ALLERGY

Question . 1. Which of the following are characteristic of allergens?

A .Proteins of molecular weight <10 kd
b. Proteins of molecular weight 10-70 kd
c. Proteins of molecular weight >70 kd
d. Lipopolysaccharides
e. Carbohydrates

Question . 2. Which of the following factors is characteristic of an atopic

response?
a.Th1 release of cytokines promoting phagocytosis(ctivate)
b.Th1 release of cytokines promoting synthesis of opsonizing.antibodies
c.Th1 and Th2 release of cytokines promoting synthesis of (only Th1) complement-fixing
antibodies
d.Th2 release of cytokines promoting phagocytosis
e.Th2 release of cytokines promoting synthesis of IgE antibodies

Question . 3. Which of the following types of cells are distributed throughout

connective tissues, often adjacent to blood vessels and below epithelial
surfaces that are exposed to the external environment, and release a diverse
array of mediators of allergic inflammation?
a.Eosinophils
b.Basophils
c.Mast cells
d.Th2 cells
e.Dendritic cells

Question . 4. Which of the following antigen-presenting cellsAPC are actively phagocytic

and reside in peripheral sites such as the skin, intestinal lamina propria, and lungs?
a.Eosinophils
b.Basophils
c.Mast cells
d.Th2 cells
e.Dendritic cells

Question . 5. Which of the following statements best describes the

relationship between allergic disorders and a possible genetic basis?
a.Allergic disorders are a response to only environmental factors
b.Allergic disorders are a response to only environmental factors and infectious agents
c.Asthma and allergic rhinitis are the only allergic disorders
with a familial predisposition
d.Any familial predisposition is related to polymorphisms of a single gene located on
chromosome 10 ‫متعدد االشكال‬
e.Any familial predisposition is related to many genetic loci and also many
polymorphisms

Question . 6. Which of the following factors may contribute to the worldwide

rise in prevalence of allergic diseases, particularly in Westernized metropolitan
areas?
a.Increasing genetic polymorphisms of CD14
b.Increased numbers of children in group daycare
c.Excessive use of antibiotics in first 2 yr of life
d.Reduced exposure to pollutants in Westernized
metropolitan areas since 1980
e.Reduced exposure to indoor allergens

Question . 7. All of the following may be signs of moderate to severe airway

obstruction resulting from allergic response except:
a.Dennie lines (Dennie-Morgan folds)
b. Supraclavicular and intercostal retractions
C.Cyanosis
d.Pulsus paradoxus
e.Respiratory distress with minimal wheezing and a few crackles

Question . 8. A 7-yr-old boy with asthma has roughness over the extensor
surfaces of the upper arms and thighs, which is caused by keratin plugs
lodged in the openings of hair follicles. This physical finding is termed:
a.Keratosis pilaris ‫خشونة‬
b.Fibroepitheliosis
c.Hidradenitis
d.Xerosis
e.Acrochordon
‫اختبار ماص اإلشعاع المؤرج‬
Question . 9. The radioallergosorbent test (RAST) determines:
a.Bronchial reactivity to subcutaneous serotonin
b.Bronchial reactivity after inhalation bronchial provocation test
c.The proportion of total allergic immunoglobulin
d.Antigen-specific serum IgE concentrations
e.The overall allergic risk profile based on absolute eosinophil count, total IgE, and skin
test results

Question . 10. All of the following statements regarding skin testing for allergic
reactivity are true except:
a.Antihistamines given prior to testing may inhibit the reaction
b.Intradermal tests are more sensitive than puncture tests
c.Positive skin test results by intradermal testing correlate better than results by puncture
tests with clinical symptoms
d.The reaction peaks within approximately 20 min and usually resolves over 20-30 min
e.Larger reactions have greater clinical relevance

Question . 11. Which of the following is an advantage of skin testing over

RAST to determine specific IgE?
a.Skin testing is not affected by administration of antihistamines
b.Skin testing has greater sensitivity than RAST
c.Skin testing is semiquantitative
d.Skin testing is associated with less risk of allergic reaction
e.Skin testing is not confounded by dermographism

Question . 12. Which of the following physical findings would be least likely on
examination of a child with moderate to severe asthma?
a.Tachypnea
b.Wheezing
c.Clubbing
d.Decreased air exchange over the right middle lobe
e.An increased anterior-posterior diameter of the chest

Question . 13. Recommendations to the parents of a child with dust mite

allergy to help reduce dust mite exposure should include all of the following
except:
a.Use a humidifier regularly
b.Place the mattress and pillow in allergen-proof
c.encasements
d.Wash bed linens in hot water weekly
e.Remove the old carpet from the bedroom

Question . 14. All of the following statements regarding decreasing exposure to cat
allergens are true except:
a.Removing the cat from the home is the most effective means of reducing exposure to
cat allergen
b.Keeping the cat out of the child's bedroom and other rooms where the sensitized child
spends large amounts of time reduces cat allergen exposure
c.Washing the cat regularly reduces cat allergen exposure
d.Using HEPA-filtered air cleaners does not reduce cat allergen exposure
e.Removing carpet decreases cat allergen exposure

Question . 15. A 12-yr-old girl with moderate to severe asthma is sensitive to

cat dander. Her family elects to remove the pet cat from the house, but to
retain the present carpeting and upholstered furniture. What is the length of
time required before the levels of cat allergen drop to levels found in homes
without a cat?
a.Immediately
b.2 days
c.2 wk
d.2 mo
e.6 mo ‫ شهور‬66666

Question . 16. Which of the following statements regarding antihistamines is

true?
a.Classification of antihistamines from type I to type VI is based on increasing
antihistamine activity
b.Second-generation antihistamines are distinguished by greater effectiveness than first-
generation antihistamines
c.Antihistamines should not be administered in combination with decongestants
d.Antihistamines are more effective in treating than preventing the action of histamine
e.The choice of antihistamines should be based on associated adverse effects and cost
Question . 17. Which of the following is an advantage of second-generation
antihistamines over first-generation antihistamines?
a.Second-generation antihistamines are often less expensive
b.Second-generation antihistamines are more frequently available in oral preparations
c.Second-generation antihistamines have less of a sedative effect and produce less
cognitive impairment
d.Many more second-generation antihistamines are available as over-the-counter
medications
e.Second-generation antihistamines are generally more effective than first-generation
antihistamines
Question . 18. Which of the following statements regarding the use of
cromolyn in the management of asthma is true? ‫كرومولين‬
a.Cromolyn prevents antibody-mediated mast cell degranulation and mediator release
b.Cromolyn prevents non-antibody-mediated mast cell degranulation
c.Cromolyn has no bronchodilator properties
d.The incidence of adverse effects is low
e.All of the above

Question . 19. The type of adrenergic activity of drugs most desirable in

treatment of asthma is: ‫مرغوب فيه‬
a.alfa1
b.Alfa2
c.Beta1
d.Beta2
Explanation: Agents with greater Beta 2-selective activity provide effective bronchodilation
with less cardiac stimulation (e.g., increase in heart rate) than may occur
with agents with both Beta 1 and Alfa 2 activities.

 allergic rhinitis.
Question . 20. A 4-yr-old boy experiences perennial clear rhinorrhea, nasal ‫معمرة‬
congestion, conjunctival injection, allergic shiners, nasal and ocular pruritus,
and occasional fits of sneezing. An environmental history is significant for two
cats in the home and flooding of the basement when it rains. He keeps twenty
stuffed animals on his bed and sleeps with a feather pillow on an old mattress.
He lives in a warm climate. Seasonal worsening of his symptoms has not been
observed. He has perennial allergic rhinitis. Which of the following groups of
allergens would be the most likely to contribute to his symptoms?
a.Dust mites, tree pollens, and weed pollens
b.Dust mites, animal danders, and molds
c.Tree, weed, and grass pollens
d.Tree pollen, grass pollen, and milk protein
Question . 21. A 7-yr-old girl presents with allergic nasal symptoms that are
prominent from the middle of August through the first frost. Which of the
following allergens is the most likely cause of her symptoms?
a.Milk protein
b.Tree pollen
c.Grass pollen
d.Weed pollen

Question . 22. A teenage boy presents in April with symptoms consistent with
seasonal allergic rhinitis. On examination of his nose, which of the following
findings suggest the need for further evaluation to exclude another diagnosis?
a.Nasal polyps
b.Pale-to-purple nasal mucosa
c.Thin, clear nasal secretions
d.A transverse nasal crease
e.Continuous open-mouth breathing
Question . 23. A 12-yr-old presents with sneezing, clear rhinorrhea, and nasal
itching. Physical examination reveals boggy, pale nasal edema with a clear
discharge. The most likely diagnosis is: ‫مستنقعى‬
a.Foreign body
b.Vasomotor rhinitis
c.Neutrophilic rhinitis
d.Nasal mastocytosis
e.Allergic rhinitis
Explanation: Allergic rhinitis is often seasonal andassociated with allergic conjunctivitis.
Eosinophils predominate in the nasal secretions.Chapter 133
Question . 24. Two weeks later, the patient described in Question 23
complains of headache, poor nasal airflow requiring mouth breathing, fever,
and a change in the nature of the nasal discharge to mucopurulent discharge.
The most likely diagnosis is:
a.Sinusitis (complic. Of Allergic rhinitis)
b.Foreign body
c.Rhinitis medicamentosa
d.Choanal stenosis
e.Ciliary dyskinesia
Question . 25. A 12-yr-old child presents with watery rhinorrhea, paroxysmal
sneezing, and nasal obstruction. The serum IgE level is normal, and skin test
results are negative. The physical examination is remarkable only for swollen
turbinates and clear nasal secretions. A trial of antihistamine-decongestant
therapy for 3 wk has not relieved symptoms. Which of the following is the
recommended management?
a.Institute strict measures to avoid outdoor allergen exposure.
b.Begin seasonal use of oral sympathomimetic drugs.
c.Begin seasonal use of topical intranasal corticosteroids.
d.Give a 10-day course of amoxicillin
e.Give a 10- to 14-day course of cefpodoxime
Topical intranasal corticosteroids (e.g.,fluticasone, budesonide) should be used in
children with allergic rhinitis that is resistant to antihistamine decongestant therapy
Question . 26. Which of the following is most useful in establishing the
diagnosis of seasonal allergic rhinitis?
a.History of good clinical response to an intranasal corticosteroid preparation
b.History of exacerbation of symptoms in the spring
c.Elevated serum IgE level
d.Positive result on skin testing for the house dust mite allergen
e.Nasal eosinophils

ASTHMA:
Question . 27. Common triggers of asthma in children include all of the
following except:
a.Secondary tobacco smoke
b.Ozone
c.Cold air
d.Exercise
e.Gelatin
Question . 28. The parents of a 3-yr-old girl with a history of several previous
coughing and wheezing exacerbations are wondering if their toddler is likely to
develop persistent asthma. Which of the following is a strong risk factor for
persistent asthma in toddlers with recurrent wheezing?
a.Eczema
b.Colic
c.Living on a farm
d.Female gender
e. Otitis media with effusion
Question . 29. A 4-yr-old boy with asthma has had mild wheezing only four
times since you began treating him 6 mo ago with theophylline (Slo-bid
Gyrocaps) twice each day. He previously experienced coughing and wheezing
at least three times each week. (A peak serum theophylline concentration 5
mo ago was 16 g/mL). For the past 4 days, he has again experienced mild
coughing and wheezing responsive to inhaled albuterol. Two days ago, an
emergency department physician began treatment with erythromycin sulfisoxazole
(Pediazole) for otitis media. This morning the youngster began
vomiting. The likely cause of the vomiting is:
a.Provocation by coughing (post-tussive emesis)
b.Sequelae of otitis media
c.Theophylline toxicity
d.Albuterol toxicity
e.Pediazole intolerance
Question . 30. A 10-yr-old child has intermittent symptoms of mild asthma.
The most appropriate treatment option is:
a.Environmental control and patient education only?no medication is indicated
b.Oral theophylline
c.Cromolyn
d.Inhaled beta 2-agonist as needed for symptoms
e.Daily inhaled corticosteroid
Question . 31. The child described in Question 30 experiences worsening of
symptoms, which are now persistent and of moderate severity. The most
appropriate treatment option is:
a.Oral theophylline
b.Inhaled beta 2-agonist as needed for symptoms
c.Daily inhaled corticosteroid and oral theophylline
d.Daily inhaled corticosteroid and a long-acting inhaled beta 2-agonist
e.Daily inhaled corticosteroid, a long-acting inhaled beta 2-agonist, and oral theophylline
Question . 32. A 12-yr-old asthmatic boy has developed an asthma exacerbation in the
past few days. Asthma symptoms have continued toprogress despite frequent albuterol
use at home. He comes to the emergencydepartment with chest tightness, dyspnea, and
wheezing, and in moderate respiratory distress. In this setting, management should
include all of the following except:
a.Close monitoring
b.Supplemental oxygen
c.Inhaled albuterol (salbutamol)
d.Theophylline
e. Systemic glucocorticoids
 Initial emergency department management of an asthma exacerbation includes:
1. close monitoring of clinical status,
2. treatment with supplemental oxygen,O2
3. inhaled beta 2-agonist every 20 min for 1 hr, and
4. if necessary, systemic glucocorticoids (2mg/kg/day) given either orally or IV.
5. Inhaled ipratropium may be added to the beta 2-agonist treatment if no significant
response is seen with the first inhaled beta 2-agonist treatment.
6. If a child responds poorly to intensive therapy with nebulized albuterol,ipratropium,and
parenteral glucocorticoids, then adding IVtheophylline could be considered
Question . 33. A 7-yr-old girl has had intermittent asthma symptoms over the
past 5 yr. Her asthma symptoms have been treated with inhaled albuterol as
needed. She mostly has exercise-induced asthma symptoms, which happens
on most school days except when she uses her albuterol inhaler before going
to recess and physical education classes. In the past year, she has had two
asthma exacerbations with viral upper respiratory tract infections, and she has
used a total of 5 albuterol metered-dose inhalers. The most appropriate
management for this asthmatic girl is:
a.Continue albuterol as needed and before physical exercise activities
b.Begin daily controller medication with an inhaled glucocorticoid, initially used more
frequently to gain control, then a reduced amount in a few months to
maintain control
c.Begin daily inhaled glucocorticoid in a low dose, increasing
the dose monthly until good control is obtained
d.Administer daily oral glucocorticoid treatment for one week,
with concurrent daily inhaled glucocorticoid
e.Begin use of a long-acting inhaled -agonist each morning
Question . 34. Components of the U.S. National Asthma Education &
Prevention Program (NAEPP) guidelines include all of the following except:
a.Regular assessment and monitoring
b.Control of factors contributing to asthma severity
c.Asthma pharmacotherapy,especially the use of anti-inflammatorycontroller medications
d.Genetic profiling
e.Patient education

atopic dermatitis
Question . 35. Features characteristically associated with atopic dermatitis
include all of the following except:
a.Allergic rhinitis or asthma= Nearly 80%
b.Elevated serum IgE level
c.Peripheral blood eosinophilia
d.Lymphopenia.
Question . 36. Major features of atopic dermatitis in children include all of the
following except:
a.Pruritus
b.Facial and extensor eczema
c.Angioedema
d.Chronic or relapsing course
e.Personal or family history of atopic disease
Question . 37. A 2-yr-old is diagnosed with atopic dermatitis. Which of the
following environmental modifications is recommended?
a.A bland diet, especially minimizing meats
b.Installation of wool carpeting instead of synthetic carpeting
c.Use of a liquid rather than powder laundry detergent, and adding a second rinse cycle
d.Use of soaps that are especially effective in removing fatty substances
e.Bathing less often than daily
Question . 38. The most appropriate prognosis to convey to the parents of the
2-yr-old with atopic dermatitis described in Question 37 is:
a.The child will be asymptomatic with environmental modifications
b.Symptoms will gradually worsen during childhood and persist stably through adulthood
c.Symptoms will exhibit a remittent but progressively worsening course through
adulthood
d.Symptoms will gradually decrease over the next several years with an approximately
50% chance of spontaneous improvement
e.Symptoms will resolve completely at puberty
Question . 39. Which of the following is the major feature of atopic dermatitis?
a.Onset shortly before or during puberty
b.Pruritus
C. Staphylococcus aureus cutaneous infections
d.Elevated serum IgE
e.Immediate skin test reactivity to allergens
Question . 40. A 5-yr-old boy with severe atopic dermatitis develops illness
with dozens of vesicles primarily covering areas of skin previously affected by
atopic dermatitis. The distribution crosses many dermatomes. Findings include
fever and lymphadenopathy. The most likely diagnosis is:
a.Chickenpox ‫عشرات الحويصالت‬
b.Zoster
c.Kaposi varicelliform eruption
d.Eczema vaccinatum
e.Coxsackievirus infection

Question . 41. A 14-yr-old presents with acute-onset urticaria that has

gradually worsened over the past 10 days. Detailed history reveals no clues to
the possible etiology. Findings on physical examination are normal except for
urticaria. Which of the following diagnostic options is recommended?
a.Systematic elimination diets to determine a possible ingestant cause
b.Allergy skin testing
c.Serum IgE and RAST
d.Skin biopsy
e.None of the above

Question . 42. Which of the following treatment options is recommended for

the patient described in Question 42?(uretcaria)
a.A bland diet
b.Wearing cotton garments
c.Oral antihistamine
d.Oral prednisone
e.Topical corticosteroid

Question . 43. Which of the following laboratory tests is most likely to give
abnormal results in a patient with chronic urticaria?
a.Serum IgE level determination
b.Skin prick testing for egg sensitivity
c.C4 level assay
d.Assay for antibodies to thyroglobulin
e.Heterophile antibody testing

Question . 44. A 12-yr-old girl with repeated episodes of streptococcal

pharyngitis experiences another episode of sore throat. The rapid strep test
result is positive, and oral amoxicillin is started, with the first dose given in the
office. One hour later, she experiences a "funny feeling" and a tingling
sensation around her mouth. Next she becomes apprehensive, has difficulty
swallowing, and develops a hoarse voice. On arrival at the emergency
department, she has giant urticaria and the following vital signs: pulse 130,
respiratory rate 32/min, blood pressure 70/30 mm Hg, and temperature
37.2°C. The most appropriate therapy is administration of:
a.Epinephrine
b.Prednisone
c.Diphenhydramine
d.Albuterol
e.Lactated Ringer's solution

Question . 45. The most likely diagnosis for the patient described in Question
45 is:
a.Streptococcal toxic shock
b.Scarlet fever
c.Stevens-Johnson syndrome
d.Reye syndrome
e.Anaphylaxis

Question . 46. The mother of an 8-yr-old boy with acute streptococcal

tonsillitis calls to report that now, within 15 min after the first dose of oral
penicillin V that you prescribed, he is complaining of itching and has developed
hives. Which of the following should you recommend?
a.Adose of oral Benadryl, with instructions to callagain if he has not improved within 30
min
b.Immediate return to your office or the nearest emergency department
c.Careful monitoring at home, with instructions to return to your office or the nearest
emergency department if he becomes short of breath or loses consciousness
d.Schedule a visit for a laboratory test to determine serum trypticase level
e.Substitution of erythromycin for penicillin

Question . 47. All of the following statements regarding anaphylaxis are true
except:
a.Virtually any foreign substance can elicit an anaphylactic reaction
b.Most anaphylactic reactions are due to drugs, latex, foods, and Hymenoptera venom
c.Oral drugs carry a higher risk of anaphylaxis than that associated with injected drugs
d.Anaphylactic reactions to foods usually begin within minutes to 2 hr of exposure
e.Exercise alone can elicit an anaphylactoid reaction

Question . 48. Administration of which of the following drugs is the treatment

of choice for anaphylaxis?
a.Diphenhydramine orally
b.Diphenhydramine by intravenous infusion
c.Aqueous epinephrine (1:1,000) by subcutaneous injection
d.Aqueous epinephrine (1:1,000) by intramuscular injection IM
e.Aqueous epinephrine (1:1,000) by intravenous infusion

Question . 49. A 16-yr-old with history of anaphylaxis to Hymenoptera suffers ‫غشائية‬

‫االجنحة‬
a sting on an extremity. The first-aid kit that is available includes aqueous
epinephrine 1:1,000 and other necessary medical supplies. All of the following
measures for management of this sting are appropriate except:
a.Infiltration of one half of the epinephrine dose subcutaneously around the site of the
sting
b.Repeat doses of aqueous epinephrine at 15-min intervals if necessary
c.Placement of a tourniquet above the site of the sting
d.Incision of and suction of venom from the site of the sting
e.Transport to an emergency department
Question . 50. The most common single cause of anaphylaxis outside of the
hospital is:
a.Insect sting allergy
b.Drug allergy
c.Food allergy
d.Latex allergy
e.Food-associated exercise-induced anaphylaxis

Question . 51. A 12-yr-old child with a history of allergy to yellow jackets is

stung and immediately begins experiencing tightness in the chest and ‫جاكت او سترة واقية‬
‫للرصاص‬
wheezing. The drug of first choice for management of this child is:
a.Inhaled albuterol
b.Subcutaneous epinephrine
c.Intramuscular diphenhydramine
d.Intramuscular epinephrine IM
e.Oral corticosteroids

Question . 52. Which of the following would be the optimal long-term

management of the child described in Question 51?
a.Daily oral non-sedating antihistamine
b.Daily low-dose oral corticosteroid
c.Daily inhaled corticosteroid
d.Inhaled corticosteroid immediately upon insect sting
e.Immunotherapy

Question . 53. A 2-yr-old child who has completed 8 days of a 10-day course
of cefaclor presents with low-grade fever, malaise, irritability,lymphadenopathy, and a
generalized erythematous rash that is mildly pruritic. The most likely diagnosis is:
a.Partially treated meningitis
b.Infectious mononucleosis
c.Kawasaki disease
d.Type I hypersensitivity reaction
e.Type III hypersensitivity reaction
Explanation: Serum sickness is a classic example of atype III hypersensitivity reaction, or
immune complexdisease. The symptoms develop as antibodies appearagainst the antigen
at a time when the antigen is stillpresent. Immune complexes may stimulate complement
and deposit in joints, the skin, and the renal glomeruli.

Question . 54. A 14-yr-old child received equine-derived antivenom for a

snake bite 5 yr ago and now requires it again. Results of skin testing to the
product are negative. Which of the following statements is true?
a.Premedication with corticosteroids is warranted to prevent serum sickness
b.Negative skin tests indicate that it is highly unlikely that he will develop serum sickness
c.He should not receive this product more than once
d.Serum sickness may begin within a few days of administration of the antivenom

Question . 55. Risk factors for adverse drug reactions include:

a.Topical administration (compared with parenteraladministration)
b.Low dose (compared with high dose)
c.Frequent, intermittent dosing frequency (comparedwith prolonged, continuous dosing)
d.No previous exposure (compared with previousadministration)
e.All of the above

Question . 56. Which of the following statements concerning adverse drug

reactions is true?
a.Adverse drug reactions are primarily IgE mediated
b.Drug-induced thrombocytopenia results from circulating immune complexes
c.Both parental and topical exposures to a drug increase the risk for an adverse reaction
d.Approximately 80% of patients with a history of penicillin allergy will have evidence of
penicillin-specific IgE antibodies on testing
e.Epidermal detachment of >30% suggests Stevens-Johnson syndrome

Question . 57. A 7-yr-old boy presents with fever and otalgia‫ الم اذن‬. On examination he
has a bulging right tympanic membrane. As you hand his mother a prescription for
amoxicillin, she informs you that when the child was 4 yr old, he broke out in an itchy
rash during treatment with amoxicillin. The most appropriate approach to management of
this patient would be:
a.Reassure the mother that since more than 2 yr have passed, it is highly unlikely that the
child is still allergic and he can now take the amoxicillin safely
b.Explain to the mother that most adverse drug reactions to amoxicillin are not IgE
mediated and that amoxicillin can be safely given.
c.Prescribe a cephalosporin and explain to the mother thatthere is no cross-reaction
between penicillins and cephalosporins
d.Prescribe a macrolide antibiotic and explain to the mother that there is no cross-reaction
between penicillins and macrolides
e.Give the child a prescription for amoxicillin, and instruct the
mother to pre-treat him with diphenhydramine (which is available without a prescription)

Question . 58 . The parents of a 6-yr-old girl relate a history of urticarial

reaction and vomiting following administration of amoxicillin in the past. Skin
testing to major and minor determinants of penicillin is positive. Which of the
following statements regarding administration of a cephalosporin constitutes
appropriate advice for the parents?
a.The child can receive a cephalosporin with no greater risk of anaphylaxis than in the
general population
b.There is a 2% risk of anaphylaxis to a cephalosporin
c.There is a 9% risk of anaphylaxis to a first-generation cephalosporin but an almost 0%
risk of anaphylaxis to a fourth generation cephalosporin
d.There is a 9% risk of anaphylaxis to a cephalosporin
e.There is a 50% risk of anaphylaxis to a cephalosporin

Question . 59. A 14-yr-old girl, who has a long-standing seizure disorder for
which she takes phenytoin, develops fever and a urinary tract infection and is
prescribed trimethoprim-sulfamethoxazole. After 9 days of antibiotic treatment
she has recurrence of fever and develops confluent purpuric macules on her
face and trunk with erosive mucosal lesions of her mouth and conjunctivae. A
skin biopsy reveals 8% epidermal detachment. Which of the following best
describes this disorder?
a.Toxic shock syndrome TSS
b.Anticonvulsant hypersensitivity syndrome
c.Allergy to sulfamethoxazole
d.Stevens-Johnson syndrome
e.Toxic epidermal necrolysis

Question . 60. All of the following may be manifestations of insect allergy except:
a.Rhinitis and conjunctivitis
b.Asthma
c.Wheal and flare
d.Anaphylaxis
e.Uveitis

Question . 61. All of the following statements concerning allergic reactions to

stinging insects are true except:
a.The majority are due to Hymenoptera
b.There is substantial cross-reactivity among vespid venoms
c.Systemic reactions can occur after the first sting
d.Most reactions are IgE mediated
e.Negative results on skin testing and RAST reliablyexclude the likelihood of anaphylaxis

Question . 62. Immunotherapy provides symptomatic improvement in all of the

following except:
a.Ragweed allergy
b.Local reaction to bee sting
c.Tree pollen allergy
d.House dust mite allergy
e.Anaphylaxis to a wasp sting

Question . 63 . An 8-yr-old boy experienced immediate urticaria surrounding a

large local reaction to a honeybee sting 2 mo ago. He had no other symptoms.
Skin testing with honeybee venom has been strongly positive at a weak
concentration. Appropriate recommendations include all of the following
except:
a.Hymenoptera venom immunotherapy
b.An epinephrine auto-injector (EpiPen) for administration after a subsequent sting
c.Wearing shoes when outdoors
d.A Medic-Alert bracelet
e.Wearing long pants

Question . 64. A 10-yr-old girl was stung on her left cheek by a yellow jacket.
She is experiencing pain. By 4 hr following the sting the left side of her face is
so swollen that her left eye is virtually closed. There are no other complaints.
The best course of action would be:
a.Apply cold compresses, and consider antihistamines and pain medication
b.Perform or refer her for skin testing to Hymenoptera venom
c.Prescribe self-injectable epinephrine and provide instructions to school/camp
d.All of the above

Question . 65 . A 7-yr-old boy was stung by an unidentified insect and within

minutes developed generalized urticaria, a repetitive cough, difficulty
breathing, and extreme dizziness. He was treated in the emergency
department with antihistamines, epinephrine, and corticosteroids. Which of the
following statements is accurate?
a.If skin tests to Hymenoptera venom are performed 1 wk later and results are negative,
he is not a candidate for venom immunotherapy
b.Testing and venom immunotherapy cannot be undertaken until the insect is identified
c.Venom immunotherapy could reduce the risk for a severe anaphylaxis on a subsequent
sting from more than 50% to less than 3%
d.If results of venom skin tests are negative, he does not need to have self-administered
epinephrine readily available
‫حمى القش‬
Question . 66. A 15-yr-old with a history of seasonal hay fever now also has
itchy eyes, profuse tearing, and reddened and edematous conjunctivae. A
treatment option effective for the ocular symptoms would be:
a.Topical antihistamines
b.Topical decongestants
c.Topical mast cell stabilizers
d.Topical nonsteroidal anti-inflammatory drugs
e.All of the above?each is an effective secondary treatment regimen for ocular allergies

Question . 67. The patient described in Question 66 continues to have

symptoms. The most appropriate next step in management would be:
a.Combination therapy such as with an antihistamine and a vasoconstrictive agent
b.Immunotherapy
c.Topical corticosteroids
d.Oral corticosteroids
e.All of the above?each is an effective tertiary treatment regimen for ocular allergies

Question . 68. All of the following statements concerning allergic reactions to

foods are true except:
a.Skin tests are of little diagnostic value for cell-mediated gastrointestinal hypersensitivity
b.Cow's milk sensitivity is the most common cause of protein induced enteropathy
c.Gastrointestinal anaphylaxis is mediated by IgA
d.The majority of children with positive results on prick skin tests to a food will not react
when the food is ingested
e.Elimination diets are the only means to establish the diagnosis of food allergies
Explanation: Gastrointestinal anaphylaxis generally presents as acute abdominal pain and
vomiting that accompanies other IgE-mediated allergic symptoms

Question . 69. Which of the following is an uncommon clinical manifestation of

food allergies?
a.Acute urticaria
b.Angioedema
c.Wheezing
d.Diarrhea
e.Chronic fatigue

Question . 70. All of the following foods are characteristically associated with
allergy except:
a. Peanuts‫فول سودانى‬
b.Tree nuts ‫مكسرات‬
c.Legumes ‫بقوليات‬
d. Eggs
e. Sea food

Question . 71. Because of a strong family history on both sides, the parents of
a newborn baby ask for guidance about preventing their child from developing
an allergy to peanuts. Which of the following approaches is recommended?
a.Begin and extend breast-feeding until age 2 yr, with exclusion of peanuts from the
mother's diet while breastfeeding
b.Begin and extend breast-feeding until age 2 yr, with the mother ingesting gradually
increasing amounts of creamy peanut butter from 18-24 mo of age
c.Begin and continue breast-feeding as routinely recommended, with the mother regularly
ingesting small amounts of peanuts but not introducing peanuts in the child's diet until
age 1 yr
d.Begin and continue breast-feeding as routinely recommended, excluding peanuts from
the mother's diet while breast-feeding and from the child's diet until age 3 yr
e.Use only creamy peanut butter and not chunky peanut butter or whole peanuts in the
child's diet (after 1 yr of age)
‫طويل‬
Question . 72. A 6-mo-old infant develops protracted projectile vomiting, and
lethargy about 2 hr after ingesting a milk formula. The most likely diagnosis is:
a.Generalized anaphylaxis
b.Milk-induced enterocolitis syndrome
c.Gastrointestinal anaphylaxis
d.Allergic eosinophilic esophagitis
e.Allergic eosinophilic gastroenteritis

Question . 73. Which of the following is the most definitive test for diagnosing
a food protein-induced enterocolitis?
a.Positive clinical history
b.Positive food challenge
c.Positive result on skin prick test
d.Positive RAST result
e.Quantitative IgE level

Q74: Which of the following statements is true concerning immunity to bacteria?

Antibodies to secreted bacterial products play no protective role

Bacteria opsonised by antibodies and complement are more effectively

phagocytosed than those opsonised by antibodies alone Your
answer

Humoral rather than cellular immunity is predominant in protection against all

types of bacteria

Phagocytes cannot engulf bacteria in the absence of antibodies

Endotoxin induces shock mainly through the activation of T cells

Q75: A 5-year-old child presented with oedema of the lips after ingesting a peanut. Which of the
following are true regarding management of this patient?

Correct
Hyposensitisation therapy should be performed True
False

Incorrect
Peanut allergy can be reliably diagnosed by skin testing True
False

Incorrect
Peanut allergy can be reliably diagnosed by serum RAST True
False

Correct
If peanut allergy is confirmed, allergy to other nuts should be considered True
False

Incorrect
A history of apparent allergic reaction to nuts is usually inadequate for a True
diagnosis
False

Incorrect
Q76: Parents of a boy with suspected peanut allergy want answers to many questions,
including prediction of the severity of future reactions and whether he will grow out the
allergy.
:
Which of the following is a valid statement?

The weal size resulting from the skinprick test is a good indicator for
the severity of the next anaphylactic reaction
 The amount of plasma-specific IgE to peanuts/treenuts is a good
indicator for the severity of the next anaphylactic reaction

The weal size resulting from the skin prick test is an excellent
predictor of a positive food challenge to peanuts Correct
answer

A negative skinprick is insufficient evidence to definitely exclude

peanut allergy Your
answer

More than 50% of peanut allergic individuals will outgrow these

allergies

Q77: Which of the following is true concerning immunity to viruses?

IgA can offer protection at mucosal surfaces

Your
answer
Cytotoxic T cells are activated before natural killer cells during the course of
infection

Viruses stimulate the non-immune cells that they infect to produce interferon-

Non-enveloped viruses are susceptible to damage by complement

Influenza virus can avoid antibody recognition by mutational changes in its

nucleocapsid proteins
Incorrect
Q78: In a patient developing anaphylaxis, which of the following is true?

May be exacerbated by exercise

Correct answer

Involves leukotriene A4

Initial symptoms include a sensation of coldness

Your answer

20% of fatalities are due to respiratory complications

Less than 10% of patients have a second episode within 24 hours

Q79: Which of the following are true regarding Hay fever?

Correct
Nasal discharge is usually watery True False

Correct
Nasal steroids are contra-indicated True False

Correct
Antihistimines may affect school performance True False

Correct
Hyposensitisation therapy is usually successful True False

Correct
First line treatment include systemic therapies True False

Q80: Which of the following definitely excludes antibody deficiency?

 Normal serum immunoglobulins

Good IgG antibody responses to immunisations

Correct answer

The presence of existing antibody responses to past infections

Your answer

Normal IgG subclasses

Normal peripheral blood lymphocyte subpopulations

Q81: In a patient with nickel-associated contact dermatitis which of the following

‫النيكل‬ statements is true?

Mediated by mast cells

Mediated by IgE

Skinprick testing is the best way to establish the sensitising antigen

Systemic cytokine release induces skin inflammation

Elimination of the responsible agent is the most important goal

Your answer

Q82: Parents of a boy with suspected peanut allergy want answers to many questions, including
prediction of the severity of future reactions and whether he will grow out the allergy.

Which of the following is a valid statement?

The weal size resulting from the skinprick test is a good indicator for the severity
of the next anaphylactic reaction
 The amount of plasma-specific IgE to peanuts/treenuts is a good indicator for the
severity of the next anaphylactic reaction

The weal size resulting from the skinprick test is an excellent predictor of a
positive food challenge to peanuts Your
answer

A negative skinprick is insufficient evidence to definitely exclude peanut allergy

More than 50% of peanut allergic individuals will outgrow these allergies

Q83: A fully immunized 5-year-old has a splenectomy for spherocytosis. Which of the following
vaccines are indicated?

Correct
Hepatitis B True False

Correct
BCG True False

Incorrect
Meningococcal group C vaccine True False

Correct
Pneumococcal True False

Correct
Influenza True False

Q84: Which of the following is true concerning complement activation?

 IgG and IgE are the main antibody classes involved in classical pathway
activation (IgG+IgM)

C1q binds to the Fab regions of antigen-complexed IgG antibodies

The alternative, but not the classical C3, convertase enzyme involves C3b
Correct
answer
Elevated serum C3dg is a good marker of complement activation

The membrane-attack complex involves polymerisation of C7

Your answer

IgG and IgM are the main antibody classes that activate the classical pathway. C1q binds to the Fc
rather than the Fab fragment that binds antibody (Fc, crystallisable fragment; Fab antigen-binding
fragment). It is C9 that polymerises in the membrane-attack complex. Clotting of blood can lead to
complement activation, and hence complement conversion products must be measured on plasma and
not serum.

2002 Self-Assessment Exercise —

VIII. Allergy and related disorders

Question 16.Answer.

A 10-year-old boy has received allergen immunotherapy for allergic

rhinitis for approximately 6 months. Fifteen minutes after receiving his
latest injections, the nurse checks his arm. She requests that you evaluate
it because he has some redness and swelling that is about 2 inches in
diameter at the injection site. He has no other symptoms.

Of the following, the MOST appropriate course of action is to:

A. add saline to his next injection

B. administer epinephrine

C. decrease the dosage for his next injection

D. discontinue immunotherapy

E. re-evaluate him in another 15 minutes

Question 55.Answer.

A mother brings her 1-year-old son to your office because she thinks he is
allergic to grass pollen. He has had intermittent rhinitis for several
months. It is December, and the family lives in the northeast United
States. Both parents have seasonal allergic rhinitis.

Of the following, your BEST advice to the mother is to:

A. begin a long-acting antihistamine to control the boy’s symptoms

B. explain that he does have allergies, but he cannot be treated until he

is older

C. explain that it is not allergy because of the boy’s age and exposure
history

D. recommend an adenoidectomy to relieve his symptoms

E. refer the boy to an allergist for testing for sensitivity to grass

pollens

Question 97.Answer.

You are seeing a 4-year-old girl in the emergency department for

treatment of an episode of anaphylaxis. She is currently taking
amoxicillin for treatment of otitis media. She had just finished lunch
today and taken her medication when she experienced respiratory
difficulties, urticaria, and general discomfort. Lunch included foods she
normally eats, except for a new brand of chicken noodle soup and plain
M & M's for dessert. She does not like eggs, and when she has eaten them
in the past, she spat them out.

Of the following, the MOST likely cause of her reaction is:

A. drug allergy

B. food allergy

C. food poisoning

D. serum sickness

E. viral urticaria
Question 143. Answer.

A 10-year-old boy who has hypertension needs a contrast study of his

kidneys. He is allergic to shrimp ‫جمبرى‬, and his parents are worried that
he will have a reaction to the iodine content in the radiocontrast media.

Of the following, the MOST appropriate management is to:

A. perform allergy tests for radiocontrast media

B. pre treat the child with antihistamines and corticosteroids 1 week

prior to the procedure

C. pre treat the child with antihistamines immediately before the

procedure

D. reassure parents that the risk of reaction is negligible

E. undertake a food challenge with shrimp to confirm the diagnosis

Question 174. Answer.

A frantic mother calls you in the early evening. The family has just
returned from dinner at their favorite Mexican restaurant, and her 12-
year-old son is complaining of abdominal pain and discomfort. He feels
nauseated. The mother has just read an article on the Internet about food
anaphylaxis, and she is concerned about his reaction. He has eaten all of
the foods he ate tonight previously, but this time he ate a very spicy type
of salsa. He has no other symptoms and no history of any other allergies.

Of the following, the MOST probable type of reaction he is experiencing

is:

A. food sensitivity

B. type I, immunoglobulin E-mediated

C. type II, antibody-antigen complex

D. type III, antibody-antigen complex with complement

E. type IV, cell-mediated immunity

Question 217. Answer.

Your practice group has decided to create a comprehensive plan of action

for your patients who have asthma. You have been assigned to create the
new hospital discharge plan. The current plan includes the initiation of
inhaled corticosteroids, as-needed short-acting beta agonists, and tapering
doses of prednisone that vary with the severity of the exacerbation.

Of the following, The BEST option to add to the plan is:

A. an assessment of asthma triggers

B. daily oral antihistamines

C. excuse from gym class for 2 months

D. pneumococcal vaccine for children

E. weekly spirometry for the 2 months following discharge

Question 10.Answer.

One month ago you prescribed sodium cromolyn three times a day for a
7-year-old patient who has mild persistent asthma. She states that she
feels much better.

Of the following, the BEST explanation for her improvement is that

A. cromolyn sodium has anti-inflammatory effects

B. cromolyn sodium is an excellent bronchodilator

C. no allergens currently are present

D. she has outgrown her asthma

E. the cold and flu season has passed

Question 35.Answer.

You have been asked to evaluate a 7-year-old boy who has moderate
persistent asthma. He has not seen any primary care physician for more
than 6 months. You decide to formulate an appropriate treatment plan for
him. Of the following, the BEST maintenance therapy is

A. inhaled beta-agonist
B. inhaled corticosteroid daily

C. leukotriene receptor antagonist daily

D. nebulized cromolyn sodium

E. oral theophylline

Question 60.Answer.

You are evaluating a 12-year-old boy who, for the past year, has had
wheezing that occurs during exercise. He states that he begins to wheeze
shortly after beginning any physical exertion. He also complains of a
nighttime cough that interferes with his sleep.

Of the following, the MOST likely diagnosis is

A. cough variant asthma

B. exercise-induced asthma

C. poor physical conditioning

D. poorly controlled asthma

E. upper respiratory tract infection

Question 91.Answer.

A 5-year-old boy from Philadelphia has had nasal congestion and

sneezing throughout the spring. His mother feels that these symptoms are
due to his excessive milk consumption. She eliminated whole milk from
his diet 1 week ago, but his symptoms have not improved.

Of the following, the MOST likely cause of this child's persistent

symptoms is

A. dust mite allergy

B. food allergy, but not to milk

C. milk allergy

D. outdoor pollen allergy

E. upper respiratory tract infection

Question 116. Answer.

A 12-year-old boy presents with urticaria of 8 weeks' duration. Four

weeks ago you evaluated him for allergies, and the results were negative.
History reveals that he has a pet bird and is a conscientious student. His
father has recently become unemployed. A review of systems produces
unremarkable findings. Results of an erythrocyte sedimentation rate,
complete blood count with differential, liver function tests, and thyroid
function tests are normal.

Of the following, the MOST likely cause of this boy's chronic urticaria is

A. a viral infection

B. allergic reaction to a pet bird

C. drug allergy

D. food allergy

E. stress reaction

Question 141. Answer.

As part of a 4-year-old child's health supervision visit, you discuss his

moderate persistent asthma with his mother, reinforcing the need to use
preventive medicine. You also review the appropriate treatment plan for
him when he has an acute exacerbation.

Of the following, the MOST appropriate first-line therapy for an acute

exacerbation of asthma is

A. high-dose inhaled corticosteroids

B. inhaled anticholinergic bronchodilators

C. inhaled long-acting beta-agonists

D. inhaled short-acting beta-agonists

E. leukotriene receptor antagonists

Question 167. Answer.

You are seeing a 6-year-old girl for her quarterly asthma evaluation. She
had been well until the age of 4 years. At her last visit, you prescribed an
inhaled corticosteroid. She has continued to have significant symptoms,
with coughing occurring at night and with exercise. The child and her
mother both insist that she is using the inhaler twice a day, as you
prescribed.

Of the following, the MOST likely reason for her poor response to the
therapy is that

A. the asthma is responding poorly to inhaled corticosteroids

B. the child and parent are not telling the truth about compliance

C. the girl has cystic fibrosis

D. the girl is not using the metered dose inhaler correctly

E. theophylline must be added to the regimen

Question 198. Answer.

A mother brings in her teenage daughter for evaluation of difficulty in

breathing. The mother believes the symptoms are due to asthma and has
given the girl a trial of her own albuterol inhaler, but the daughter has not
responded after 2 hours. The mother is concerned because albuterol
works faster for her. She requests information about the onset of action of
albuterol.

Of the following, the MOST appropriate response is that albuterol has

A. peak effect in 2 minutes, duration of 2 hours

B. peak effect in 5 minutes, duration of 8 hours

C. peak effect in 10 minutes, duration of 6 hours

D. peak effect in 15 minutes, duration of 4 hours

E. peak effect in 30 minutes, duration of 12 hours

Question 223. Answer.

A 17-year-old boy presents to the emergency department immediately
after being stung on the lip by a yellow jacket. He has significant swelling
of his face and diffuse urticaria on his body.

Of the following, the BEST management for this boy is

A. intramuscular antihistamines

B. intravenous corticosteroids

C. no treatment

D. referral to allergist

E. subcutaneous epinephrine

Question 248. Answer.

A 14-year-old boy who lives in the inner city is experiencing difficulty

controlling his asthma. His wheezing occurs primarily during exercise,
and he is having trouble completing his summer football workouts. He
feels that some weeks have been better than others.

Of the following, the MOST likely cause of his increased symptoms is

A. a new pet cat

B. decreasing efficacy of his asthma medication

C. expected seasonal exacerbations of asthma

D. summer upper respiratory tract infection

E. unhealthy air quality

Question 23.Answer.

A teenage patient asks you about recent advances in asthma therapy for
his science project. You describe a new class of agents called
antileukotrienes.

Of the following, the BEST response concerning the impact of this new
class of drugs on the lives of patients who have asthma is that the
antileukotrienes

A. are equal in effectiveness to theophylline

B. have decreased the mortality rate due to asthma

C. have eliminated the need for beta-agonist medication

D. have had no impact

E. show promise for better control and convenience

Question 24.Answer.

A 12-year-old boy is brought to the emergency department because of

lethargy and poor oral intake. On physical examination, his blood
pressure is 110/70 mm Hg and his pulse is 120 beats/min. Results of
laboratory evaluation include: creatinine, 0.7 mg/dL; sodium, 125 mEq/L;
potassium, 5.4 mEq/L; chloride, 90 mEq/L; bicarbonate, 15 mEq/L;
glucose, 1,000 mg/dL; calcium, 9.0 mg/dL; phosphorus, 2.5 mg/dL.

The MOST likely explanation for this hyponatremia is

A. dehydration

B. hyperglycemia

C. hypophosphatemia

D. metabolic acidosis

E. syndrome of inappropriate antidiuretic hormone secretion

Question 43.Answer.

A 10-month-old boy has a history of repeated bouts of sinusitis and

chronic otitis media. He has been hospitalized twice for treatment of
pneumonia. Physical examination reveals no palpable lymph nodes and
absent tonsillar tissue. Results of laboratory testing include a normal
complete blood count and nondetectable levels of immunoglobulin A
(IgA), IgE, IgG, and IgM.

Of the following, the most appropriate INITIAL management of this

child is

A. antibiotic prophylaxis

B. bone marrow transplantation

C. granulocyte transfusions

D. monthly intravenous immune globulin infusions IVIG

E. splenectomy

Question 64.Answer.

A 15-year-old patient who has stable asthma brings you a school medical
form to complete. The only medication she is receiving is albuterol via
metered dose inhaler. You describe the known side effects of this
medication, including the effects of an overdose.

Of the following, the MOST common side effect of this agent is

A. hyperkalemia

B. muscle weakness

C. oral thrush

D. somnolence

E. tachycardia

Question 84.Answer.

A 14-year-old girl is undergoing a sports preparticipation evaluation. She

has asthma that is triggered by both exercise and exposure to allergens.
She has been using her albuterol metered dose inhaler prior to exercise.
She feels fine initially, but becomes symptomatic several hours later.

Of the following, the MOST appropriate management is to

A. advise her to discontinue exercise completely

B. prescribe an inhaled corticosteroid for use prior to exercise

C. prescribe inhaled albuterol for use after her symptoms develop

D. prescribe inhaled sodium cromolyn for use prior to exercise

E. prescribe oral antihistamines for use prior to exercise

Question 101. Answer.

A 14-year-old patient is seen in September for routine evaluation of
allergic rhinitis and asthma. Immediately upon entering the room you are
struck by his weight gain and the round, flushed appearance of his face.

Of the following, the MOST likely explanation for these findings is

A. Addison disease

B. exposure to adult dosages of both nasal and inhaled steroids

C. hypothyroidism

D. overeating throughout the summer

E. side effects from anabolic steroid use for weightlifting

Question 123. Answer.

A 15-year-old boy who has asthma is working on a school project

explaining the triggers for an asthmatic attack. He knows that irritants
such as cigarette smoke and strong fumes, upper respiratory tract
infections, and exposure to pets and allergens can trigger his attacks. He
read that aspirin may provoke symptoms and asks you about any other
medications that should be avoided.

Of the following, you are MOST likely to mention that such patients
should avoid

A. acetaminophen

B. antihistamines

C. beta-adrenergic blocking agents

D. inhaled corticosteroids

E. penicillin-derived antibiotics

Question 162. Answer.

A 4-month-old child is brought to your office because he became irritable

and developed diarrhea and emesis shortly after his third feeding with a
milk-based formula. The first time he had taken this formula there were
no problems, and the second time he developed an urticarial rash. He had
not received any milk-based products previously because of severe
eczema. Examination reveals only a few eczematous patches.

Of the following, the most appropriate INITIAL step in evaluation of this

child is to

A. begin immunotherapy against milk protein based on history alone

B. eliminate milk from the diet for only 1 month

C. order radioallergosorbent (RAST) testing to milk

D. perform a milk challenge in the office

E. refer to a pediatric allergist for skin testing to milk

Question 180. Answer.

During a health supervision visit, you discover that a patient has daily
symptoms of cough and shortness of breath with exercise as well as
nighttime cough (usually in the middle of the night). She has been seen in
the emergency department four times this year and has been hospitalized
twice for treatment of asthma. Physical examination reveals mild
scattered wheezing. Peak flow measurement is 60% of predicted.

Of the following, the MOST appropriate classification of this girl's

symptoms is

A. extrinsic asthma

B. mild asthma

C. mild asthma with an exacerbation

D. moderate persistent asthma

E. severe persistent asthma

Question 202. Answer.

You are seeing a 7-year-old girl who has allergic rhinitis and has had
documented reactions to multiple pollens. Oral antihistamines have been
effective in controlling her symptoms until recently.

Of the following, the BEST management at this time is to

A. administer an intranasal corticosteroid INS

B. administer an oral decongestant

C. administer sodium cromolyn nasal spray

D. begin saline nasal washes

E. continue the current antihistamine therapy

Question 222. Answer.

During a health supervision visit, you note clear rhinorrhea in a 4-year-

old child who has eczema. The parents report that the symptoms appear
each spring as the trees began to blossom, and you diagnose allergic
rhinitis. You counsel the parents that when a child has one atopic
syndrome, such as eczema, he or she has a threefold greater risk of
developing another component, such as rhinitis or asthma.

Of the following, the MOST important factor influencing atopy in this

child is

A. allergy to peanuts in the child's cousin

B. asthma in the child's brother

C. asthma in the father's uncle

D. atopy in both of the child's parents

E. the month of the year in which the child was born

Question 242. Answer.

A school nurse contacts you about ways to improve the classroom

environment for children who have asthma.

Of the following, the MOST appropriate intervention to recommend is to

A. have the windows open during classroom hours to provide better

air circulation

B. place an air cleaner with a high-efficiency particulate arrestor

(HEPA) filter in the classroom

C. place a humidifier in the classroom during the winter months

D. purchase a filter vacuum cleaner for the school

E. remove any furred animals from the classroom

Question 261. Answer.

A 12-year-old boy who has asthma is brought to the emergency

department at midnight for the third time in 7 days with mild wheezing.
His asthma had been well-controlled with as-needed albuterol by metered
dose inhaler until this past week. He is known to be allergic to furry
animals, and a rabbit has been placed in his classroom, but he appears
fine when leaving school.

Of the following, the MOST likely explanation for these findings is that
the boy

A. always has had these symptoms, but now is recognizing them and
seeking care

B. has a newly acquired upper respiratory tract infection and requires

the addition of theophylline

C. has become tolerant to the inhaled albuterol therapy

D. is experiencing a late-phase reaction to exposure to the rabbit ‫ارنب‬

in the classroom

E. is suffering from gastroesophageal reflux at night that is worsening

his asthma

Question 9. Answer.

You are meeting with a couple for a prenatal visit. They are concerned
because both have atopic disorders.

Of the following, the factor that is MOST likely to modify the potential
for allergic disease in their infant is

A. breastfeeding exclusively during the first 6 months of life

B. elimination of bananas, apples, and rice during the first 6 months of

life
C. elimination of milk, eggs, wheat, and shellfish from the maternal
diet during pregnancy

D. supplementation of human milk with cow milk formula during the

first 6 months of life

E. supplementation of human milk with soy formula during the first 3

months of life

Question 42.Answer.

For the past few months, a 3-year-old girl who has asthma has had
repeated exacerbations treated with nebulized albuterol every 6 to 8 hours
as needed. Previous attacks have responded to prednisone. Findings
include mild bilateral expiratory wheezes without retractions. Results of a
previous sweat test, chest radiography, and barium swallow were normal.

Of the following, the BEST management is to

A. add nebulized cromolyn sodium three times daily

B. add oral beta2-agonist therapy

C. add oral theophylline therapy

D. change the nebulized albuterol schedule to every 4 hours

E. continue with the current regimen

Question 79.Answer.

A 14-year-old boy who has allergic rhinitis reports that he frequently

develops coughing and wheezing after about 5 minutes of playing soccer.
These symptoms improve after resting for 30 minutes.

Of the following, the drug that will give the BEST response in this patient
if administered just prior to exercise is

A. inhaled beta2-agonist

B. inhaled corticosteroid

C. oral beta2-agonist

D. oral corticosteroid
E. oral theophylline

Question 118. Answer.

Findings from the history of a 12-year-old girl who has asthma suggest
that she has been “overusing” her beta2-agonist inhaler. She states that
over the past 3 months she felt the need to use it more frequently than
prescribed. The dose of inhaled steroid she receives twice daily is
appropriate, and results of pulmonary function studies are normal.

Of the following, the BEST management is to

A. begin regularly scheduled nebulized albuterol at home

B. have her return for weekly pulmonary function studies

C. increase her inhaled steroid dose to three times a day

D. initiate oral theophylline therapy twice daily

E. recommend she use home peak flow monitoring daily and when
she feels “tight”

Question 154. Answer.

A 12-year-old boy has a history of hives after receiving several

antibiotics. He has had repeated episodes of pharyngitis and sinusitis that
required antibiotic therapy, and his parents would like to know which
antibiotics should be avoided. They have asked whether allergy skin
testing would be helpful.

For which ONE of the following antibiotics is an immunoglobulin E

(IgE)-mediated skin test available?

A. Cefaclor

B. Clarithromycin

C. Erythromycin

D. Penicillin

E. Vancomycin

Question 191. Answer.

A 13-year-old boy is stung by a bee and develops hives and wheezing. He
is hypotensive when evaluated in the emergency department. He is
treated successfully with epinephrine, diphenhydramine, and fluids. He is
given a prescription for injectable epinephrine at the time of discharge.

Of the following, the BEST recommendation for the patient is to

A. avoid all contact with bees

B. carry an albuterol inhaler at all times

C. have diphenhydramine available when outdoors

D. not participate in any outdoor sports

E. undergo skin testing for possible venom immunotherapy

Question 223. Answer.

A 9-year-old girl has moderate persistent asthma that has been stable for
several years. She has been hospitalized twice in the past few months.
She has been using all of her usual medications as instructed. Additional
questioning reveals that her family recently adopted a stray cat that has
started to sleep in her bedroom.

Of the following, the BEST management for this child is to

A. add alternate-day prednisone to her daily regimen

B. arrange a family conference to discuss the implications for her

asthma of having a cat

C. install a special filter on the furnace

D. instruct her parents that they have to remove the cat from the home

E. suggest bathing the cat every 6 months

Question 252. Answer.

A 15-year-old boy who has asthma takes theophylline and inhaled

corticosteroids regularly as well as an inhaled beta2-agonist as needed.
During a flare, he has received three nebulized treatments of albuterol and
intravenous methylprednisolone, which resulted in moderate
improvement in his respiratory status.
The finding that is MOST likely to predict that hospitalization now may
be warranted is

A. history of inhaled corticosteroid use

B. history of intravenous corticosteroid use

C. history of intubation during a prior asthma attack

D. oxygen saturation of 91% by pulse oximetry

E. the need for an aminophylline infusion during this episode

Question 34.Answer.

You are evaluating a 13-year-old boy who has asthma and required
mechanical ventilation following a respiratory arrest 2 years ago. He is
using an inhaled bronchodilator as needed, 3 to 4 times a day, and has not
seen a physician in more than 8 months. He has no complaints, but
reports he gets short of breath easily.

In addition to an inhaled bronchodilator as needed, the BEST drug to treat

this patient's asthma is inhaled

A. anticholinergic agent

B. corticosteroid

C. cromolyn sodium

D. long-acting bronchodilator

E. nedocromil sodium

Question 69.Answer.

Four days after receiving an intramuscular injection of benzathine

penicillin to treat syphilis, a 17-year-old girl reports feeling "funny" in
her chest and having a rash. She was told in the past that she was allergic
to cefaclor. Results ofimmediate-type skin testing with major and minor
determinants to penicillin are negative.

If this patient receives another course of oral penicillin in the future, she
is MOST likely to experience
A. anaphylaxis

B. hematuria

C. hemolytic anemia

D. maculopapular rash

E. neutropenia

Question 101. Answer.

At an outdoor party for your daughter, a 4-year-old who ate cake, candy,
and peanuts develops diffuse urticaria, angioedema of the lips and
eyelids, wheezing, dyspnea, and a cough.

Of the following, the MOST likely cause of this child's symptoms is

A. anaphylactoid reaction

B. anaphylaxis

C. exercise-induced asthma

D. idiopathic urticaria/angioedema

E. idiosyncratic reaction to artificial preservatives

Question 132. Answer.

Each May for the past 3 years, a 12-year-old boy has developed sneezing
and itching of the nose and eyes. Symptoms generally last 4 to 6 weeks.

Of the following, the MOST likely explanation for this boy's findings is

A. allergic rhinitis

B. infectious rhinitis

C. irritant rhinitis

D. rhinitis medicamentosa

E. vasomotor rhinitis

Question 166. Answer.

A 3-month-old infant has failure to thrive, oral candidiasis, and chronic
diarrhea.

Among the following, the diagnostic study MOST likely to explain these
findings is

A. CD4 lymphocyte count

B. polymerase chain reaction for human immunodeficiency virus

C. skin testing for delayed hypersensitivity

D. stool culture for fungus

E. total hemolytic complement level

Question 167. Answer.

A 3-day-old girl who has had a lumbar sacral myelomeningocele repaired

has vomited twice. Physical examination reveals fullness of the anterior
fontanelle and opisthotonic posturing. The head size has increased 1 cm
since birth.

Of the following, the MOST likely cause of these findings is

A. acute hydrocephalus

B. seizures

C. subdural effusion

D. tethering of the spinal cord

E. urosepsis

Question 202. Answer.

A 13-month-old boy who has atopic dermatitis has had two significant
flares in his skin disease recently. The first occurred 1 month ago when
he was switched from soy formula to cow milk. His skin condition
improved when he was returned to soy formula. His parents allowed him
to have cheese during the past week and his skin condition has worsened.

Of the following, the most appropriate NEXT step in management is to

A. diagnose him as being allergic to cow milk

B. introduce cow milk in a slow, desensitizing fashion

C. obtain a D-xylose test

D. perform another challenge with cow milk

E. refer him to an allergist for skin testing

Question 234. Answer.

The parents of a 10-year-old boy who has mild asthma but no allergic
symptoms ask whether their son will outgrow the asthma.

Because he has no evidence of allergies, you tell them that the likelihood
that he will outgrow his asthma by adulthood is CLOSEST to

A. 20%

B. 30%

C. 40%

D. 50%

E. 60%

Question 267. Answer.

A 10-year-old boy reports he has had wheezing following exercise and

has had symptomatic relief after using his brother's albuterol inhaler
when he has a cold. He never has required treatment in your office or at
the hospital. Pulmonary function testing reveals that his forced expiratory
volume in 1 second (FEV1) is 85% of predicted.

Of the following, the MOST likely diagnosis is

A. asthmatic bronchitis

B. bronchitis

C. exercise-induced asthma

D. mild intermittent asthma

E. moderate persistent asthma

 IMMUNOLOGY
Question . 1. A 40-day-old, previously healthy, full-term female infant\ manifests fever,
lethargy, and poor feeding for 12 hr. Physical examination reveals a lethargic child with
vital signs of respiratory rate 70/min, heart rate 185/min, mean blood pressure 25 mm Hg,
and temperature 39.5°C. Peripheral perfusion is poor. The chest examination reveals
retractions, the abdomen is soft and reveals persistence of the umbilical cord, and the
extremities are cool. Laboratory studies reveal a white blood cell count of 67,800/mm3
and a platelet count of 105,000/mm3. Family history reveals that a male sibling died
suddenly at the age of 2 mo, 10 yr prior to the birth of this child. The most likely
diagnosis is:
a.Chronic granulomatous disease
b.Congenital leukemia
c.Kostmann syndrome
d.Leukocyte adhesion deficiency
e.Neutrophil myeloperoxidase deficiency
Explanation: This infant has the clinical picture of sepsis with additional findings of
delayed separation of the umbilical cord, extreme leukocytosis, and a family history of
early childhood death. This pattern is suggestive of a leukocyte adhesion deficiency,
which predisposes to sepsis

Question . 2. Evaluation of immune function should be initiated for otherwise

healthy children with which of the following infections?
a.A life-threatening bacterial infection (e.g., sepsis,meningitis)
b.A systemic fungal infection (e.g., coccidioidomycosis)
c.Eight or more upper respiratory tract infections within 12 mo
d.Infection with unusual organisms (e.g., Nocardia)
e.All of the above
Explanation: Immune evaluations should be initiated for children with unusual, chronic,
or recurrent infections, suchas :
(1) two or more systemic or serious bacterial infections;
(2) three or more serious respiratory or documented bacterial soft tissue infections within
12 mo;
(3) infections at unusual sites;
(4) infections with unusual organisms; and
(5) infections with common childhood pathogens but of unusual severity

Question . 3. A 3-yr-old girl has a history of recurrent, serious skin and soft
tissue infections caused by Staphylococcus aureus and group A
streptococcus. The initial screening laboratory evaluation for possible
immunodeficiency includes all of the following except:
a. Complete blood count and manual differential
b. Absolute lymphocyte count
c. Platelet count
d. CH50
e. Immunoglobulin levels

Question . 4. Which of the following is an effective screening test for T-cell

function?
 a. Absolute lymphocyte count
b. Flow cytometry for CD4 (helper) and CD8 (cytotoxic) T cells
c. Respiratory burst assay
d. Candida skin test
e. Mumps antibody titer after mumps vaccination

Question . 5. Infections characteristic of T-cell immunodeficiency include all of

the following except:
a. Pneumocystis carinii pneumonia
b. Cryptosporidium diarrhea
c. Severe disseminated chickenpox (varicella)
d. Serratia marcescens abscess
e.Strongyloides stercoralis hyperinfection syndrome

Question . 6. Useful test for evaluation of possible B-cell (antibody) deficiency

include all of the following except:
a. Isohemagglutinins
b. Antibodies to tetanus
c. Flow cytometry for CD3 cells
d. Serum IgA level
e. Total IgG level

Question . 7. A 2-yr-old boy is diagnosed with an immune deficiency. There is

no other family history suggestive of immunodeficiency. Which of the following
constitutes appropriate advice for the parents regarding possible future
pregnancies?
a. Immune deficiencies primarily occur as spontaneous mutations and therefore no
genetic counseling is necessary.
b. Inherited immunodeficiencies reflect the complex interactions of multiple genes
with variable expressivity, and therefore genetic counseling is not accurate.
c. The absence of other immunodeficiencies in this family indicates that this
immunodeficiency most likely does nohave a genetic component.
d. This immune deficiency is almost certainly X-linked.
e. None of the above.

Question . 8. Complications of intravenous immunoglobulin (IVIG) therapy

include all of the following except:
a. Anaphylaxis
b. Fluid overload
c. Transmission of HIV
d. Aseptic meningitis
e. Systemic reactions

Question . 9. A 1-yr-old child is found to have a normal WBC count but no

circulating B cells, small tonsils, and no palpable lymph nodes. Serum
concentrations of IgG, IgA, IgM, and IgE are below the 95% lower limits for
age. The most likely diagnosis is:
a. Ataxia-telangiectasia
b. X-linked lymphoproliferative syndrome
c. DiGeorge syndrome
d. Common variable immunodeficiency
e. X-linked agammaglobulinemia
 Explanation: X-linked agammaglobulinemia (XLA), orBruton
agammaglobulinemia, is suggested by low concentrations of all Ig classes.
Affected patients are also unable to respond to immunizations, unlike infants with
transient agammaglobulinemia of infancy
Question . 10. The most common defined immunodeficiency disorder is:
a.Common variable immunodeficiency
b.Selective IgA deficiency
c.X-linked agammaglobulinemia
d.X-linked lymphoproliferative syndrome
e.Ataxia-telangiectasia

Question . 11. The X-linked lymphoproliferative (XLP) syndrome is classically

associated with overwhelming infection by which of the following agents?
a.Epstein-Barr virus EBV
b.Enteroviruses
c.Catalase-positive bacteria
d.Neisseria meningitidis
e.Pneumocystis carinii

Question . 12. Features of the complete DiGeorge syndrome include

susceptibility to infection and:
a. Neonatal hypocalcemia
b. Anomalies of the great vessels
c. Graft versus host disease after blood transfusion wit nonirradiated blood
d. Micrognathia
e. Onset of infections after age 12 mo

Question . 13. All of the following statements regarding DiGeorge syndrome

are true except:
a. It occurs approximately equally in both males and females.
b. Variable hypoplasia of the thymus and parathyroids is mor common than
complete aplasia.
c. Children with partial DiGeorge syndrome may have little trouble with infections.
d. Absolute lymphocyte counts are usually markedly low only moderately low for
age)
e.Concentrations of serum immunoglobulins are usually normal.

Question . 14. All of the following are prominent features of Wiskott-Aldrich

syndrome except:
a. Atopic dermatitis
b. Thrombocytopenia
c. Recurrent infections with encapsulated bacteria
d. Autosomal dominant inheritance (XLR)
e. More frequent occurrence in males
Explanation: The combination of atopic dermatitis, thrombocytopenic purpura,
and susceptibility to infection in males is the classic presentation of Wiskott-
Aldrich syndrome, which is an X-linked recessive syndrome

Question 15. manifestations of hyper IgE syndrome frequently include:

a. Recurrent pneumonia
b. Pneumatoceles
c. Recurrent fractures
 d. Hyperextensible joints
e. All of the above

Question . 16. The recommended treatment for severe combined

immunodeficiency is:
A. Gene therapy
B. Monthly IVIG
C. Monthly IVIG and IFNMonthly
D. IVIG and IL-8 monoclonal antibody
E. Stem cell transplantation

Question . 17. All of the following statements regarding monocytes and

neutrophils are true except:
A. Monocytes, unlike neutrophils, have an unlimited capacity to divide.
B. Monocytes remain longer in the circulation than do neutrophils.
C. Monocytes in tissues (macrophages) can persist for months.
D. Only neutrophils kill organisms by ingestion.
E. There are many varieties of mononuclear phagocytes, bu only one type of
neutrophil

Question . 18. Monocytes leave the bloodstream and differentiate in the

tissues into macrophages with variable morphology and function. All of the
following cell types are monocyte-derived except:
A. Dendritic cells
B. Microglial cells
C. Kupffer cells
D. Osteoblasts (osteoclasts,)
E. Multinucleated giant cells

Question . 19. A 6-yr-old girl has had intermittent fever, decreased appetite,
and weight loss since starting first grade 4 mo ago. Physical examination
reveals generalized lymphadenopathy, and a chest film shows prominent paraaortic
nodes. Past medical history is negative for infection except for
Salmonella paratyphi septicemia and liver abscess at 3 yr of age, successfully
treated with antibiotics. Cervical lymph node biopsy shows marked histiocytic
infiltration but no granulomas or giant cells; the acid-fast stain is positive. The
most likely diagnosis is:
A. Congenital hypogammaglobulinemia
B. Leukocyte mycobactericidal defect
C. Severe combined immunodeficiency disease
D. Normal child
E. Langerhans cell histiocytosis
Individuals with inherited deficiency inmacrophage receptors for IFN- or lymphocyte
receptorsfor IL-12, or in IL-12 itself, suffer a severe, profound, and selectivesusceptibility
to infection by nontuberculous mycobacteria such as Mycobacterium avium or bacille
Calmette-Guérin (BCG). About half of these patients have had disseminated Salmonella
infection. These abnormalities are now grouped under the term leukocyte
mycobactericidal defect

Question . 20. All of the following are typically associated with an eosinophilic
response and eosinophilia except:
A. Allergic rhinitis
 B. Hypersensitivity drug reactions
C. Trichinosis (Trichinella spiralis)
D. Pinworms (Enterobius vermicularis)
E. Wiskott-Aldrich syndrome

Question . 21. Delayed separation of the umbilical cord after birth suggests
which of the following types of immune dysfunction?
A. B-cell defect
B. T-cell defect
C. Combined B- and T-cell defect
D. Phagocyte function defect
E. Complement component deficiency

Question . 22. The phagocytic defect of chronic granulomatous disease is:

A. Defect of transendothelial migration
B. Inability to ingest microorganisms
C. Inability to kill some microorganisms
D. Myeloperoxidase deficiency
E. Excessive formation of H2O2
Question . 23. All of the following are associated with chronic granulomatous
disease (CGD) except:
A. X-linked and autosomal recessive inheritance
B. Pyloric outlet obstruction
C. Aspergillus pneumonia
D. Perianal abscess
E. Hypogammaglobulinemia= hypergammaglobulinemia

Question . 24. A 5-yr-old boy presents with his third episode of painful cervical
lymphadenitis. Each was treated with incision and drainage, and cultures grew
Staphylococcus aureus. At the age of 2 yr, he required surgical aspiration of a
liver abscess. The most important laboratory test is:
A. PCR assay for ADA deficiency
B. Fluorescence assay using dihydrorhodamine 123
C. MAC-1 assay
D. Neutrophil count
E. Bone marrow aspiration

Question . 25. The most likely diagnosis for the patient described in Question
24 is:
A. Bruton agammaglobulinemia
B. AIDS
C. Chronic granulomatous disease
D. Kostmann disease
E. Cyclic neutropenia

Question . 26. Long-term effective therapy for the patient described in

Question 24 is best accomplished with:
A. Intravenous immunoglobulin
B. IFN
C. IL-2
D. Bone marrow transplantation
E. Granulocyte transfusion
Question . 27. Neutropenia is noted in children in all of the following
conditions except:
A. Kostmann disease
B. Viral infection
C. Maternal preeclampsia
D. Hunter syndrome
E. Shwachman-Diamond syndrome

Question . 28. A 5-mo-old girl presents with diarrhea and malabsorption, and
on initial laboratory testing has a WBC count of 900/mm3. Which of the
following is the most likely diagnosis?
A. Cystic fibrosis
B. Shwachman-Diamond syndrome=AR
C. Cyclic neutropenia
D. Chronic granulomatous disease
E. Severe combined immunodeficiency
Explanation: Schwachman-Diamond syndrome is an autosomal recessive disorder
characterized by digestive abnormalities and leucopenia

Question . 29. All of the following may be associated with neutropenia except:
A. Leukocyte adhesion deficiency
B. Shwachman-Diamond syndrome
C. Cartilage-hair hypoplasia
D. Chédiak-Higashi syndrome
E. Glycogen storage disease type Ib

Question . 30. Features associated with cyclic neutropenia include:

A. An oscillatory period of 21 ± 3 days
B. Oral ulcerations and stomatitis
C. Serious infections including pneumonia
D. Septicemia, notably with Clostridium perfringens
E. All of the above

Question . 31. A 6-mo-old child presents with recurrent cellulitis and

bacteremia due to Staphylococcus aureus. The white blood cell count is
2500/mm3 with 5% neutrophils, 10% eosinophils, 35% monocytes, and 50%
lymphocytes. The platelet count is 650,000/mm3. A brother and a female
cousin died at the ages of 18 mo and 2 yr, respectively. The most likely
diagnosis is:
A. AIDS
B. Severe combined immunodeficiency
C. Kostmann disease
D. Cyclic neutropenia
E. Chronic granulomatous disease
Question . 32. Long-term treatment of the disease described in Question 31 is
best accomplished with:
A. Prophylactic antibiotics
B. Intravenous immunoglobulin monthly
C. IFN
D. Recombinant human G-CSF
E. Stem cell transplantation
Question . 33. A 12-yr-old boy has a total white blood cell count of
13,000/mm3, with 60% neutrophils, 14% bands, 25% lymphocytes, and 1%
monocytes. Which of the following describes this result?
A. Neutrophilia
B. Leukocytosis
C. Shift to the left
D. Leukocytosis and shift to the left
E. Neutrophilia, shift to the left, and lymphopenia
Band forms normally constitute 1-5% of thecirculating neutrophils. An increase in
band forms is termeda "shift to the left." The total white count is normal, and
therefore there is not a leukocytosis. The percentage ofneutrophils is within normal limits,
and therefore there is nota neutrophilia. The percentage of lymphocytes is within normal
limits, and the absolute lymphocyte count is2,800/mm3, and therefore there is not a
lymphopenia

Question . 34. Repeated meningococcal infections suggest which of the

following types of immune disorder?
A. B-cell defect
B. T-cell defect
C. Combined B- and T-cell defect
D. Phagocyte function defect
E. Complement component deficiency

Question . 35. A 10-yr-old boy undergoes stem cell transplantation with stem
cells harvested from his 14-yr-old sister. Which of the following terms
describes this type of transplantation?
A. Autologous
B. Syngeneic
C. Familiogeneic
D. Allogeneic
E. Xenogeneic
Cells for autologous transplantation (afterremoval of cancer cells) are obtained from
the patient. Cellsfor syngeneic transplantation are obtained from an identical twin.
Cells for allogeneic transplantation are obtained from a nonidentical person

Question . 36. A 4-mo-old girl has severe persistent neutropenia (absolute

neutrophil count 200 cells/mm3), thrombocytopenia (platelet count
<20,000/mm3), and reticulocytopenia (reticulocyte count <1% when anemia is
present). She has an HLA-matched family donor. The treatment of choice is:
A. IFNIFN-and IL-8
B. IFN- (, platelet-derived growth factor, and monthly IVIG
C. Recombinant human G-CSF, platelet-derived growth factor,and monthly
(asneeded) red blood cell transfusions
D. Stem cell transplantation

Question . 37. The most important factor contributing to graft failure and graft
rejection is:
A. HLA disparity
B. Pretransplantation alloimmunization by transfusions
C. The conditioning regimen
D. Transplanted stem cell dose
 E. Post-transplantation viral infections

Question . 38. A 9-yr-old boy undergoes stem cell transplantation for acute
myelogenous leukemia in remission. Approximately 4 mo after transplantation,
he has persistent maculopapular rash over 25% of his body, generalized
erythroderma, bilirubin 8.4 mg/dL, and diarrhea with >1,000 mL of feces per
day. He complains of xerostomia. The most likely diagnosis is:
A. Post-transplantation Sj gren syndrome
B. Acute graft versus host disease.
C. Chronic graft versus host disease
D. Acute cytomegalovirus infection
E. Reactivated cytomegalovirus infection

Question . 39. Which of the following statements regarding cyclosporine is

true?
A.Adverse effects, other than immunosuppression, areuncommon.
B.Cyclosporine should generally be used with tacrolimus forsynergy.
C.Cyclosporine is as effective as methotrexate for post-stemcell transplantation
immunosuppression.
D.The only significant drug interaction requiring dosageadjustment is with ketoconazole.
E.The dosage should be adjusted regularly based ondrug levels.

Question . 40. Well-recognized late effects of total body irradiation as part of

the preparative regimen for stem cell transplantation include all of the following
except:
A.Leukoencephalopathy
B.Secondary malignancies
C.Hyperthyroidism
D.Growth depression
E. Cataracts

RHeumatolgy

- A 2-year-old boy presents with fever and knee pain for 18 hours. He has
previously been well. Full term normal delivery, no neonatal problems. Immunisations
up to date. No family or social history of note.
On examination the temperature is 38.9oC, with respiratory rate 24/min and pulse
100/min. He is alert and well perfused. His left knee is swollen, warm, red and
exquisitely tender. It is held partly flexed.

What is the most likely diagnosis?

(Please select 1 option)

Haemophilia A

Juvenile rheumatoid arthritis

Osteomyelitis
 Reactive arthritis

Septic arthritis
The short history, fever, location and clinical findings all point to a septic arthritis. This
can be confirmed by blood culture and needle aspiration of the joint.

The common organisms are Staph. aureus and gram negative bacilli, with GBS in
<3/12 infants.

Treatment is with IV antibiotics, with resolution followed by settling WCC, ESR and
CRP.

- A 12-year-old girl presents with joint pain and stiffness of four months duration. This
affects the hands, wrists, elbows, knees and ankles bilaterally, and she is stiff in the
mornings. Paracetamol has been of little benefit.

She had a full term normal delivery with no neonatal problems. Her immunisations
are up to date. There is no family or social history of note.

On examination the temperature is 36.7°C, respiratory rate 12/min and pulse 80/min.
She has swelling of the MCP and IP joints of all digits bilaterally. Her wrists, elbows,
knees and ankles have limitation of movement and are swollen and warm.

What is the most likely diagnosis?

(Please select 1 option)

Dermatomyositis

Oligoarticular juvenile rheumatoid arthritis

Polyarticular juvenile rheumatoid arthritis

Reactive arthritis

Systemic juvenile rheumatoid arthritis

The symmetrical prolonged joint pain and swelling are characteristic of polyarticular
juvenile chronic arthtitis.

Involvement of the temperomandibular joints can cause micrognathia, and cervical

involvement can cause atlanto-axial instability.

- A 7-year-old boy presents with knee pain of two months duration. He feels stiff in
the mornings, and takes 30 minutes to get going. He feels tired by the end of school.

He had a full term normal delivery with no neonatal problems. His immunisations are
up to date. There is no family or social history of note.
What is the most likely diagnosis?

(Please select 1 option)

Dermatomyositis

Oligoarticular juvenile rheumatoid arthritis

Polyarticular juvenile rheumatoid arthritis

Reactive arthritis

Systemic juvenile rheumatoid arthritis

The history of oligoarthritis of more than 6/52 duration accompanied by inflammation
and limitation of movement in a single limb suggests pauciarticular (oligoarticular)
juvenile chronic arthritis.

The diagnosis is clinical, though inflammatory markers are often raised.

Although uveitis can occur with any, antinuclear factor (ANF) positive cases are at
higher risk of this complication.

- A 7-year-old girl presents with ankle and knee pain and skin rash. She has been
well apart from a cold two weeks previously.

She had a full term normal delivery with no neonatal problems. Her immunisations
are up to date. There is no family or social history of note.

On examination she looks well. The temperature is 37.8°C, with respiratory rate
15/min, pulse 80/min and blood pressure 100/70 mmHg. She has a scanty non-
blanching rash over the shins. Her abdomen is soft and non-tender. There is
swelling, redness, tenderness and decreased movement of the right knee and left
ankle.

What is the most likely diagnosis?

(Please select 1 option)

Acute leukaemia

Chronic meningococcaemia

Henoch-Schonlein purpura

Rheumatic fever

Von Willebrand's disease

The history of preceding throat infection, joint pain and characteristic rash in a well
child point to Henoch-Schonlein purpura as the diagnosis.
Urine dipstick testing should be done to look for renal involvement.

Some patients can have abdominal pain, vomiting or blood PR because of

gastrointestinal involvement.

- A 12-year-old Afro-Caribbean girl presents with fever, malaise, and joint pains of
three months duration. She was previously well.

She had a full term normal delivery with no neonatal problems. Her immunisations
are up to date. There is no family or social history of note.

On examination the temperature is 37.6°C, respiratory rate 14/min, pulse 80/min and
blood pressure is 100/70 mmHg. She appears subdued and well perfused. She has a
scanty rash over her cheeks. She has generalised joint tenderness on extremes of
movement, but there is no obvious effusion or warmth in them. She has 2+
haematuria and 2+ proteinuria.

What is the most likely diagnosis?

(Please select 1 option)

Chronic multifocal osteomyelitis

Reactive arthritis

Septic arthritis

Sickle cell crisis

Systemic lupus erythematosus

The prolonged history of fever, malaise, joint pains, malar rash and renal involvement
point to a multisystem disease.

In this ethnic group systemic lupus erythematosus (SLE) is the most likely diagnosis.
This can involve any system and is a great mimic.

Treatment is with non-steroidal anti-inflammatory drugs (NSAIDs) for joints plus

immunosuppressives for the renal involvement.

Therapy may be difficult and prolonged.

- An obese 14-year-old boy presents acutely with hip pain, which began the previous
day and has prevented walking. He has previously been well.

He had a full term normal delivery with no neonatal problems. His immunisations are
up to date. There is no family or social history of note.
On examination the temperature is 36.5°C, RR 12/min and HR 80/min. He has
severe limitation of movements of the right hip because of the degree of discomfort.
The hip is held flexed and externally rotated.

What is the most likely diagnosis?

(Please select 1 option)

Legg-Calve-Perthes

Osteomyelitis

Reactive arthritis

Septic arthritis

Slipped capital femoral epiphysis

The history of acute hip pain in an obese adolescent without fever suggests a slipped
capital femoral epiphysis (SCFE).

It may present subacutely or with pain referred to the knee.

In the subacute case the child walks painfully with the knee externally rotated on the
affected side.

The SCFE is pinned to prevent further slippage.

- A 7-year-old boy presents with a limp and intermittent thigh pain of two months
duration. He has previously been well.

He had a full term normal delivery with no neonatal problems. His immunisations are
up to date. There is no family or social history of note.

On examination he is well and apyrexial. Respiratory rate is 15/min and pulse 80/min.
He is on the 10% for height and the 25% for weight. He limps with minimal pain, but
has limitation of abduction and internal rotation of the left hip.

What is the most likely diagnosis?

(Please select 1 option)

Irritable hip

Legg-Calve-Perthes

Reactive arthritis

Septic arthritis
 Slipped femoral epiphysis
The history of 'painless limp' with reduction in hip movements suggests Legge-Calve-
Perthes disease.

This is an avascular necrosis of the femoral head in a growing child, especially pre-
pubertal.

There may be thigh muscle atrophy and slightly short stature.

The disease is staged radiographically (several classifications available).

Treatment is aimed at reducing femoral head deformity and later osteoporosis.

- A 6-year-old boy presents with hip pain of one day duration. He has previously been
well apart from a sore throat four weeks previously.

Full term normal delivery, no neonatal problems. Immunisations up to date. No family

or social history of note.
On examination the temperature is 36.8°C, respiratory rate 16/min and pulse 95/min.
He looks well. The right hip is painful to move with slight limitation of movements in
all directions. Full blood count shows a white cell count of 7.8 x109/L (4-11 x109)
(normal differential) and CRP of 12 mg/L (<10).

What is the most likely diagnosis?

(Please select 1 option)

Legg-Calve-Perthes

Lyme disease

Osteomyelitis

Reactive arthritis

Septic arthritis
The history of recent infection followed by mild joint symptoms at this age, with no
evidence of fever or raised inflammatory mediators suggests a toxic synovitis
(transient or reactive synovitis).

Ultrasound scan may show widening of the joint space.

Aspiration may be needed to exclude a septic arthritis.

- A 5-year-old girl presents with fever and inability to bear weight.

She had fallen from her bicycle four days before, and had had a fever for two days.
This morning she had been unable to move her left hip because of severe pain.
She had a full term normal delivery with no neonatal complications. Her
immunisations are up to date. There was no FH/SH of note.

On examination temperature is 39.4°C, respiratory rate 20/min and pulse 100/min.

Well perfused and cooperative, though tearful when leg examined. Left leg is held
flexed and externally rotated.

What is the most likely diagnosis?

(Please select 1 option)

Juvenile arthritis

Osteomyelitis

Reactive arthritis

Rheumatic fever

Septic arthritis
The minor trauma, fever and exquisite joint pain suggest a septic arthritis.

The joint is held to minimise stretch on the joint capsule.

Ultrasound scan (USS), x ray and bone scans are used to define the extent of
disease.

Blood culture identifies an organism in 50%.

Intravenous antibiotics should penetrate bone and cover Staph. aureus, streptococci
and H. influenzae (for example, cefotaxime).

- A boisterous 15 month old girl present with a painful elbow. She was reluctant to
come with mother, who pulled her up by the arm with sudden onset of pain. Full term
normal delivery, no neonatal problems. Immunisations up to date. No family or social
history of note.

On examination the temperature is 36.5°C, respiratory rate 25/min and pulse

100/min. The left arm is held pronated across her chest.

What is the most likely diagnosis?

(Please select 1 option)

Dislocation

Fracture

"Pulled" elbow
 Reactive arthritis

Septic arthritis
The mechanism of injury and clinical findings point to a pulled (nursemaid's) elbow
(subluxed annular ligament of radius). This can be restored by supinating the elbow
and pushing backwards whilst holding the elbow. A click is usually felt with full
immediate relief of symptoms.

- A 9-year-old girl presents with knee swelling. She had a diarrhoeal illness four
weeks before, but has otherwise been healthy.

Full term normal delivery, no neonatal problems. Immunisations up to date. No family

or social history of note.

On examination the temperature is 36.9°C, respiratory rate is 15/min and pulse is

80/min. She has slight swelling of the right knee, which has 20 degrees loss of both
flexion and extension.

What is the most likely diagnosis?

(Please select 1 option)

Dermatomyositis

Oligoarticular juvenile rheumatoid arthritis

Polyarticular juvenile rheumatoid arthritis

Reactive arthritis

Systemic juvenile rheumatoid arthritis

The history of mild joint inflammation a few weeks after a diarrhoeal illness suggests
a reactive arthritis.

This usually settles within six weeks, which helps to distinguish it from juvenile
chronic arthritis.

Bacterial triggers include:

 Campylobacter
 Shigella
 Salmonella
 Yersinia.

Viral triggers include:

 Rubella
‫‪‬‬ ‫‪Hepatitis B‬‬
‫‪‬‬ ‫‪Parvovirus and‬‬
‫‪‬‬ ‫‪Epstein-Barr virus (EBV).‬‬
‫ده البروبليم اللي جاءت في االمتحان االخير وقد سمحو للكل بان يشيل الورقه معاهو‪.............‬‬

‫اللهم اجعل هذا الجهد خالصا لوجهك الكريم ‪ ....‬وال تنسونا من صالح الدعوات‪...‬‬

‫عبدالباقي ابوكساوي‪..‬‬