
1. Observe
*note: internal tibial torsion doesn't need anything done
but the metatarsus adductus should at least be treated with stretching (though most resolve spontaneously), and potentially casting depending on if it's flexible or not. W sitting is related to internal femoral torsion, but you could still discourage it to prevent that from happening later
- internal tib torsion: starts to correct as child begins walking - may correct as early as 4 years or up to
10 years
41
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
c. no treatment necessary as this invariably resolves
Make sure metatarsus adductus is flexible and recommend stretching exercises
42
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
a) no intervention is necessary
Treatment reserved for small subset who have symptoms
- flexible soled shoes
- non Rx orthosis
- PT
43
An 18 month old infant of African immigrant parents presents to you because he is not cruising or walking. He was exclusively breastfed until the age of 6 months, and now eats mainly purees, fruits and vegetables. On examination there is prominence at his distal radius and ulna and medially at his proximal tibia. Which of the
following lab abnormalities will support your diagnosis:
a. Low PTH
b. High ionized Ca
c. Low 25-OH vit D
d. Low ALP
c. Low 25-OH vit D
Expecting Low Ca and Vitamin D in diet
● PTH high
● High Alk Phos (compensation)
Rickets
44
An 8 year old boy with an unremarkable past medical history comes to you because his mother notices that he walks on his toes.
a. Name 4 causes of bilateral toe walking.
- should walk heel-toe by age 4 - refer to ortho if still toe walking by 4
- Causes
o Idiopathic (no abnormalities on exam, just when walking), +/- Heel cord contracture
o Cerebral Palsy
o Duschenne Muscular Dystrophy
o Tethered spinal cord
o Autism spectrum disorder
45
Best determinant of scoliosis on Physical Exam.
1. leg length discrepancy
2. asymmetric shoulder height
3. asymmetric ribcage on bending over
4. asymmetry on lateral flexion
3. asymmetric ribcage on bending over
Adam’s Forward Bend Test
46
14 yo girl with idiopathic scoliosis. Give 3 indications for referral to ortho.
Ix: standing PA and lateral of entire spine and calculate Cobb angle
Referral:
- Progression of curve > 5
- Curve >20 degrees in prepubertal girls or boys 12-14
- Curve >30 degrees (any age)
- Pain
- Abnormal PFTs
47
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
c. refer for posterior spinal fusion
- Braces are offered to skeletally immature patients with curves >30 at first visit, or in patients who are being followed and have developed progression of their curvature beyond 25 degrees
- Bracing is ineffective in curves >45
- Surgery recommended for progressive curves >45 degrees and skeletally mature patients with curves >50
48
Teen post op scoliosis repair. Day 6. Billious vomiting. Weight loss. ABdo pain. What is most likely complication?
a) Superior mesenteric artery syndrome
b) Adhesions
c) Volvulus
a) Superior mesenteric artery syndrome
Superior mesenteric artery syndrome:
- Typically due to the loss of mesenteric fat pad (significant weight loss caused by medical, psychological d/o or surgery) - duodenum gets squished between the SMA and the Aorta leading to bilious vomiting
- In young patients it most commonly occurs after corrective spinal surgery for scoliosis
49
3 yo girl generally well but has had 3 weeks of right knee swelling. Best initial treatment?
a. Steroids
b. Methotrexate
c. NSAIDS
c. NSAIDS
- tx for transient synovitis: NSAIDs and limitation of activity - can take up to 2 weeks for resolution of symptoms
- ddx to consider:
- septic arthritis
- reactive arthritis (following enteropathic or urogenital infection)
- post-infectious arthritis (following some other infection like viral URTI)
- acute rheumatic fever
- lyme arthritis
- JIA
50
3 y/o with mono arthritis for a few weeks. What is the most likely test result:
1. Positive RF
2. Positive ANA
3. Increased WBC
4. Increased ESR
5. Decreased Hgb
4. Increased ESR
| - most likely transient synovitis which can have mild increased in ESR and CRP
51
12 yo girl with arthritis, some blood in the urine. Three things on differential?
SLE
HSP
Post strep GN
Systemic vasculitis
52
Child recovered from recent reactive arthritis. Has residual 30 degree painless flexion contracture of knee. Name 3 non-pharmacologic treatment modalities.
- Physio for stretch + strengthening
- bracing / splinting
- Heat therapy
- surgery
- botox
53
Child with monoarthritis. Name 3 medications from different classes of medications that are used for treatment.
1. NSAIDs: ibuprofen
2. Intra-articular corticosteroid injections
3. DMARDs: methotrexate
4. Biologics: infliximab, rituximab,etancercept
54
Boy had recent illness - fever, diarrhea, conjunctivitis, urethritis now with sacroilitis. You diagnose him with Reiter syndrome. List 4 organisms that could cause Reiter syndrome.
Reiter syndrome: reactive arthritis with bilateral purulent conjunctivitis and urethritis - following GI or GU infection
- "can't see, can't pee, can't climb a tree"
- salmonella
- shigella
- yersinia
- campylobacter
- chlamydia
- e coli
Post infectious arthritis - not GU/GI specific
- strep, Hep B, rubella, parvo B19, varicella, CMV
Symptoms worse if HLA-B27
55
Which of the following is the best confirmatory test for juvenile dermatomyositis?
a. EMG
b. CK
c. ANA
b. CK
- key features are proximal muscle weakness and heliotrope rash and Gottron's papules
Either CK or EMG would meet a criteria, however EMG is very painful and is rarely done today. MRI is now more common.
Dx: Must have classic rash plus 3 of:
- Symmetric proximities weakness
- Muscle enzyme elevation
- EMG changes
- Positive Bx
56
What are the diagnostic criteria for juvenile dermatomyositis?
heliotrope rash/Gottron's papules + 3 of:
- symmetric proximal muscle weakness
- elevated of 1+ muscle enzymes (CK, AST, LDH)
- EMG changes
- muscle biopsy showing inflammation (only indicated if diagnosis is uncertain or to grade severity)
57
12 year female with a 2 week history of fever, polyarthralgia. Looks well, but pale. T=37.6. No joint swelling. Trace protein and blood in urine. Normal creatinine. Most likely diagnosis is:
a. systemic JIA
b. SLE
c. rheumatic fever
d. Goodpasture’s syndrome
b. SLE
- most common complaints in kids are fever, fatigue, hematologic abnormalities, arthralgias and arthritis (symmetric polyarthritis)
- renal involvement usually asymptomatic so need to look for it (HTN, proteinuria, hematuria, edema, nephrotic syndrome, renal failure)
Note: *arthritis must be present to diagnose ANY type of JIA
- Goodpasture: pulmonary hemorrhage and glomerulonephritis
58
What is the diagnostic criteria for JIA? How do you classify it?
- arthritis (dx of arthritis = swelling OR 2 of decreased ROM, pain with motion, warmth)
- duration 6 weeks minimum
- classify based poly (5+ joints involved in first 6 months after onset), oligo (1-4 joints), or systemic onset (arthritis with fever and rash)
59
10-year-old girl with a 1 week history of fever (not greater than 38.5) and migratory arthritis. On examination there is evidence of arthritis in the right wrist, but the rest of the exam is normal. WBC is 25 with a left shift. ESR 45. Most likely diagnosis:
a) acute rheumatic fever
b) juvenile rheumatoid arthritis
c) systemic lupus
d) osteomyelitis
e) septic arthritis
a) acute rheumatic fever
* * though the ESR here is not quite high enough (?misremembered)
Key is MIGRATORY
Timeline not long enough for JIA (6 weeks)
Jones criteria - 2 major OR 1 major and 2 minor (plus evidence of previous GAS infection - except w/ chorea)
Major: Arthritis, Carditis, Subcutaneous nodules, Erythema marginatum, Chorea
Minor: elevated ESR, CRP, temp 38.5, arthralgia, prolonged PR
60
Child presents with fever, polyarthritis, increased ESR and ASOT=625. Echo is normal. Best management:
Mgmt of acute rheumatic fever without heart disease:
1. ASA for fixed period (dosing progressively lowered over 6 weeks, then stopped)
2. Pen V for 10 days to eradicate strep infection
3. Strep prophylaxis: Pen G benzathine IM q4 weeks, or BID Pen V or daily sulfasalazine until age 21
61
Child with a 2 week history of migratory arthritis, fever 38.5, a normal echo, WBC 18, ESR 75, throat swab negative, and an ASOT > 625. What should you do:
a. ASA 100mg/kg until arthritis resolves
b. ASA prn pain, treat 10 days with penicillin
c. ASA 100mg/kg until arthritis resolves, treat 10 days with penicillin
d. ASA 100 mg/kg until arthritis resolves, treat 10 days with penicillin followed by q monthly IM penicillin
e. ASA 100mg/kg until arthritis resolves, treat 10 days with penicillin, oral penicillin for dental procedures
d. ASA 100 mg/kg until arthritis resolves, treat 10 days with penicillin followed by q monthly IM penicillin
Mgmt of ARF:
- 10 days Penicillin to abolish acute infection
- ABx prophylaxis:
- if carditis: until adulthood, possibly life
- if no carditis: til 21 yo or 5 years post ARF, whichever is longer
ASA duration a little less clear - Nelson's says total 4-5 weeks
62
8y female with subtle choreoathetotic movements. Handwriting has worsened and she is emotionally labile . Evaluations including a throat culture are negative. What is the most likely diagnosis?
a. Huntington’s chorea
b. Syndenham’s chorea
c. SLE
b. Syndenham’s chorea
- chorea, emotional lability and hypotonia/incoordination and pronation of the hand causing difficulties writing are all classic features
- culture and ASOT often negative as can occur months after strep infection
- treat with long term antibiotic prophylaxis
- chorea resolves in 6-9 months
63
Rheumatic fever – which most likely causes long-lasting problems?
a) carditis
b) chorea
c) nodules
d) Polyarthritis
a) carditis
- cardiac is long-term sequelae of ARF
Nelson:
those who have carditis with their initial episode of RF are at higher risk of havign cariditis with recurrences and sustaining additional cardiac damage
64
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
d) Systemic JIA
- fevers once-twice daily for at least 2 weeks, and unwell during this time
Dx: arthritis in min. 1 joint x2 wks with, or preceded by, fever documented daily (“quotidian”) x 2 weeks and accompanied by min 1 of
o Evanescent (nonfixed) erythematous rash (macular, non pruritic, transient +/- crops over trunk + limbs)
o Generalized lymph node enlargement
o Hepatomegaly or splenomegaly or both
o Serositis
65
What are some prognostic factors for systemic onset JIA?
Systemic JIA worse prognosis in general
- worse prognosis if:
- polyarticular
- fever >3 months
- increased inflammatory markers on BW x>6 months
66
Features of Kawasaki disease include all EXCEPT:
a) elevated WBC
b) ANA negative
c) platelet count 75
d) urine with 10-15 WBC/hpf
```
c) platelet count 75
● Leukocytosis, Anemia, Thrombocytosis after week 1
● Elevated CRP and ESR
● Hypoalbuminemia
● Hyponatremia
● Abnormal plasma lipids
● Sterile pyuria
● Elevated serum transaminases and GGT
● Pleocytosis of CSF
● Leukocytosis in synovial fluid
```
67
```
Kawasaki dz, parents refuse IVIG. What is an acceptable
alternative?
a) ASA
b) ASA + steroids
c) ASA + cyclophosmide
d) steroids alone
```
b) ASA + steroids
- ASA always anyway
- steroids second line
68
3 year old with a history of fevers. Occur every 4 to 12 weeks for 1-4 days. Growing well. Treated for numerous otitis and pharyngitis.
A) multiple viral infections
B) familial med fever
C) CVID
A) multiple viral infections
69
List 5 warning signs of primary immunodeficiency
1. 4 new ear infections in a year
2. 2 serious sinus infections in a year
3. 2 pneumonias within a year
4. 2 deep seeded infections in life
5. 2 months on antibiotics with little effect
6. needing IV abx to clear infection
7. recurrent abscesses
8. persistent thrush or fungal infection
9. FTT
10. family hx of primary immunodeficiency
70
```
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.
a) acute rheumatic fever
b) Wegener’s granulomatosis
c) systemic lupus erythematosus
d) juvenile rheumatoid arthritis
```
c) systemic lupus erythematosus
- arthritis, anemia, arthralgia, renal disease in a 12 yo female - fits with SLE
- classic presentation SLE: fever, rash, renal, MSK, heme (anemia, leukopenia, TCP)
- Wegener's: granulomatosis with polyangiitis: respiratory symptoms (SOB, cough), fatigue, malaise, fever and renal involvement so is possible BUT less common
71
What is the diagnostic criteria for SLE?
4/11 of SOAP BRAIN MD - at least 1 clinical and 1 immunologic
- serositis (pleuritis, pericarditis)
- oral or nasal ulcers
- arthritis (oligo or poly)
- photosensitivity
- blood cells (all lines low)
- renal (nephrotic)
- ANA+
- immune markers + (anti-Smith, anti-dsDNA, anti-phospholipid)
- neuropsych (seizures, psychosis)
- malar rash
- discoid rash
72
(Picture of a child with an erythematous rash over the face, concentrated over the upper eyelids, and over the MCPs and PIPs) A 6 year old boy comes to you with a history of progressive fatigue over the past month. You note the following rash on physical examination.
a. What is your diagnosis?
b. Name 3 tests that will help to confirm your diagnosis.
c. What one medication would you consider starting at this point?
a. juvenile dermatomyositis
b. muscle enzymes (CK, AST, LDH)
- EMG
- muscle biopsy
- MRI
- proximal muscle weakness - positive Gower's
c. Prednisone
73
Boy with Kawasaki’s disease. Give 5 criteria for Kawasaki’s
5 days of fever
- cervical LAD >1.5cm
- bilateral non-purulent conjunctivitis
- swelling/redness/peeling of hands and feet
- rash (diffuse, maculopapular)
- oral membrane involvement (cracked, red lips, strawberry tongue, pharyngitis)
74
14 year old boy with low back pain. You suspect ankylosing spondylitis.
1. What are 2 findings on physical exam?
2. What are two tests to help you in this diagnosis?
3. How is this treated?
1. SI tenderness on FABER test
- Schober test (15cm span marked starting at level of iliac crest while standing) - distance measured after forward bend - positive if distance increases by <5cm
- Occiput to wall
- SI joint tenderness
- Limited chest expansion
2. ESR and RF normal
- HLA B27 positive (present in 90%)
- XR: late findings identified like squaring of vertebral bodies
- MRI: bone marrow deem adjacent to joint
3. NSAIDs, intra-articular steroids, DMARDs, physio
75
Neonate with thrombocytopenia, elevated liver enzymes, target lesion rash. What is the diagnosis?
Neonatal lupus
76
Kid with JIA, high fever, hypotensive, high ferritin and high trigs, pancytopenic. what is the ddx:
macrophage activation syndrome
- occurs most often in first weeks to months after onset of JIA symptoms, though can happen any time in course of disease
Diagnostic criteria - 3/5 of:
- fever >38.5
- splenomegaly
- cytopenia (at least 2/3 cell lines)
- increased triglycerides OR low fibrinogen
- elevated ferritin (often >1000, must be >500)
77
(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
This could be drug induced lupus from phenytoin
- drug induced lupus can be true SLE in a predisposed individual that is triggered by drug (this will not resolve)
- or it can be a lupus-like syndrome that is caused by the drug and resolves after the drug is discontinued (though can take months to years for full recovery)
78
Rash over backs of hands, muscle pain, being teased at school for weakness.
a. DMD
b. JDM
c. SLE
b. JDM
- Peak age onset 4-10years (second peak in adulthood)
- Girls to boys 2:1
Clinical Manifestations:
- insidious onset of rash and or weakness
- commonly see fevers, dysphagia, dysphonia, arthritis, muscle tenderness, fatuge
- ASK about: Dysphagia, Dysphonia, GERD!
Diagnostic Criteria:
- Classic Rash (Heliotrope or Gottron papules)
Plus 3 of:
- Weakness (symmetric and proximal)
- Muscle enzyme elevation (CK, AST, LD, Aldolase)
- EMG changes
- Muscle Biopsy (necrosis or inflammation)
79
Evanescent rash, lymphadenopathy, hepatomegaly. What does this suggest?
a. lupus
b. systemic onset JIA
c. kawasaki
d. rheumatic fever
b. systemic onset JIA
80
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
d) Systemic JIA
| * fits best with JIA, but very abnormal that the MSK exam is normal
81
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
a. hypoalbuminemia
82
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
a. Low albumin
83
Child with pulmonary findings, eosinophilia, slightly elevated calcium (2.8)
a. miliary TB
b. sarcoidosis
c. cryptococcus
d. blastomycosis
b. sarcoidosis
- multisystem granulomatous disease of unknown etiology
- older kids are like adults (mild pulmonary involvement - dry persistent cough, LAD)
- early onset sarcoid (<4 years): rash, uveitis and arthritis
- also nonspecific sx like fever, wt loss, malaise
- CXR: bilateral hilar adenopathy
- small percentage have hypercalcemia/hypercalciuria
- leukopenia, TCP and eosinophilia can be seen
84
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
a. SLE
85
Child with wt loss anemia, normal plts, low WBC, protein/blood in urine. Dx?
a. SLE
b. RF
c. PSGN
a. SLE
● most common presenting complaints of children with SLE include fever, fatigue, hematologic abnormalities, arthralgia, and arthritis → arthritis does not have to be
present in a dx of SLE but definitely needs to be present in all forms of JIA
86
4 year girl with arthritis of two months duration. On exam she has a swollen elbow and knee. Her ANA is positive. What is her diagnosis?. What is one complication that she is at risk for. What would your initial treatment be (1) ?
1. oligoarticular JIA
2. complication: uveitis (girls with oligoarthritis who are ANA positive are highest risk of this) - can lead to cataracts and blindness
3. NSAIDs (high dose Naproxen)
87
Three ways that maternal SLE can affect neonate.
- heart block
- thrombocytopenia (many kinds of cytopenias)
- rash
- hepatitis
- Cholestasis
88
14 yo girl with leg pain, which is worse after activity and at night. On examination there is tenderness and swelling above the knee joint but no effusion. A radiograph shows a lesion in the distal femur with periosteal elevation. What is the likely cause?
a. osteoid osteoma
b. osteogenic sarcoma
c. subperiosteal hematoma
d. osteomyelitis
b. osteogenic sarcoma
- the description of periosteal elevation (aka onion skinning) is more typical for Ewing sarcoma, but these tumours are more common in kids under age 10
- osteomyelitis also possible, but pain worse at night suspicious for cancer
89
Pt with HSP. What would you do to monitor:
a. urinalysis
b. IgA
c. Stool for o/b
d. AXR
a. urinalysis
Renal: weekly UA + BP while active clinical disease then monthly x 6 month (to R/O late onset renal disease)
o If all (-) in this FU period then unlikely to develop nephritis after 6 months
o If (+), HTN, renal failure, hematuria -> talk to nephro
90
Child with a head that looked like this - picture of infant with dolichocephaly. What is the diagnosis? What finding on physical examination would support this?
1. craniosynostosis
| 2. closure of sagittal suture with no mobility, prominent boney ridge
91
```
Teen (gymnast) insidious onset lower back pain. Pain on extension, hamstring tightness. Paraspinal muscle spasm. Normal neuro exam. Positive TC99 scan. What is
the dx.
a) Spondyloarthropathy
b) Spondylolysis
c) Posterior element overuse
d) Vertebral avulsion fracture
```
b) Spondylolysis
spondylolysis
● anatomic defect (radiolucent gap) in pars interarticularis with adjacent bone sclerosis - develop over time, not present at birth
● mechanism → usually activity related and occurs from repetitive hyperextension - prevalence as high as 47% in certain athletes (gymnasts, weightlifters, football
linemen)
- can be seen on bone scan
92
Emotional lability and choreiform movements
a. Tourettes
b. SLE
c. Huntingtons
d. Sydenhams
d. Sydenhams
93
A child was playing soccer when he collided with another child, sustaining a head injury with brief (seconds) loss of consciousness. He currently has no complaints. What do you advise to his coach:
a. wait 15 minutes and if he is OK then allow him to go back into the game
b. remove him from the game, he should not play soccer for 1 week
c. send him home with a note for his parents about head injuries
d. let him go back into the game immediately
b. remove him from the game, he should not play soccer for 1 week
94
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). What is your initial management.
1. NSAIDS
2. nail it
3. cast it
4. arthrocentesis
2. nail it
95
What condition is associated with bone age that matches chronological age?
a. Psychosocial dwarfism
b. Constitutional delay
c. Familial short stature
d. Hypothyroidism
c. Familial short stature
96
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?
1. Reassurance/observation If tibial torsion will correct by age 8
2. Refer to Ortho for for special shoes
3. X-rays
1. Reassurance/observation If tibial torsion will correct by age 8
97
A 6 year old boy presents to the family doctor with an eczematous rash. On exam he looks unwell and is tachypneic. He has a large rash with scaling at the edges. On eye exam he has miliary conjunctivitis. His mother says that he has joint pain in the morning and he has a knee effusion on exam. His bloodwork reveals eosinophilia, with leucopenia with normal calcium. He also has hilar nodes on his chest X-ray. What is the cause of his symptoms.
1) Miliary TB
2) Cryptococcosis
3) Blastomycosis
4) Sarcoidosis
4) Sarcoidosis
Early-onset sarcoidosis in children <4 has a triad!
- Rash, Uveitis, Polyarthritis
Sarcoid macrophage produces and secretes 1-25(OH)2-vitamin D (Calcitriol)
So you have increased intestinal absorption of Ca++ and phos, you may end up with hypercalcemia and hypercalciuria
98
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
1. Osgoode Schlatter
2. Patella fracture
3. Patellofemoral syndrome
4. Meniscal tear
5. Iliotibial band syndrome
3. Patellofemoral syndrome
Pain beneath or near the patella is most common syndrome, classically when walking up and down stairs (puts patella under high compressive loads), also hurts with squatting, running and other vigorous activities)
Tx: mainstay is PT
99
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?
Fracture
Conversion disorder
Reflex sympathetic dystrophy
Reflex sympathetic dystrophy
(Complex regional pain syndrome)
Ongoing burning limb pain subsequent to an injury, immobilization or other noxious event to extremity
Key: pain that is disproportionate to inciting event, persistent allodynia (pain to normally non-noxious stimuli), hyperalgesia (exaggerated pain to noxious stimuli), swelling of distal extremities, autonomic dysfunction (cyanosis, mottling, hyperhidrosis, coolness)
100
Ankle injury with weight bearing in ER. When to xray?
1. pain to posterior edge of lateral malleolus
2. pain to anterior edge of medial malleolus
3. cannot weight bear in ER
4. swelling
1. pain to posterior edge of lateral malleolus
Ankle Rules;
Pain in malleolar zone and any of:
- Bony tenderness at posterior edge or tip of lateral malleolus
- Bony tenderness at posterior edge or tip of medial malleolus
- Inability to take 4 steps immediately and in ER
101
What lab abnormalities would you find in Kawasaki.
a) neutropenia
b) thrombocytopenia
c) hypoalbuminemia
c) hypoalbuminemia
```
Elevated WBC with neutrophil predominance
Elevated CRP, ESR
Low serum sodium and albumin
Elevated liver enzymes
Sterile pyuria
Thrombocytosis
```
102
```
13 yo female with jaundice and fatigue.
Labs:
AST 222 ALT 150 Bili 35/20 Alpha1-antitrypsin 2.5
Genotype MZ.
HepB S Ag neg
Hep C IgM neg
Anti-Sm Ab positive.
```
a) autoimmune hepatitis
b) hepatitis c
c) wilson disease
d) primary sclerosing cholangitis
e) alpha-1-antitrypsin
a) Autoimmune Hepatitis
Positive Anti-smooth muscle
(Other markers: ANA, Anti-actin, soluble liver antigen, liver-pancreas, etc)
Not Hep C (IgM negative)
Wilson : asymptomatic hepatomegaly - > acute hepatic failure, high urine copper and serum copper, Keyser-flesher rings
PSC - bill should be sky high
Alpha-1-antitrypsin: Homozygotes (ZZ) have anti-trypsin levels < 2
103
Kid with fever for 6 days, bilat conjunctivitis, mp rash, mucus membrane. What lab abn?
a) hypoalbumin
b) neutropenia
c) high ASOT
d) monospot +ve
a) hypoalbumin
KD: neutrophilia, elevated ESR/CRP, low Na+, low albumin, elevated AST/ALT, sterile pyuria, thrombocytosis
104
Patient with Achondroplasia. What is the mechanism of limb shortening?
a. Metaphyseal shortening
b. Diaphyseal shortening
c. Epiphyseal shortening
d. Uniform shortening
c. Epiphyseal shortening
Proximal (rhizomelic) shortening
105
Girl with symptoms sounded like Systemic Lupus Erythematous – hypertension, hematuria, rash on face, HSM. Which is most consistent with diagnosis:
a. Pulmonary hypertension
b. Psychosis
c. Pancytopenia
b. Psychosis
(PANcytopenia not in Dx criteria)
SLE Dx:
- Malar rash
- Discoid Rash
- Photosensitivity
- Oral or nasal ulcers
- Non-erosive ≥ 2 jt arthritis
- Serositis (pleurites, pericarditis, peritonitis)
- Renal: +ve biopsy, persistent proteinuria or casts
-Seizure or psychosis
Heme: hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia
Immune: +ve dsdNA or antiSmith, ANA, false +ve rapid plasma reagin, +ve lupus anticoagulant, elevated anticardiolipin
106
4 year old boy with fevers q 3-4 days, Erisypelas like rash, family history of renal disease, what is the treatment
Colchicine
Methotrexte
Naproxen
Colchicine
```
FMF
Jewish and Mediterranean ethnicity
- erysipelas-like rash
- monoarthritis
- fever lasting 1-3 days
- serositis
```
** uncontrolled goes to amyloidosis
Management:
Prophylactic daily colchicine
107
Child with 2 wks of fever, splenomegaly, transient pink macular rash, lymphadenopathy, normal MSK exam.
a. ALL
b. Systemic onset JIA
c. FMF
sJIA
In sJIA the arthritis may be preceded by the systemic symptoms by months.
In the absence of arthritis, the DDx includes malignancy, periodic fever syndrome, infection
108
Best for diagnosing early Legg-Calve-Perthes
a. Bone scan
b. X-ray
c. Reason for pain in functional disorder
d. Motility issue + hypersensitive
MRI would be best answer
Bone scan probably an old answer
Don't always see changes early on in disease on XR - but they are primary diagnostic tool.
109
Kid with fever, limp/refusing to weight bear elevated ESR and WBC U/S shows fluid in hip
a. Admit, IV abx
b. Urgent ortho consult
c. Reassure, NSAIDS
b. Urgent ortho consult
Septic Arthritis is a surgical emergency - goes to OR in first 8 hours
110
3 year old girl presents to the emergency department with right knee pain. You diagnose pauciarticular (oligoarticular) arthritis. On further assessment, there are no signs of uveitis, ANA testing is negative. Which of the following treatments would you recommend?
a) NSAIDs
b) Methotrexate
c) Anti-TNF alpha therapy
d) Pulse IV methylprednisone
NSAIDS
Oligo JIA
- Initial Tx: NSAIDs or intra-articular glucocorticoid injections
111
A school-aged girl is referred to your office for joint pains. On further history, she describes rashes, pain and swelling in different joints, as well as gross hematuria. On physical exam, she is hypertensive with active arthritis. Which of the following is the most specific test to confirm the suspected diagnosis?
a) ANA
b) RF
c) Anti-dsDNA antibodies
d) Anti-smooth muscle antibodies
c) Anti-dsDNA antibodies
ANA - 99% sensitive, lease specific
Anti-dsDNA: very specific, 75% sensitive, useful to monitor disease activity
Anti-Smith: MOSt specific, 50% sensitive, cannot be used to monitor disease activity
Anti-Ro, Anti-La: higher risk of sicca (monitor in pregnancy)
Antiphospholipid: higher risk of thromboembolism
False positive RPR
112
A patient presents to your clinic with lower limb “bruises”, abdominal pain, and arthralgias. Were you to test for them, which of the following lab findings are you most likely to find?
a) Increased circulating IgA
b) Schizocytes on the blood smear
c) Decreased C3
d) Thrombocytopenia
HSP:
a) Increased circulating IgA
IgA elevated in 50% (does not correlate with disease severity)
No Lab tests are specific for HSP.
CBC usually normal, no thrombocytopenia.
Coags normal
Most important is UA because renal disease is leading cause of morbidity in HSP.
Normal C3/C4, ANA, dsDNA can help differentiate from SLE or other vasculitis
113
A 5 year old girl is diagnosed with a systemic arthritis and treatment with methotrexate begun. Three months later, she presents to hospital with fever, hepatomegaly, hepatic transaminitis, anemia, and thrombocytopenia with petechiae. What is the most likely diagnosis?
a) Mononucelosis
b) Macrophage activation syndrome
c) Infectious hepatitis
d) Methotrexate toxicity
b) Macrophage activation syndrome
114
An 18 month old child presents with fever and decreased range of motion of his hip. On examination there is pain with movement and decreased internal rotation. What is your next course of action?
a) aspirate hip
b) blood culture and IV antibiotics
c) hip ultrasound
d) bone scan
c) hip ultrasound (practically the first step in most cases of suspected hip pathology)
a) aspirate hip (diagnostic test)
b) blood culture and IV antibiotics (will also do this)
d) bone scan
115
Child with pericarditis. You are considering SLE. Which would help with diagnosis.
a) ANCA
b) HLA-B27
c) RPR
d) Thrombocytosis
c) RPR
RPR is falsely positive in SLE
116
Kid on methotrexate for systemic JIA. Comes in with irritability, abdo pain, petechiae, hepatomegaly. Elevated liver enzymes, ESR 30. No CBC. What’s her most likely diagnosis?
a. methotrexate toxicity
b. sepsis
c. autoimmune hepatitis
d. macrophage activation syndrome
d. macrophage activation syndrome
117
16yo girl with optic neuritis. Mom wants to discuss prognosis (or risk of recurrence). What do you tell her?
A. She has been treated with steroids, so the symptoms should not recur
B. She will likely have further episodes
C. Receiving immunoglobulin will protect her for the next 6 months
D. She is at high risk of developing multiple sclerosis
D. She is at high risk of developing multiple sclerosis
If she has no brain or spinal cord involvement - only 5% risk of recurrence
13-36% are eventually Dx with MS, higher if white matter lesion on MRI
Treatment is with IV Methylpred 30mg/kg for 3-5 days
118
Kocher Criteria for Septic Arthritis
Kochers criteria
- -- Fever > 38.5 C
- -- Inability to WB
- -- ESR > 40
- -- WBC > 12000
```
Likelihood of septic arthritis:
1 point – 3%
2 points – 40%
3 points – 93%
4 points – 99%
```
119
Haematuria 4+, proteinuria 2+, mild hypertension. Otherwise well. C3 and C4 were normal. Most likely cause?
A. lupus nephritis
b. Membranoproliferative glomerulonephritis
C. IgA nephropathy
D. post-infectious GN
C. IgA nephropathy
120
3 yo 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
b) Positive ANA
Oligoarthritis, ANA will be positive in 60%, ESR and CRP may be mildly elevated (or normal)
121
Girl who is active. Heel pain worse with activity such as running and jumping. No concerns with swimming. Tender achilles on exam. How to manage.
a. Avoid activity and rest
b. Something that sounds like an air cast
c. Use NSAIDS for the pain
d. X-rays
c. Use NSAIDS for the pain
- should be activity modifaction
This is Sever’s Disease (calcaneal apophysitis). Apophysitis represents inflammation at the tendinous insertion of a muscle from repetitive tensile loading and is most commonly observed during periods of rapid growth.
treatment includes activity modification, nonsteroidal antiinflammatory medications, heel cord stretching exercises, and heel cushions or arch supports.
122
You see a child with fever, arthralgias, and a rash on his lower limbs (palpable purpura). What test needs to be done now?
a) Abdominal ultrasound
b) Urinalysis
c) IgA
b) Urinalysis
HSP
123
2 year old infant presents with refusal to weight bear and is found on imaging to have a spiral fracture. What is the most likely explanation?
a. Toddler’s fracture
b. Non accidental injury
c. Metabolic bone disease
d. Osteogenesis imperfecta
a. Toddler’s fracture
124
Young boy ( ?6 yo) with history of four weeks of decreased energy. He has recently started to complain about leg pain. On exam, you find bilateral tenderness over his proximal tibia. There is no erythema and no warmth?
What are two diseases that could cause this (2) ?
Leukemia
Enthesitis JIA
Osteosarcoma
Osgood Schlager
125
Lupus malar rash (picture) + hypertension what is diagnosis and 2 renal complications (other than hypertension)
Lupus nephritis
Nephrotic syndrome
Renal failure
126
Child had a URTI a week ago. He now presents with blood diarrhea, abdominal pain and a petechial rash. What is his diagnosis?
Henoch Schonlein Purpura
Skin: Purpuric rash - usually symmetric and in gravity dependent areas or pressure points
MSK: Arthritis and arthralgia - oligoarticular usually lower extremities
GI: Abdominal pain, vomiting, diarrhea, paralytic ileus, melena, intussusception, mesenteric ischemia
GU: asymptomatic microscopic hematuria to severe progressive glomerular nephritis
Neuro: Usually due to HTN or CNS vasculitis - intracerebral hemorrhage, seizures, headache, behavioural changes
127
Northern infant with bowed legs, etc. What laboratory tests do you do to confirm diagnosis?
Vitamin D Deficient Rickets
```
25-hydroxyvitamin D
Calcium
Phosphorus
ALP - Alkaline phosphatase
PTH - parathyroid hormone
```
128
14 year old with genital pain and mild headache. On exam, you find two 0.5 cm ulcers in the inside of the labia majora. Besides herpes simplex virus, what 4 diagnoses should you consider?
```
Lipschultz ulcer
Syphilis
Chlamydia
Chancroid (Hemophilis ducreyi)
Fixed drug reaction
Behcet
Neoplasm
Crohns
Trauma
```
129
What is the most severe complication of missed DDH in the first year of life?
What 2 symptoms would an 18-month old present with if DDH was missed?
List one finding on physical exam in an 18 month old with missed DDH:
a) Avascular necrosis of femoral epiphysis
b) Waddling gait, limp, excessive lordosis, trendelenberg sign
c) leg length discrepancy
130
Child with suspected Guillain Barre Syndrome. What are three possible severe complications to be aware of?
Autonomic dysregulation - cardiac dysrhythmias, hypotension
Bulbar - dysphagia, dysphonia
Respiratory compromise - CO2 retention without WOB
131
A 15 year old girl was treated 2 weeks ago with ciprofloxacin for a lower urinary tract infection.
She now presents with fever, lymphadenopathy, a diffuse maculopapular rash and back pain. On exam she has bilateral CVA tenderness.
Her CBC shows the following: eosinophils 12%
Her Creatinine in 142.
What is the diagnosis?
What is the treatment of this diagnosis?
Drug rash with eosinophilia and systemic symptoms
Stop offending agents
Oral corticosteroids for rapidly progressing renal involvement or lung involvement
132
Heart block is a severe complication of neonatal lupus. What two auto-antibodies are involved?
anti-Ro (Anti-Sjögren's-syndrome-related antigen A)
| anti-La (Anti-Sjögren's-syndrome-related antigen B)
133
What antibodies are related to the following:
Granulomatous Polyangitis
Systemic Sclerosis
Lupus
Autoimmune Hepatitis
Granulomatous Polyangitis: pANCA or cANCA
Systemic Sclerosis = ANA and Anti-Scl-70
Lupus = ANA, dsDNA, anti-Smith, SSA/Ro, SSB-LA
Autoimmune Hepatitis = anti Smooth muscle
134
A child has Kawasaki’s disease. What two medications would you start right away? Write the order – be specific.
IVIG 2 g/kg IV over 4 hours
| ASA 80 mg/kg/day until afebrile
135
Teenage girl, with ?( LUPUS,) splenomegaly, hepatomegaly, pancytopenic, fatigue for a few weeks, rash, fever, arthtitis
List 2 non infectious causes of the aquired form of this illness:
- Procainamide ***
- Hydralazine ***
- Minocycline
- Quinidine
136
Child with JIA. Which subset of JIA is most likely to be associated with anterior uveitis? What test? How often should they be seen?
Oligoarthritis
ANA+
Slit lamp exam at Dx, then q3-4 mos
High Risk:
- Oligo/Poly, onset <7, ANA+
```
Medium Risk (screen q6mos):
Oligo/Poly, ANA-ve, any age
```
Onset > 7 regardless of ANA
Low (screen q12mos):
Systemic onset JIA
137
Young girl with back pain with extension. Physical was normal.
a. What Ix would you do
b. What management
c. What is suggesting time to return to activities
Spondylolysis
a. Xray lumbar spine PA and lateral. CT
b. Pain control, Physiotherapy, rest, return to activity with or without brace
c. 4-8 weeks
138
Picture of erythema nodosum
List 5 differential diagnoses
```
Inflammatory bowel disease
SLE
Sarcoidosis
Lymphoma
Idiopathic
Infection:
- Group A Strep
- Yersinia
- EBV
- Mumps
Medications:
- Cephalosporins
- Penicillins
- Macrolides
- OCP
```
139
Child with cyclical fevers, and oral ulcers on examination.
a. what is the likely diagnosis
b. what is the treatment
a. Periodic fever pathos stomatitis pharyngitis and cervical adenitis
b. colchicine (prophylaxis)
glucocorticoids for episodic tx
140
What are the 5 criteria to make the diagnosis of systemic JIA (other than the rash)?
```
Daily spiking fevers >39
Hepatosplenomegaly
Lymphadenopathy
Serositis - pericarditis
Arthritis
Leukocytosis
Thrombocytosis
Anemia
Increased transaminases
Increased ESR
```
141
12yo boy with right anterior knee pain. No history of trauma. On exam, she has tenderness at the tibial tubercle.
What are 3 recommendations you'd make for management of this patient?
Osgood-Sclatter
- Rest
- Activity modification
- Knee immobilization
- Stretches
- Graduated return to activity
