Rhematology LE5

Question 1

61. A 7-year-old boy is brought to the clinic because he has been limping for the past few days. He was treated with paracetamol with only mild relief of pain. He is febrile (T 38.0°C). On examination, his right knee is red, warm, and swollen. Range of motion is limited because the patient is guarding and begins crying. What is the best next step in management?
    Diagnosis: Suspected septic arthritis
    A. Immediately admit the patient and start antibiotics
    B. Provide reassurance by advising rest, ice, compression, and elevation
    C. Send the patient for an X-ray of the right knee and hip joint and ask them to follow up
    D. Refer to orthopedic surgery

Answer 1

A. Immediately admit the patient and start antibiotics
Rationale:
🦠 Septic arthritis is a medical emergency that requires immediate IV antibiotics and joint drainage to prevent joint destruction.
🚨 Delaying treatment can lead to irreversible damage, systemic infection, and sepsis.
🚫 Rest, ice, and compression (B) are insufficient, and X-ray (C) is not the primary diagnostic step.
🚫 Referral (D) may be needed, but immediate antibiotic therapy is the priority.

Question 2

62. Which imaging study is a quick and noninvasive means of detecting the presence of hip arthritis with effusion?
    A. CT scan
    B. Magnetic resonance imaging (MRI)
    C. Bone scan
    D. Ultrasound

Answer 2

D. Ultrasound
Rationale:
📡 Ultrasound is a quick, noninvasive, and highly sensitive tool for detecting joint effusion in septic arthritis.
🚫 MRI (B) is more detailed but not a first-line imaging modality for initial assessment.
🚫 CT scan (A) and bone scan (C) are less useful in early septic arthritis diagnosis.

Question 3

63. Which of the following statements about septic arthritis is TRUE?
    A. Septic arthritis is most commonly found in adolescent males.
    B. In septic arthritis, the hips and knees are the most commonly affected joints.
    C. In a child with septic arthritis of the hip, redness, swelling, and warmth are often detectable on physical examination.
    D. Children with septic arthritis never present with fever.

Answer 3

B. In septic arthritis, the hips and knees are the most commonly affected joints.
Rationale:
🦵 Septic arthritis most commonly affects the hips and knees due to hematogenous spread.
🚫 It is more common in younger children, not just adolescent males (A).
🚫 Hip septic arthritis may lack visible redness and swelling due to deep joint location (C).
🚫 Fever is a common finding in septic arthritis (D).

Question 4

64. Which of the following statements regarding acute osteomyelitis is TRUE?
    A. The most common pathogen in acute hematogenous osteomyelitis is Group A Streptococcus.
    B. Plain X-ray usually begins to show acute changes 5–7 days into the course of the disease.
    C. The most common bone involved in acute hematogenous osteomyelitis in children is the tibia.
    D. Osteomyelitis has the propensity to involve the diaphyses of the long bones.

Answer 4

B. Plain X-ray usually begins to show acute changes 5–7 days into the course of the disease.
Rationale:
📸 Radiographic changes in osteomyelitis typically appear after 5–7 days when bone destruction becomes evident.
🚫 Staphylococcus aureus, not Group A Streptococcus (A), is the most common pathogen.
🚫 The femur is the most commonly involved bone in children, not the tibia (C).
🚫 Osteomyelitis primarily affects the metaphyses, not the diaphyses (D).

Question 5

65. Which of the following is a very sensitive test to confirm the diagnosis of acute osteomyelitis in children?
    A. Plain films of the long bones
    B. Radionuclide bone scan
    C. CT scan
    D. Ultrasound

Answer 5

B. Radionuclide bone scan
Rationale:
🩻 Radionuclide bone scans are highly sensitive for early detection of osteomyelitis before X-ray changes appear.
🚫 Plain films (A) may take days to show changes.
🚫 CT scans (C) are better for detecting sequestrum but are not as sensitive in early cases.
🚫 Ultrasound (D) detects soft tissue involvement but is not diagnostic for osteomyelitis.

Question 6

66. The required duration of treatment for acute osteomyelitis in children is at least:
    A. 1–2 weeks
    B. 2–3 weeks
    C. 4–6 weeks
    D. 6–8 weeks

Answer 6

C. 4–6 weeks
Rationale:
💊 Osteomyelitis requires at least 4–6 weeks of antibiotic therapy to ensure complete eradication of infection.
🚫 Shorter durations (A, B) increase the risk of recurrence.
🚫 6–8 weeks (D) may be needed in complicated cases but is not always required.

Question 7

67. The classic clinical description of osteogenesis imperfecta includes a combination of the following findings EXCEPT:
    A. Blue sclera
    B. Deafness
    C. Mental retardation
    D. Bone fractures

Answer 7

C. Mental retardation
Rationale:
🦴 Osteogenesis imperfecta (OI) is characterized by:

Blue sclera
Bone fractures
Hearing loss (deafness)
🚫 OI does not typically cause intellectual disability (C).

Question 8

68. This condition is considered tuberculosis of the spine and may occur in the cervical, dorsal, and lumbar regions:
    A. Haglund’s disease
    B. Pott’s disease
    C. Still’s disease
    D. Pott’s syndrome

Answer 8

B. Pott’s disease
Rationale:
🦠 Pott’s disease is tuberculosis of the spine, commonly affecting the thoracic and lumbar regions, leading to vertebral collapse and spinal deformity.
🚫 Haglund’s disease (A) is a bony deformity of the heel.
🚫 Still’s disease (C) is systemic juvenile idiopathic arthritis.

Question 9

69. Curvature of the spine may be caused by prolonged, unequal compression of intervertebral cartilages. When two lateral curvatures greater than or equal to 10 degrees with convexities turned in opposite directions occur, this is called:
    A. Lordosis
    B. Ankylosis
    C. Scoliosis
    D. Kyphosis

Answer 9

C. Scoliosis
Rationale:
🦴 Scoliosis is an abnormal lateral curvature of the spine, often detected by the presence of two opposite convex curvatures.
🚫 Lordosis (A) refers to excessive inward curvature.
🚫 Ankylosis (B) is joint stiffness due to fusion.
🚫 Kyphosis (D) is excessive outward curvature of the spine.

Question 10

70. The most common cause of in-toeing in children 2 years old or older, in which affected children assume a “W” sitting position, is:
    A. Internal femoral torsion
    B. External femoral torsion
    C. Internal tibial torsion
    D. External tibial torsion

Answer 10

A. Internal femoral torsion
Rationale:
👶 Internal femoral torsion (also called femoral anteversion) is the most common cause of in-toeing in children >2 years and is associated with a “W” sitting position.
🚫 External femoral torsion (B) and tibial torsion (C, D) are not typically linked to in-toeing.

Question 11

71. If physiologic genu varum (bowlegs) usually resolves spontaneously by age 2, physiologic genu valgum (knock-knees) resolves spontaneously by what age?
    A. 1–2 years
    B. 3–5 years
    C. 5–8 years
    D. 8–10 years

Answer 11

C. 5-8 years
Rationale:
🦵 Physiologic genu valgum (knock-knees) typically resolves spontaneously by 5-8 years of age.
📏 Genu valgum peaks around 3-4 years before gradually resolving.
🚫 Options A and B (1-5 years) are too early for complete resolution.
🚫 Persistence beyond 8-10 years (D) may suggest an underlying pathology.

Question 12

72. A 5-year-old boy presents with a 2-day history of left hip pain preceded by an upper respiratory tract infection (URTI) and low-grade fever. He appears mildly ill with a fever of 38.0°C, refuses to walk, holds his hip flexed, abducted, and externally rotated, and exhibits equal leg lengths. His WBC count is 11,000/mm³, and ESR is 35 mm/hr. The most likely cause of acute hip pain in this patient is:
    A. Septic arthritis
    B. Early childhood-onset pauciarticular juvenile rheumatoid arthritis (JRA)
    C. Transient synovitis
    D. Legg-Calvé-Perthes disease

Answer 12

C. Transient synovitis
Rationale:
🦠 Transient synovitis is the most common cause of hip pain in children following an upper respiratory tract infection.
📉 Low-grade fever, normal/mildly elevated WBC (11,000), and ESR (35 mm/hr) favor transient synovitis over septic arthritis.
🚫 Septic arthritis (A) typically presents with a high fever, leukocytosis, and ESR >40 mm/hr.
🚫 Juvenile idiopathic arthritis (B) has a chronic course.
🚫 Legg-Calvé-Perthes disease (D) presents with insidious, painless limp rather than acute onset.

Question 13

73. Diagnostic signs of developmental dysplasia of the hip include all of the following EXCEPT:
    A. Asymmetry of thigh and gluteal folds
    B. (+) Galeazzi test
    C. (+) Ortolani test
    D. (+) Allis test
    E. Limited hip abduction

Answer 13

C. (+) Ortolani Test ❌

This is because the Ortolani test is not diagnostic in older infants (>3-6 months old).
• Why? The Ortolani test is only positive in newborns with a dislocatable but reducible hip.
• After 3-6 months, the hip becomes more fixed in a dislocated position, making the test negative even if DDH is present. Instead, limited hip abduction becomes the key finding.

Diagnostic Signs of DDH:

✅ A. Asymmetry of thigh and gluteal folds – Suggests unilateral DDH.
✅ B/D. (+) Galeazzi/Allis Test – Lower knee height on the affected side in unilateral DDH.
✅ E. Limited hip abduction – Most reliable sign in infants >3 months.

Key Takeaway:
• Ortolani Test (+) → Only useful in newborns (≤3 months).
• After 3-6 months → Limited hip abduction is the best indicator.
• Since the question does not specify the age range, C is the best answer because Ortolani is not always diagnostic, especially in older infants.

Question 14

74. All the following are risk factors for slipped capital femoral epiphysis (SCFE) EXCEPT:
    A. Obesity
    B. Trisomy 21
    C. Hyperthyroidism
    D. Pituitary tumor
    E. Growth hormone deficiency

Answer 14

C. Hyperthyroidism
Rationale:
🦵 Slipped capital femoral epiphysis (SCFE) is associated with endocrine disorders causing delayed skeletal maturation, including:

Obesity (A)
Trisomy 21 (B)
Pituitary tumors (D)
Growth hormone deficiency (E)
🚫 Hyperthyroidism (C) is not a risk factor; instead, hypothyroidism increases SCFE risk.

Question 15

75. The MOST common cause of in-toeing in a child younger than 2 years old is:
    A. Internal femoral torsion
    B. Internal tibial torsion
    C. Metatarsus adductus
    D. Talipes equinovarus (clubfoot)
    E. Developmental hip dysplasia

Answer 15

B. Internal tibial torsion
Rationale:
🦶 Internal tibial torsion is the most common cause of in-toeing in children <2 years.
📏 It is due to intrauterine positioning and usually resolves by age 3-4.
🚫 Internal femoral torsion (A) is more common after 2 years.
🚫 Metatarsus adductus (C) affects foot alignment rather than leg rotation.
🚫 Clubfoot (D) is a distinct congenital deformity.
🚫 Developmental hip dysplasia (E) causes abnormal hip positioning, not in-toeing.

Question 16

76. More than 60% of patients with congenital scoliosis have other associated abnormalities. The most common one is:
    A. Renal anomalies
    B. Congenital heart disease
    C. Syringomyelia
    D. Diastematomyelia

Answer 16

A. Renal anomalies
Rationale:
🩺 More than 60% of patients with congenital scoliosis have associated anomalies, with renal abnormalities being the most common.
🚫 Congenital heart disease (B) and spinal cord defects (C, D) are also seen but are less frequent.

Question 17

77. Idiopathic scoliosis is characterized by all the following EXCEPT:
    A. It is the most common form of scoliosis.
    B. It occurs in children with neurological defects.
    C. The incidence is slightly higher in girls than boys.
    D. The condition is more likely to progress and require treatment in females.

Answer 17

B. It occurs in children with neurological defect
Rationale:
🦴 Idiopathic scoliosis occurs in otherwise healthy children and is not associated with neurological disorders.
✅ True characteristics of idiopathic scoliosis:

Most common form of scoliosis (A).
More common in girls than boys (C).
Higher progression risk in females (D).

Question 18

78. Initial treatment for scoliosis is likely observation and repeat radiographs to assess for progression. The risk factors for curve progression include all the following EXCEPT:
    A. Gender
    B. Curve location and magnitude
    C. Patient age
    D. Skeletal maturity

Answer 18

D. Skeletal maturity
Rationale:
📏 Risk factors for scoliosis progression include:

Gender (A) – females at higher risk.
Curve location/magnitude (B) – thoracic curves progress more.
Patient age (C) – younger age means higher risk of progression.
🚫 Skeletal maturity (D) is a protective factor, as growth completion reduces progression risk.

Question 19

79. Metatarsus adductus is the most common foot disorder in infants. Which of the following is a feature of this disorder?
    A. It is caused by in utero positioning.
    B. It is rarely bilateral.
    C. It is more common in boys.
    D. It is less common in first-born children.

Answer 19

A. It is caused by in utero positioning
Rationale:
🦶 Metatarsus adductus results from intrauterine crowding, causing the forefoot to curve inward.
🚫 It is often bilateral (B), not rare.
🚫 It affects boys and girls equally (C).
🚫 It is more common in first-born children (D) due to limited intrauterine space.

Question 20

80. Infants are born with maximum genu varum. The lower extremities straighten out around the age of:
    A. 12 months
    B. 18 months
    C. 24 months
    D. 30 months

Answer 20

C. 24 months
Rationale:
🦵 Infants are born with physiologic genu varum (bowlegs), which naturally resolves around 24 months.
📏 By 2 years, the legs straighten, and physiologic genu valgum begins to develop.
🚫 It does not resolve as early as 12 months (A) or 18 months (B).
🚫 By 30 months (D), valgus angulation starts to peak.

Question 21

81. A 20-month-old child presents with symmetrical genu varum. His height is on the 10th percentile, weight on the 25th percentile, with no dysmorphic features. His calcium, phosphorus, and alkaline phosphatase levels are normal for his age, with no abnormal radiological findings. The MOST likely diagnosis is:
    A. Physiologic bowlegs
    B. Blount disease
    C. Active rickets
    D. Skeletal dysplasia

Answer 21

A. Physiologic bowlegs
Rationale:
🦵 Physiologic genu varum (bowlegs) is common in children under 2 years and resolves by 24 months to 3 years without intervention.
📏 Normal height, weight, and biochemical markers (calcium, phosphorus, ALP) suggest a physiologic process rather than a pathological disorder.
🚫 Blount disease (B) presents with progressive, asymmetric bowing and abnormal X-rays.
🚫 Rickets (C) presents with low calcium/phosphorus and elevated ALP.
🚫 Skeletal dysplasia (D) often has dysmorphic features and growth abnormalities.

Question 22

82. A 12-year-old presents with severe arthritis of the hips and sacroiliac joints. Labs reveal that the patient is HLA-B27 positive. Which of the following is the most likely diagnosis?
    A. Juvenile idiopathic arthritis
    B. Systemic lupus erythematosus
    C. Henoch-Schönlein purpura
    D. Reactive arthritis

Answer 22

A. Juvenile idiopathic arthritis (JIA)
Rationale:
🦴 Juvenile idiopathic arthritis, particularly the enthesitis-related arthritis subtype, presents with severe hip and sacroiliac joint involvement.
🧬 HLA-B27 positivity is a key marker for this condition.
🚫 Systemic lupus erythematosus (B) causes polyarthritis but primarily affects small joints and has additional systemic symptoms.
🚫 Henoch-Schönlein purpura (C) is associated with arthritis but more commonly in the lower extremities with a purpuric rash.
🚫 Reactive arthritis (D) occurs post-infection and is usually asymmetric, not symmetric like JIA.

Question 23

83. A sexually active 16-year-old boy presents with arthritis, proximal muscle weakness, erythematous hypertrophic papules over the knuckles, and a violaceous heliotrope rash around the eyes. This is consistent with a diagnosis of:
    A. Henoch-Schönlein purpura
    B. Systemic lupus erythematosus
    C. Kawasaki disease
    D. Dermatomyositis

Answer 23

D. Dermatomyositis
Rationale:
💪 Dermatomyositis is an inflammatory myopathy characterized by:

Proximal muscle weakness
Heliotrope rash (violaceous discoloration around the eyes)
Gottron papules (erythematous hypertrophic papules over the knuckles)
🚫 Henoch-Schönlein purpura (A) presents with a purpuric rash, not heliotrope rash.
🚫 Systemic lupus erythematosus (B) may have arthritis and rash but does not typically cause muscle weakness or Gottron papules.
🚫 Kawasaki disease (C) presents with fever, conjunctivitis, and mucocutaneous symptoms.

Question 24

84. A 5-year-old girl presents with arthritis, abdominal pain, and a petechial eruption on her buttocks. These findings are consistent with a diagnosis of:
    A. Henoch-Schönlein purpura
    B. Systemic lupus erythematosus
    C. Kawasaki disease
    D. Dermatomyositis

Answer 24

A. Henoch-Schönlein purpura (HSP)
Rationale:
🩸 HSP is the most common vasculitis in children and presents with:

Palpable purpura (esp. on the buttocks and lower extremities)
Arthritis (usually in knees, ankles)
Abdominal pain (can indicate GI involvement)
🚫 Systemic lupus erythematosus (B) does not typically present with lower limb purpura.
🚫 Kawasaki disease (C) presents with prolonged fever and mucocutaneous changes.
🚫 Dermatomyositis (D) does not involve purpura or abdominal pain.

Question 25

85. A 3-year-old boy presents to the ER with fever and sore throat for five days. Physical examination reveals an irritable but consolable child, febrile (39.9°C). Other pertinent findings include bilateral non-purulent conjunctivitis, red cracked lips, swollen indurated fingers with erythematous palms, and a macular rash on the trunk. These findings are consistent with a diagnosis of:
    A. Juvenile idiopathic arthritis
    B. Systemic lupus erythematosus
    C. Kawasaki disease
    D. Dermatomyositis

Answer 25

C. Kawasaki disease
Rationale:
🔥 Kawasaki disease is a vasculitis presenting with:

≥5 days of fever
Bilateral non-purulent conjunctivitis
Cracked lips, strawberry tongue
Swelling and erythema of hands and feet
Polymorphous rash
🚫 Juvenile idiopathic arthritis (A) does not cause mucocutaneous symptoms.
🚫 Systemic lupus erythematosus (B) usually presents in older children with systemic involvement.
🚫 Dermatomyositis (D) presents with muscle weakness, not prolonged fever.

Question 26

86. A 12-year-old obese boy presents with pain in the right hip and thigh for the past 24 hours. He is also limping. Six months ago, he was diagnosed with slipped capital femoral epiphysis (SCFE). Which of the following tests would be appropriate to assess for other pathology associated with SCFE?
    A. Thyroid function tests
    B. Calcium level
    C. Rheumatoid factor
    D. Antinuclear antibody

Answer 26

A. Thyroid function tests
Rationale:
🦵 Slipped Capital Femoral Epiphysis (SCFE) is associated with underlying endocrine disorders, particularly hypothyroidism.
🔬 Thyroid function tests are necessary to evaluate for hypothyroidism, which increases the risk of SCFE.
🚫 Calcium levels (B) are not directly related to SCFE.
🚫 Rheumatoid factor (C) and antinuclear antibody (D) are associated with autoimmune arthritis, not SCFE.

Question 27

87. A 15-month-old boy is brought to the ER with high fever and refusal to walk. No trauma occurred. On exam, the child is fussy, and manipulation of the left hip elicits moderate discomfort. CBC shows WBC 28,000/mm³, ESR 80 mm/hr. The most likely cause of hip pain in this boy is:
    A. Toxic synovitis
    B. Septic arthritis
    C. Osteomyelitis
    D. Reactive arthritis

Answer 27

B. Septic arthritis
Rationale:
🦠 Septic arthritis presents with:

High fever, refusal to walk, and joint pain
Elevated WBC (28,000) and ESR (80 mm/hr), indicating infection
Pain on hip manipulation
🚫 Toxic synovitis (A) presents similarly but with milder symptoms and lower inflammatory markers.
🚫 Osteomyelitis (C) usually presents with more localized bone pain, rather than joint involvement.
🚫 Reactive arthritis (D) follows an infection but does not cause such high inflammatory markers.

Question 28

88. A 15-year-old girl presents with knee pain. She is on her high school basketball team and began experiencing knee pain about four weeks after preseason training started. On examination, she has mild tenderness and swelling of the left anterior tibial tuberosity. The most likely cause of knee pain in this girl is:
    A. Osgood-Schlatter disease
    B. Sever disease
    C. Slipped capital femoral epiphysis
    D. Legg-Calvé-Perthes disease

Answer 28

A. Osgood-Schlatter disease
Rationale:
🏀 Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle, commonly seen in adolescent athletes.

Localized pain at the anterior tibial tuberosity
Swelling and tenderness
🚫 Sever disease (B) affects the heel, not the knee.
🚫 SCFE (C) affects the hip, not the knee.
🚫 Legg-Calvé-Perthes disease (D) affects the hip joint.