Pediatrics

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Dr Bhatia Medical Institute
Visual Questions for Pediatrics

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1. A 2-year-old child (A) presents with a four-day history of a rash limited to the feet and ankles. The
papular rash is both pruritic and erythematous. The 3-month-old sibling of this patient (B) has
similar lesions also involving the head and neck. Appropriate treatment for this condition
includes (See Fig)

(A). Coal-tar soap
(C). Hydrocortisone cream

(B). Permethrin
(D). Emollients

1. Ans. (A). Coal-tar soap
When the clinical signs of constricted pupils, bradycardia, and muscle fasciculations are associated with the sudden onset
of neurologic symptoms, progressive respiratory distress, diaphoresis, diarrhea, and overabundant salivation, a diagnosis
of organophosphate poisoning should be suspected. Intake of organophosphate agents can occur by ingestion, inhalation,
or absorption through skin or mucosa. Organophosphates inhibit carboxylic esterase enzymes, including
acetylcholinesterase and pseudocholinesterase; toxicity depends primarily on the inactivation or inhibition of
acetylcholinesterase.
Treatment consists of gastric lavage, if the poison has been ingested, or decontamination of the skin, if exposure has been
through contact. Maintenance of adequate ventilation and fluid and electrolyte balance also is indicated. All symptomatic
children should receive atropine and, if severely affected, cholinesterase-reactivating oximes as well. Cholinesterasereactivating oximes quickly restore consciousness by inhibiting muscarine- and nicotine-like synaptic actions of
acetylcholine. Cholinesterase-reactivating oximes include pralidoxime chloride or obidoxime.

2. A 1-week-old black infant presents to you for the first time with a large, fairly well-defined, purple
lesion over the buttocks bilaterally, as shown in the photograph. The lesion is not palpable, and it is not
warm or tender. The mother denies trauma and reports that the lesion has been present since birth. This
otherwise well-appearing infant is growing and developing normally and appears normal upon physical
examination. The most likely diagnosis in this infant is (See Fig)

(A). Child abuse
(B). Mongolian spot
(C). Subcutaneous fat necrosis
(D). Vitamin K deficiency
2. Ans. (B). Mongolian spot (Behrman, 16/e, pp 455, 1970.)
Mongolian spots are bluish-gray lesions located over the buttocks, lower back, and occasionally, the extensor surfaces of
the extremities. They are common in blacks, Asians, and Latin Americans. They tend to disappear by 1 to 2 years of age,
although those on the extremities may not fully resolve. Child abuse is unlikely to present with bruises alone; children
frequently present with more extensive injuries. Subcutaneous fat necrosis is usually found as a sharply demarcated, hard
lesion on the cheeks, buttocks, and limbs. The lesion usually is red. Hemophilia and vitamin K deficiency rarely present
with subcutaneous lesions as described and are more likely to present as a bleeding episode.
3. You see the baby shown in the picture for the first time in the nursery as a newborn. You consult
plastic and reconstructive surgery as well as the hospital’s speech therapist. Understandably, the parents
have many questions. Which of the statements listed below is appropriate anticipatory guidance for this
family? (See Fig.)

(A). Parenteral alimentation is recommended to prevent aspiration
(B). Surgical closure of the palatal defect should be done before 3 months of age
(C). Good anatomic closure will preclude the development of speech defects
(D). Recurrent otitis media and hearing loss are likely complications
3. Ans. (D). Recurrent otitis media and hearing loss are likely complications
The infant pictured has bilateral cleft lip and palate. This defect occurs in about 4% of the siblings of affected infants; its
incidence in the general population is 1 in 1000. Evaluation for other structural and chromosomal abnormalities is
indicated. Although affected infants are likely to have feeding problems initially, these problems usually can be overcome
by feeding in a propped-up position and using special nipples. Complications include recurrent otitis media and hearing
loss as well as speech defects, which may be present despite good anatomic closure. Repair of a cleft lip usually is
performed within the first 2 to 3 months of life; the palate is repaired later, usually between the ages of 6 months and 5
years.
4. The infant in the following pictures (A) and (B) presented with hepatosplenomegaly, anemia,
persistent rhinitis, and a maculopapular rash. The most likely diagnosis for this child is (See Fig. )

A

B

(A). Toxoplasmosis
(B). Glycogen storage disease
(C). Congenital hypothyroidism
(D). Congenital syphilis
4. Ans. (D). Congenital syphilis

(Behrman, 16/e, pp 903–907..)

The clinical presentation of congenital syphilis is varied. Many newborns appear normal at birth and continue to be
asymptomatic for the first few weeks or months of life. Most untreated infants will develop a skin lesion, the usual one
being an infiltrative, maculopapular peeling rash that is most prominent on the face, palms, and soles. Involvement of the
nasal mucous membranes causes rhinitis with a resultant serous and occasionally purulent, blood-tinged discharge
(snuffles).
This, as well as scrapings from the skin lesions, contains abundant viable treponemes. Hepatosplenomegaly and
lymphadenopathy are common, and early jaundice is a manifestation of syphilitic hepatitis. Among the later
manifestations, or stigmata, of congenital syphilis is interstitial keratitis, which is an acute inflammation of the cornea that
begins in early childhood (most commonly between 6 and 14 years of age). Interstitial keratitis represents the response of
the tissue to earlier sensitization. Findings include marked photophobia, lacrimation, corneal haziness, and eventual
scarring.

5. A 3-year-old girl is admitted with the x-ray pictured. The child lives with her parents and a 6-week-old
brother. Her grandfather stayed with the family for 2 months. The grandfather had a 3-month history of
weight loss, fever, and hemoptysis. Appropriate management of this problem includes (See Fig)

(A). Bronchoscopy and culture of washings for all family members
(B). Placement of a Mantoux test on the 6-week-old sibling
(C). Isolating the 3-year-old patient for 1 month
(D). Treating the 3-year-old patient with isoniazid (INH) and rifampin
5. Ans. (D). Treating the 3-year-old patient with isoniazid (INH) and rifampin (Behrman, 16/e, pp 885–
897.)
The key to controlling tuberculosis in children and eradicating the disease is early detection and appropriate treatment of
adult cases; the child, once infected, is at lifelong risk for the development of the disease and for infecting others unless
given isoniazid prophylaxis. The usual source of the disease is an infected adult. Household contacts of a person with
newly diagnosed active disease have a considerable risk of developing active tuberculosis, and the risk is greatest for
infants and children. Therefore, when tuberculosis is diagnosed in a child, the immediate family and close contacts should
be tested with tuberculin skin tests and chest radiographs and treated appropriately when indicated. Bronchoscopy would
be indicated only in unusual circumstances. Three to eight weeks is required after exposure before hypersensitivity to
tuberculin develops. This means that the tuberculin test must be repeated in exposed persons if there is a negative
reaction at the time that contact with the source of infection is broken. TB skin tests are usually negative in infants of this
age, even when active disease is ongoing. A logical preventive measure is the administration of isoniazid to the baby for 3
months when a Mantoux (purified protein derivative, PPD) can then be placed. Transmission of tuberculosis occurs when
bacilli-laden, small-sized droplets are dispersed into the air by the cough or sneeze of an infected adult. Small children
with primary pulmonary tuberculosis are not considered infectious to others, and they are not capable of coughing up and
producing sputum. Sputum, when produced, is promptly swallowed, and for this reason specimens for microbial
confirmation can be obtained by means of gastric lavage from smaller children.

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