Embed Size (px)
Citation preview
MCQ TEST Evaluation
MastercoursePaediatric Allergology
CLINICAL CASE 1
Eight week old baby whose mother cannot continue to breastfeed
1. Considering that it was definitely impossible to convince themother to continue breastfeeding, what formula do yourecommend?
a) Standard first infant formula
b) Extensively hydrolizedcow´s milk based formula
c) Partially hydrolized cow´s milk based formula
d) Soy based formula
e) b or c 0
2
4
6
8
10
12
a) b) c) d) e)
1st Test 2nd Test2nd Test
2. After the parents left, your assistant nurse asked for youropinion on the possible use of formulae with pro, pre orsymbiotics for allergy prevention. What would you say?
a) They have a well proven effect, so youwould definitely recommend thissupplementation
b) It has been well demonstrated that theyhave absolutely no effect, so their use isa waste of money
c) So far, there is insufficient documentation for a preventive effect of this supplementation, so you would not recommend
d) They may harm the baby because of thechanges induced in the gut flora
e) They are only useful if given to themother during pregnancy, so there is nopoint in adding them to infant formulae
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
3. What follow-up feeding practice would you recommend if the baby never develops allergic symptoms?
a) Continue the milk formula prescribed at 8 weeks at least until the age of 12 months
b) Delay the introduction of egg, fish and standard milk or formula until the age of 2 years
c) Delay the introduction of egg, fish and standard milk or formula until the age of 1 year
d) Delay the introduction of peanuts, tree nuts and chocolate until de age of 4 years
e) Start the gradual introduction of other foods, including wheat, egg, fish, vegetables, pea nuts, and tree nuts after the age of 4 months
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
4. There is some evidence that some dietetic measures for “high-risk” infants reduce the risk for development of food allergy and atopic eczema. Which of the following is recommended by the recent EAACI Guidelines?
a) Exclusive breastfeeding during at least 6 months
b) Avoidance of cow’s milk products during at least the first year of life
c) Exclusive breastfeeding and/or a documented hypoallergen formula during the first 4 months of life
d) Exclusive breastfeeding and/or a documented hypoallergen formula during the first 2 months of life
e) Avoidance of “hyperallergenic” foods e.g. cow’s milk, hens egg, peanut, tree nuts and fish the first year of life
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
5. Early dietary allergy prevention strategies have shown some effect on development of allergic diseases. Which one of the following statements is correct ?
a) Early dietary intervention in high risk infants can reduce the risk for development of food allergy and eczema
b) Early dietary intervention in high risk infants can reduce the risk for development of allergic asthma
c) Early dietary intervention in high risk infants can reduce the risk for development of allergic rhinitis
d) Early dietary intervention in high risk infants increases the risk for development of allergic asthma
e) Early dietary intervention in high risk infants modifies the natural course of the allergic march
0
2
4
6
8
10
12
14
16
a) b) c) d) e)
1st Test 2nd Test2nd Test
Early dietary intervention in high risk infants can reduce the risk for development of food allergy and eczema but does not modify the natural course of the allergic march in the long run!
CLINICAL CASE 2
Five week old boy who after introduction of normal adapted cow’s milk base formula became uneasy with colic, vomiting x 2-4 daily, development of exanthema/urticaria, and also nasal itching.
6. The symptoms are suggestive of:
a) Lactose intolerance
b) Gastroenteritis
c) Constipation
d) Pyloric stenosis
e) Cow’s milk protein allergy0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
7. Clinical approach after physical examination consider the following:
a) Testing for allergy (IgEsensitization)
b) Lactose test
c) Ultrasound of abdomen
d) Examination of urine for glucose, protein, ketones
e) Echocardiography
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
8. Which test might give a quick indication of the diagnosis?
a) Skin prick test
b) Esophagoscopy/ gastroscopy
c) Inspection of stools
d) Measurement of pH in esophagus
e) Challenge meal with cow’s milk 0
2
4
6
8
10
12
14
16
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENT
A challenge meal with cow´s milk wouldcertainly indicate the diagnosis, but skin pricktest is simpler, quicker and less hazardous
9. You are not able to perform the tests today. Which advice would you give the mother?
a) Continue with breastfeeding and supplement of cow’s milk based formula
b) Change the current cow’s milk based formula to another cow’s milk based formula
c) Avoid cow’s milk formula containing lactose
d) Continue breastfeeding exclusively
e) Continue breastfeeding and give supplements of documented hypoallergenic formula when needed for 3 days and see the infant for follow-up
0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test2nd Test
CONCLUSION
• Skin prick test to cow’s milk protein was positive with a mean wheal diameter of 8 mm.
• All symptoms disappeared on breastfeeding and extensively hydrolysed formula
10. How do you diagnose a food allergy?
a) Skin prick test positive for the food in question
b) Specific IgE positive against the food in question
c) Patch test positive against the food in question
d) Positive histamine release test to the food in question
e) Elimination and controlled food challenge
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
CLINICAL CASE 3
Boy seven years old, with continuous snoring and a tendency to sleep apnoea, nasal stuffiness, morning headache and worsening of asthma symptoms
Previous history:
Family history: Mother atopic dermatitis and asthma since early childhood.
The boy has suffered from atopic dermatitis and recurrent wheezing since 12 months of age. Skin prick test at 4 years of age showed positive reaction against house dust mites Since four years of age treated with inhaled steroids and inhaled beta-2-agonists on demand.
11. Tentative diagnosis?
a) Nasal infection
b) Nasal polyposis
c) Hypertrophy of the tonsils
d) Nasal septum deviation
e) Allergic rhinitis
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
12. Physical examination: What would you focus on?
a) Inspection of cavum nasii, colour, inflammation or obstruction
b) Stetoscopia pulmonum
c) Stetoscopia cordis
d) Inspection of cavum oris
e) Neurological examination
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
13. Which tests would you perform/consider?
a) A new allergy testing (skin prick test or specific IgE) against inhalant allergens
b) A new skin prick test or specific IgE for standard allergens + relevant common food allergens
c) Allergy testing for food additives
d) Biopsy from the nose for histological examination
e) Culture from the nose
0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test2nd Test
14. In case your testing showed the following:Skin prick test positive against house dust mites (mean wheal diameter 10 mm) Skin prick test against egg (mean wheal diameter 8 mm) - what would you do to confirm the diagnosis?
a) Start nasal steroid treatment
b) Start local nasal steroid treatment + antihistamine treatment
c) Start antihistamine treatment local or systemic
d) Advice to avoid intake of egg/egg products in the future
e) Advice to avoid egg/egg products for one month, follow-up after 1 month, and in case of disappearance of the symptoms followed by supervised controlled egg challenge in the clinic
0
2
4
6
8
10
12
14
16
18
20
a) b) c) d) e)
1st Test 2nd Test2nd Test
CONCLUSION
• He suffered from challenge proven egg allergy.
• All symptoms disappeared on egg free diet and reappeared on egg challenge
CLINICAL CASE 4Girl aged 7 years, with long lasting nasal symptoms and more recently significant snoring and sleep disturbance and also intermittent hearing impairment.
Family history:
Mother has asthma and father allergic rhinitis
Clinical History:
History of “chronic cold” (stuffy nose, frequent rhinorrhoea, repeated sneezing, frequent nasal itch). Usually worse during autumn and winter .
several episodes of acute otitis media
Occasional mild wheezing during respiratory infections.
Partial relief with antihistamines.
15. Which diagnosis seems more probable to you?
a) Recurrent respiratory infections
b) Allergic Rhinitis
c) Vasomotor Rhinitis
d) Chronic adenoiditis
e) Chronic bacterial sinusitis
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
16. If your diagnosis was Rhinitis, how would you classify its gravity according to the ARIA guidelines?
a) Intermittent mild
b) Intermittent moderate to severe
c) Persistent mild
d) Persistent moderate to severe
e) Perennial moderate to severe
0
2
4
6
8
10
12
14
16
18
20
a) b) c) d) e)
1st Test 2nd Test2nd Test
ARIA Guidelines do not contemplartethe designation Perennial indicatingPersistent instead
17. What pharmacological treatment would you recommend, considering that antihistamines had only provided partial relief of symptoms?
a) Leukotriene receptor antagonists
b) Intranasal corticosteroid associated or not with an oral antihistamine
c) Oral antihistamine + Leukotriene receptor antagonist
d) a +b
e) b or c or d0
2
4
6
8
10
12
14
16
18
20
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENT
Since the child also wheezes with viral infection, addition ofa Leukotriene receptor antagonist is a feasible option, withthe added benefit of possible improved control of rhinitis.For this reason, e) is our choice
However, b), intranasal corticosteroid associated or notwith an oral antihistamine, is also an acceptable answer.
Otoscopy and tympanogram
Left
Left
Right
Right
18. How would you describe the findings of otoscopy and tympanogram?
a) Acute otitis media on the left and otitis media with effusion (serous otitis) on the right
b) Otitis media with effusion on the left and normal on the right
c) Bilateral otitis media with effusion , more serious on the left
d) Acute otitis media on the left and normal on the right
e) Cholesteatoma on the left and normal on the right
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
19. How would you manage the patient in relation to this specific aspect of her pathology?
a) Referral to a ENT surgeon with an indication for adenoidectomy
b) Referral to a ENT surgeon with an indication for left tympanostomy tube placement
c) a + b
d) Antibiotic treatment during 10 days
e) Medical treatment of rhinitis
0
2
4
6
8
10
12
14
16
a) b) c) d) e)
1st Test 2nd Test
20. After 3 weeks treatment the patient had improved considerably, however, she started bleeding from both nostrils and clinical exam showed that both Kiesselbach areas had a fragile appearance. How would you handle this situation?
a) Prescribe a blood coagulation study
b) Review the administration technique of the intranasal corticosteroid, in order to avoid direct pulverization of the septum
c) Referral to an ENT specialist for cauterization of Kiesselbach areas
d) Suspend intranasal corticosteroid
e) Use a different intranasal corticosteroid
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
Use of nasal Spray
Use of nasal Spray
Follow-up
You then decided to refer the patient to a paediatric allergologist who performed a complete allergy evaluation for standard inhalant allergens plus common food allergens.
The only relevant sensitization found was to House Dust Mites, particularly DermatophagoidesPteronissinus (DP)
The allergologist recommended appropriate environmental measures and Specific Allergen Immunotherapy with a DP extract
21. How could this therapy be administered?
a) Subcutaneously at home by a friend nurse
b) Subcutaneously in the Hospital or Clinic under medical supervision, with a strict safety monitoring protocol
c) Intramuscularly in the Hospital or Clinic under medical supervision, with a strict safety monitoring protocol
d) Sublingually at home with proper instructions to the patient and caregivers
e) b or d
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
22. This treatment should be given during:
a) 6 to 12 months
b) 1 to 2 years
c) 3 to 5 years
d) 5 to 10 years
e) Could be any of the previous depending on clinical evolution
0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test
CLINICAL CASE 5
Boy aged 10 years, with bothersome nasal and ocular symptoms during the last two springs
Family history: mother has possible allergic rhinitis
Environment: House in a rural area, built 15 years ago. No apparent moulds, no carpets or soft toys in the room. Dog usually outside. Father smokes out of the house
Clinical History: Since the age of 9, from April to June, he has daily complaints of nasal and eye itch, frequent sneezes and sometimes, very abundant rhinorrhoea. This year, eye itch was particularly intense. Symptoms are often very bothersome and interfere with his school and social activities. He gets better when it rains. There is no history of wheezing, even with exercise. He is well during the rest of the year
23. Which diagnosis seems more probable?
a) Allergic Rhinoconjuntivitistriggered by House Dust Mites
b) Allergic Rhinoconjunctivitistriggered by Pollens
c) Allergic Rhinoconjuntivitistriggered by Moulds
d) Vasomotor Rhinitis
e) b and/or c 0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
24. If your diagnosis was Rhinitis, how would you classify its gravity according to the ARIA guidelines?
a) Intermittent mild
b) Intermittent moderate to severe
c) Persistent mild
d) Persistent moderate to severe
e) Seasonal moderate to severe 0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test2nd Test
ARIA Guidelines do not contemplate thedesignation Seasonal.
Rhinitis in this child altough occuring only inthe in the pollen season, correspond to thecriteria of Persistent. (4 days per week and >4 weeks)
25 . How would you manage this patient?
a) Refer to a paediatric allergologist for allergy evaluation and possible specific immunotherapy
b) Daily oral antihistamine and/or intranasal costicosteroid from March 1st to July 31st
c) Antihistamine or nedocromil eye drops from March 1st to July 31st
d) Recommendations to decrease exposure to pollens
e) All of the above are acceptable and may be complementary measures 0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
CLINICAL CASE 6
• An infant boy presents at the emergency ward at 3 months of age with a one-day history of increasing tachypnoea and problems with breast-feeding. He is restless and tired.
• He is accompanied by his paternal grand-mother who does not know much about the baby’s or mothers medical history. Father had recurrent bronchitis as a child. The mother is away for one day in another city
CLINICAL CASE 6On clinical examination:
Respiratory rate 50
On auscultation: you hear vesicular
respiratory sounds, evenly distributed,
prolonged expiration, fine crackles
particularly basally all around, faint
wheezing at the front and back, basally.
Palpation: the liver is palpated
approximately 2 cm below the right costal
boarder.
Oxygen saturation (SaO2) is 88%
26 . What is your most likely diagnosis?
a) Asthma
b) Bronchiolitis
c) Pneumonia
d) Interstital lung disease
e) Cystic fibrosis0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENTS
This is a very characteristic case of bronchiolitis,although other diagnoses should be on the list.
Several respiratory diseases in this age may presentwith tachypnoea and chest recessions. In fact, thepicture shown is from a child with interstitial lungdisease! However, the most common and mostlikely diagnosis in this type of clinical presentation isacute bronchiolitis
27 . What would be your first choice of treatment?
a) Inhalations of bronchodilator (salbutamol or epinephrine)
b) Inhaled corticosteroids
c) Antibiotics
d) Systemic corticosteroids (soluble per oral or intravenous)
e) Supplementary oxygen0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENTS
According to up-dated guidelines, there is nodocumentation to suggest that salbutamol orepinephrine are effective as first choice in thisage, and systemic steroids should not be usedfor acute bronchiolitis. In fact, the onlyappropriate option above according to theclinical presentation is giving supplementaryoxygen and supportive care
FOLLOW UP
The child was discharged after two days of hospitalisation.
Nine months later he is referred to you, and comes accompanied bythe mother who tells you the subsequent clinical history :
In addition to the hospitalisation (Questions 26-27), he has had 3-4episodes of cough and wheeze for 10-14 days, particularly at night,accompanied by periods of runny nose. Additionally, he tends to haveother periods of cough at night (2-3 weeks), but the mother is not surewhether this happens together with a runny nose or not. He has notreceived any treatment
28 . What would you specifically ask the mother for, considering the most likely diagnosis?
a) Familial cystic fibrosis and personal history of diarrhoea
b) Familial asthma and allergies and personal manifestations of skin disease
c) Somatic growth, general development/well-being and environmental factors (including tobacco and pets)
d) b+c
e) a+c 0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENTS
The most likely diagnosis is asthma, although other chronicdiseases such as malacia (tracheo-broncho), CF and otherchronic lung diseases should be included in the differentialdiagnosis list.
Although we would always ask for parental lung disease, thepresent question is in relation to the most likely diagnosis,which in this case is related to asthma risk factors.
The boy has had episodic respiratory symptoms in relation toviral infections after the acute bronchiolitis, night cough. Thesymptom presentation and age is classical in relation to earlyasthma manifestation.
Further EvaluationYou establish that there is no history suspicious of allergy to food or inhalant allergens. He
has periodically some patches of mild itchy rash on the cheeks, chest and extremities
effectively treated with emollients and sometimes a mild (1%) hydrocortisone cream. He is a
generally happy, although not very active child, with periods of 3-6 weeks free of respiratory
symptoms.
On clinical examination he is in his habitual state:
The boy’s weight is just under the 2.5 percentile for length, and the length is around 10th
percentile for age.
He has no respiratory distress, respiratory rate is 18-20, no audible wheeze, but he coughs a
little. He has some crusty, yellow nasal secretions. No exanthema presently, no generalised
or local lymphadenopathy.
On auscultation: slightly diminished vesicular respiratory sounds, and slight sibiliations
(wheeze) on assisted forced expiration.
The liver is approximately 2.5 cm below the right costal boarder, but no organomegaly.
Clinical investigations:
Total IgE 5, no specific IgE antibodies to egg, wheat, cow’s milk, cat, dog, birch or grass. Skin
prick test is negative to the same.
29. What would be your next step?
a) Start a trial of short acting inhaled β-2 agonist (MDI and spacer) only for 2-3 months
b) Start a trial of inhaled β-2 agonist + low dose inhaled corticosteroids (MDI and spacer) for 2-3 months
c) Start a trial of leukotrieneantagonist (granulations) monotherapy
d) Give oral corticosteroids for 3-5 days
e) Perform chest X ray or thoracic CT-scan
0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENTSThis child, even though there is no suspicion of allergy (so
far) has, nevertheless, considerable chronic symptoms
(cough at night and wheeze triggered during infections and
activity) that suggest an on-going underlying inflammation.
It is, therefore acceptable to try a course of low-dose anti-
inflammatory treatment
Since he has periods with no symptoms, and is generally
happy it is acceptable to do this therapeutic trial before
subjecting him to further radiological investigations
CLINICAL CASE 7Girl, 5 years old, with long lasting symptoms of recurrent of cough and wheeze.Family History: Mother has asthma and older brother had atopic dermatitis in infancyEnvironment: old house with good ventilation, but some moisture problems. Bed room with carpets, curtains and many soft toys. No pets. Both parents are smokers.Clinical History:Since the age of 3 years, after entering nursery school, she started suffering episodes of cough and wheeze associated with viral respiratory infections, 4 to 6 times a year in the cold months. Well during summertime. Throughout autumn and winter, she often coughs and sometimes wheezes at night or with exercise, even without a cold or other apparent infection. Antibiotics have been prescribed several times, during acute episodes, for alleged “acute bronchitis”.Particularly in autumn and winter, she frequently snores and sometimes appears to have brief episodes of sleep apnoeaNo long term medicationPhysical exam: Good general condition. Enlarged nasal base, transverse nasal crease, enlarged turbinates with shiny pale mucosa, pulmonary auscultation normal. Peak Flow: 210 l/min
30. What is the most probable diagnosis?
a) Bronchitis
b) Asma + Allergic rhinitis
c) Asthma
d) Primary immunedeficiency
e) Other
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
31. What relief on demand medication would you prescribe?
a) Inhaled salbutamol
b) Inhaled terbutalinesulfate
c) Oral antihistamine
d) Inhaled ipatropiumbromide
e) a or b 0
2
4
6
8
10
12
14
16
18
20
a) b) c) d) e)
1st Test 2nd Test2nd Test
32. Would you recommend daily pharmacological treatment in this case?
a) Yes, with low dose inhaled corticosteroid
b) Yes, with an antileukotriene
c) Yes with a long acting β2 agonist (LABA)
d) a or b (maybe only from September to May depending on symptoms during summer)
e) No, I would only recommend relief medication on demand 0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test
33. If you decide to use inhalatory therapy, which devices would you prescribe?
a) pMDI + spacer for acute episodes and daily therapy
b) DPI for acute episodes and daily therapy
c) pMDI + spacer for acute episodes and DPI for daily therapy
d) DPI for acute episodes and pMDI + spacer for daily therapy
e) a or b or c, depending on the ability of the patient to use DPI devices
0
2
4
6
8
10
12
a) b) c) d) e)
1st Test 2nd Test
CLINICAL CASE 8
9 month old boy
History of severe atopic dermatitis from the fifth month of life.
Peribuccal Erythema with tomato
viral-induced asthma twice
Positive Skin Tests, Specific IgEand porvocation to wheat and eggs
34. When is allergy testing necessary in a 9 month old child with atopic eczema (AE)?
a) with moderate and severe persiInall cases
b) Always when the child has a reaction to foods, e.g. a local perioral rash after eating tomato
c) In children with moderate and severe persisting AE
d) When the total IgE is above 100 IU/mL
e) When there is a history of wheezing
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
35. Which statement is incorrect regarding treatment of AE?
a) One bath a week is enough otherwise the skin gets too dry
b) Bleach can be added to the bath in order to reduce germs on the skin
c) It might be helpful to use cream or ointments, according to the dryness of the skin
d) wet wraps can be useful when the skin is very inflamed and dry
e) Antihistamines seem to help some children, with AE largely due to their sleep-inducing side effects.
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test
,
2nd Test
36. Which statement is correct regarding the pathogenesis of AE?
a) The fillagrin inhibitor FI902 is missing in most AE patients
b) Wool is a very strong allergen in AE
c) Pruritus results from colonization of skin molds
d) Food allergies contribute to AE, but are not the cause of AE
e) Airborne allergens are almost never relevant in AE
0
2
4
6
8
10
12
14
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENT
There may be a deficit of fillagrin, but NOT ofthe fillagrin inhibitor FI902 !
37. Which allergy test result is most probably not related to the clinical picture in a case of AE?
a) A positive egg white skin test in a 12 month old child with AE
b) A positive wheat challenge that can provoke wheals within 30 minutes, and worsening of AE for 3 days
c) A specific IgE to wheat at 26 kU/L in a18 month old child with AE with no symptoms of AE when eating bread
d) A specific IgE to milk at 6 kU/L
e) A positive DermatophagoidesPteronissinus Atopy Patch Test in a AE patient with nocturnal exacerbation of symptoms
0
2
4
6
8
10
12
14
16
18
20
a) b) c) d) e)
1st Test 2nd Test2nd Test
38. The incidence (new cases) of atopic eczema is highest at age:
a) 6-12 months
b) 24-36 months
c) 2 months
d) 18 months
e) 5-10 years
0
2
4
6
8
10
12
14
16
18
20
a) b) c) d) e)
1st Test 2nd Test2nd Test
39. Sensitization to foods is frequent in children with AE in approximately:
a) 100%
b) up to 50%
c) 10%
d) 25%
e) 80%
0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test2nd Test
CLINICAL CASE 9A 7 year old boy was taken to the emergency room for difficult breathing, tongue itching, hives and oedema of the face and lips, all having started minutes after eating a piece of chocolate cake.
He was very anxious and called frequently for his mother.
He has asthma since the age of 3 and had manifestations of atopic eczema until the age of about 2 years.
Doccumented allergy to HDM and Peanut
40. What is your diagnosis and immediate attitude?
a) Anaphylaxis; give intramuscular adrenalin
b) Anaphylaxis; give oxygen + IV antihistamine + IV corticosteroid
c) Anaphylaxis; give oxygen + IV adrenaline + IV antihistamine + IV corticosteroid
d) Asthma attack; give oxygen and nebulized salbutamol + ipatropium
e) Unclear diagnosis; monitor the patient and observe evolution
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
Other measures may be also indicated but not as 1st priorityINTRAMUSCULAR,not INTRAVENOUS Adrenaline is indicated
Do not forget
a free airway
& recumbent position
Other measures may be also indicated but not as 1st priority
41. What is your proposal for initial investigations and observation? Please indicate one WRONG answer
a) Measure blood pressure
b) Measure serum tryptasewithin few hours
c) Observe as inpatient 24 hours
d) Discharge as soon as the reaction is declining
e) Refer to allergy testing
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
42. It turned out that the chocolate cake had been prepared with peanut butter (hidden allergen!). Which recommendations will you give the family?
a) In the case of a similar reaction the patient should be treated with a corticosteroid p.o immediately as first line treatment
b) In case of a similar reaction later on he should be treated with antihistamine p.o. immediately as first line treatment
c) In the future the patient should completely avoid peanuts and other nuts and carry an Adrenaline auto-injector
d) The patient and his caregivers should be instructed and motivated for the careful reading of food labels and always be very careful when eating at parties
e) c + d
0
5
10
15
20
25
30
a) b) c) d) e)
1st Test 2nd Test2nd Test
43. Does it matter that he has atopic asthma or allergic rhinitis?
a) Yes, severe/unstable asthma is a risk factor for severe anaphylaxis
b) No, asthma has no influence on the course
c) Yes, because asthma medication is a risk factor for anaphylaxis
d) Yes, because if he has allergic rhinitis and is treated with antihistamine on a daily basis, the risk for anaphylaxis will be markedly reduced and there will be no need to prescribe an adrenaline auto-injector
e) No, the association of food allergy and concomitant asthma is not an indication for prescribing self-administrative adrenaline auto-injector
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
CLINICAL CASE 10A 4-year old boy developed a
generalized urticarial rash 5 days
after introduction of amoxicillin for
an acute otitis media.
The parents mentioned that the
rash appeared 8 hours after the last
dose. He did not have any other
symptoms and the physical
examination was normal, except
the generalized urticaria.
The symptoms disappeared within
4 days
44. Most of the patients experiencing an adverse reaction during a betalactam treatment are labeled as “penicillin allergic”. Among those children, how many will have a positive allergic work-up confirming a penicillin allergy?
a) 1-4%
b) 5-15%
c) 20-30%
d) 50-60%
e) 70-80%0
2
4
6
8
10
12
14
a) b) c) d) e)
1st Test 2nd Test2nd Test
45. The most common cause of skin rash in children treated by amoxicillin is:
a) Amoxicillin allergy
b) EBV infection
c) Bacterial infection
d) Enterovirus infection
e) Measles
0
5
10
15
20
25
a) b) c) d) e)
1st Test 2nd Test2nd Test
46. Which would be the most adequate clinical approach to this patient?
a) The patient should have a complete allergic work-up 2 months later, including skin tests and if negative, a drug provocation test
b) Penicillin should be avoided due to high risk of severe reaction
c) The patient can be directly challenged 2 months later, without skin testing before
d) The patient should be challenged one year later, only if skin tests and specific IgE to Penicillin are negative
e) In this case, all cephalosporinsshould be avoided due to the risk of cross-reactivity (around 10%)
0
2
4
6
8
10
12
a) b) c) d) e)
1st Test 2nd Test2nd Test
47. Which one of the following is NOT a danger sign?
a) Nikolsky sign
b) Eosinophilia
c) Duration of the rash
d) Dysphonia
e) Skin extension > 30%
0
2
4
6
8
10
12
14
a) b) c) d) e)
1st Test 2nd Test2nd Test
48. Regarding diagnostic tests in penicillin allergy, which one of the following statements is correct?
a) The sensitivity of skin tests is low
b) The negative predictive value of oral provocation test is 100%
c) The sensitivity of specific IgE is high
d) The positive predictive value of skin tests is high
e) The negative predictive value of specific IgE in patients with history of penicillin allergy is low
0
1
2
3
4
5
6
7
8
9
10
a) b) c) d) e)
1st Test 2nd Test2nd Test
CLINICAL CASE 11Five year old girl with a long lasting
(7 weeks) generalized rash constituted by
erythematous, papulous, very itchy
lesions, each lasting less than 24 hours but
continually replicating in different
locations of the skin
Treatment with desloratadine, 2,5
mg/day, did not lead to significant clinical
improvement
Moreover several episodes of facial
angioedema associated with urticarial
lesions occurred during this 7 week
period.
No food or drug trigger was apparent
49. Concerning this patient, which of the following statements is FALSE?
a) The clinical picture described is not suggestive of Vasculitis
b) In spite of the association of angioedema it is not likely to be a situation of hereditary angioedema.
c) Some residual lesions are to be expected, considering the duration of the episode
d) Since urticaria persists for more than 2 weeks without a significant clinical improvement, the amount given of 2nd
generation H1 antihistamines, may be increased up to fourfold the standard daily dosage
e) A low pseudoallergen diet for at least four weeks might be an appropriate recommendation after other causes have been excluded
0
2
4
6
8
10
12
14
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENT
Although the episode is lasting for 7 weeks, individual lesions last for less than 24 hours andand not likely to leave trace
Residual lesions are to be expected in cases ofvasculitis
50. Which of the following is correct concerning paediatric urticaria?
a) Drug allergy is the main cause of acute urticarial in the pediatric age.
b) Chronic urticaria is often associated with IgE-mediated allergy in children.
c) Inducible urticaria is a subtype of chronic urticaria
d) Anti-H2 antihistamines are 2nd line therapy of urticaria, according to the new international guidelines.
e) Omalizumab therapy is only indicated in chronic urticaria, if the condition is associated with IgE-mediated allergy.
0
2
4
6
8
10
12
14
16
a) b) c) d) e)
1st Test 2nd Test2nd Test
51. One of the following statements is TRUE:
a) Chronic urticaria is the most frequent type of urticaria in the paediatric age
b) The etiopathogenesis of chronic urticaria has different specificities in children and adults
c) A well-structured and thorough clinical history permits the identification of the underlying etiology in most paediatric patients with chronic urticaria
d) Eradication of infectious agents and treatment of inflammatory processes are an essential part of the management of chronic urticaria
e) Histamine is the main inflammatory mediator implicated in urticariarelated to auto-inflammatory syndromes
0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test2nd Test
52. One of the following statements is FALSE:
a) Chronic urticaria is defined as urticaria lasting for more than 4 weeks
b) Auto-immunity reactions are implicated in about 30% of chronic urticaria cases in children
c) .Acute urticaria in children may be often associated to viral infections
d) Anti leukotrienes are an accepted third line therapy for chronic urticaria
e) Angioedema causes sometimes pain rather than itching
0
2
4
6
8
10
12
14
16
18
a) b) c) d) e)
1st Test 2nd Test2nd Test
COMMENT
Chronic urticaria is definedas urticaria lasting for morethan 6 weeks and not 4weeks
Test Results by Groups
0
5
10
15
20
25
30
35
40
45
50
1st Test 2nd Test
1st Test Mean Value: 28.9 2nd Test Mean Value: 37,2
2nd Test
Thank you very much. It was Great to meet you
![Training staff to use a new MCQ Generation methodology ... · concerning the most appropriate format of MCQ test item [10] and a specification for a formal MCQ-Creation methodology[11]](https://img.pdfslide.net/doc/110x75/5f066af47e708231d417e4b0/training-staff-to-use-a-new-mcq-generation-methodology-concerning-the-most-appropriate.jpg)
