Pediatric Examination and Board Review (96 page)

Behrman RE, Kliegman RM, Jenson HB, et al.
Nelson Textbook of Pediatrics
. Philadelphia, PA: WB Saunders; 2007.

Kirschner RE. Cleft lip and palate.
Otolaryngol Clin North Am.
2000;33(6):1191-1215.

Lack G. Pediatric allergic rhinitis and comorbid disorders.
J Allergy Clin Immunol.
2001;108:S9-S15.

Martof A. Consultation with the specialist: dental care.
Pediatr Rev.
2001;22(1):13-15.

Scadding G. Optimal management of nasal congestion caused by allergic rhinitis in children: safety and efficacy of medical treatments.
Pediatric Drugs.
2008;10(3):151-162.

CASE 59: A 4-YEAR-OLD GIRL WITH “PINK EYE”

A 4-year-old girl comes in with eye swelling of 3 days’ duration. She is a new patient and has brought her old records with her. Her mother confirms that she has had no immunizations, based on parental refusal. The girl is rubbing at her eye a lot, and it is red and puffy. Her mother says that she thinks her daughter “has pink eye” and saw a doctor at another office several weeks ago for it. At that time she was congested and had a cough, and she was sent home with no medication.

On examination you note that she is afebrile and slightly fussy. She has 2 cm of erythema and edema surrounding the right eye and it is very tender. She is able to follow your finger in all directions and has no proptosis. Her nose, throat, and lung examinations are normal.

SELECT THE ONE BEST ANSWER

1.
What is her most likely diagnosis?

(A) Pott puffy tumor

(B) acute bacterial sinusitis

(C) preseptal cellulitis

(D) orbital cellulitis

(E) type 1 hypersensitivity reaction

2.
In this case, what is the most helpful information to make the diagnosis?

(A) physical examination and history

(B) CBC with differential leukocyte count

(C) blood culture

(D) culture of eye discharge

(E) CT of orbits

3.
How would you treat this child?

(A) oral cephalexin

(B) oral dicloxacillin

(C) oral prednisone

(D) IV ceftriaxone and clindamycin

(E) IV ceftriaxone alone

4.
A 6-year-old boy is brought to your office by his mother because he has had some increasing swelling around his eye for the last several days that seems worse today. This morning he was having difficulty “looking around” with that eye and is complaining that it hurts. On examination he is afebrile, has right-sided lid edema and erythema, proptosis, and lateral gaze is decreased. What is his diagnosis?

(A) Pott puffy tumor

(B) acute bacterial sinusitis

(C) preseptal cellulitis

(D) orbital cellulitis

(E) type 1 hypersensitivity reaction

5.
What is the most common associated finding of this disease?

(A) paranasal sinusitis

(B) frontal sinusitis

(C) conjunctivitis

(D) bacteremia with hematogenous spread

(E) trauma to the orbit

6.
Which organism(s) is (are) the
least
likely to cause this disease in young children?

(A) group A streptococci

(B)
S pneumoniae
(C)
H influenzae
type b

(D)
S aureus
(E) A and D

7.
Which of the following tests is the gold standard in diagnosing an orbital abscess?

(A) testing of visual acuity and extraocular movements

(B) ultrasound

(C) radiographs of the sinus and orbits

(D) CT of orbit

(E) MRI of orbit

8.
For how long should he receive antibiotics for his disease?

(A) 7 days

(B) 10 days

(C) 14 days

(D) 21 days

(E) 30 days

9.
Preseptal cellulitis occurs in an older age group than orbital cellulitis

(A) true

(B) false

10.
Sinusitis more commonly is an associated finding of orbital cellulitis than preseptal cellulitis

(A) true

(B) false

11.
A 12-year-old boy is seen in your office with redness in both eyes of 3 days’ duration. They do not itch. He also has had nasal congestion and a cough for 5 days. On examination he is afebrile. He has audible congestion and scant clear rhinorrhea. His turbinates are red and swollen. His eyes are bilaterally mildly injected and watery, with no discharge currently. There is no surrounding erythema or edema, and his fundoscopic examination is normal bilaterally. His lungs are clear bilaterally. What is the most likely diagnosis?

(A) bacterial conjunctivitis

(B) viral conjunctivitis

(C) allergic conjunctivitis

(D) herpes simplex conjunctivitis

(E) dacryocystitis

12.
The child from question 11 returns several days later with the same eye complaints but has developed a sore throat. He has been intermittently febrile (101.2°F [38.4°C] orally), and his eye examination has only changed in that the conjunctival erythema has become more intense. His posterior pharynx is slightly red, there are no exudates or petechiae, and the oral cavity is normal. He has a few tender cervical and preauricular lymph nodes, all smaller than 2 cm. What is the most likely pathogen causing this disease?

(A) EBV

(B) Coxsackie virus

(C) herpes simplex virus

(D) adenovirus

(E) influenza virus

13.
You see a 13-year-old boy in your office because of redness in one eye that is persisting for 3 days. It does not itch, but he is concerned because this morning there was thick, yellow discharge from the eye. Upon waking, his eyelids were stuck together. He had a “cold” last week but that has resolved. On examination, he is afebrile, and his left eye is severely injected, with dried and crusted yellowish discharge. His extraocular movements are intact. There is no preseptal erythema or edema. The rest of his examination is normal. What is his diagnosis?

(A) bacterial conjunctivitis

(B) viral conjunctivitis

(C) allergic conjunctivitis

(D) herpes simplex conjunctivitis

(E) dacryocystitis

14.
What will you prescribe for the boy from question 13 to treat this condition?

(A) steroid and antibiotic eye drops

(B) oral amoxicillin

(C) oral doxycycline

(D) antibiotic eye drops

(E) warm compress only

15.
You see a 6-month-old in the office because of “stuff coming out of his eye.” His father describes a yellowish watery discharge that makes his left eye stuck closed in the morning. This has been going on for 3 days. On examination, the baby smiles while you examine him. You note unilateral watery discharge and some scant yellow discharge. The conjunctiva is white. The infant fixes and follows on your hand 180 degrees. What is his diagnosis?

(A) dacryocystitis

(B) nasolacrimal duct obstruction

(C) viral conjunctivitis

(D)
Chlamydia trachomatis
conjunctivitis

(E)
Neisseria gonorrhoeae
conjunctivitis

16.
You see a 5-year-old boy in your office because of a “lump” in his eye. It has been there for several weeks, is not red, does not hurt, but he does play with it frequently, which bothers his parents. On examination, he is afebrile and cooperative. You note a firm, nontender nodule in the lower left lid. There is no overlying erythema. His extraocular movements and gross visual acuity are intact. Which gland does this involve?

(A) gland of Zeis

(B) lacrimal gland

(C) gland of Moll

(D) meibomian gland

(E) none of the above

17.
You get a call at night from a mother worried about her 8-year-old daughter, who has a “red lump” in her eye. It developed 2 days ago and looks worse to her mother today. She describes a red, tender lump about 0.5 cm across that is just at the edge of the lower eyelid. From her description, what is the
most
likely diagnosis?

(A) internal hordeolum

(B) external hordeolum

(C) chalazion

(D) dacryocystitis

(E) blepharitis

18.
Which of the following is
not
associated with childhood ptosis?

(A) botulism

(B) myasthenia gravis

(C) trisomy 13

(D) amblyopia

(E) muscular dystrophy

ANSWERS

1.
(C)
This is most likely preseptal cellulitis based on the physical findings (see
Figure 59-1
). Preseptal (or periorbital) is differentiated from orbital cellulitis anatomically, symptomatically, and by physical findings (see below for further discussion).