Pediatrics (PA easy)

Q 47.1: Which valve is the most commonly affected in a case of rheumatic heart disease? A Aortic B Mitral C Tricuspid D Pulmonic E Bicuspid aortic valve

The Correct Answer is: B The mitral valve is affected in about 75 to 80% of all cases of rheumatic heart disease. The aortic valve is second, and it is rare that the right-sided valves get diseased.

Q 39.23: A 12 year old female found a tick on her leg after a camping trip. The tick was removed without incident. According to CDC recommendations, what is the appropriate testing for Lyme disease? A ELISA, if + or equivocal, follow up with Western Blot B Western Blot, if + or equivocal, follow up with ELISA C Cbc with diff and skin biopsy D Skin biopsy and gram stain

The CDC recommends first using ELISA to test for Lyme disease. If this is positive, then a Western Blot should be performed as confirmation. Acute and convalescent titers should be tested as only 20-30% of patients have a positive response in the acute phase. That percentage rises to 70-80% in the convalescent phase.

Q 45.3: In a 4-year-old female child who presents with "toeing in," which of the following is the likely etiology? A femoral anteversion B genu valgum C genu varum D tibial torsion

The Correct Answer is: A "Toeing in" in children before the age of 2 is typically due to tibial torsion; however, any "toeing in" after the age of 2 to 3, is usually due to femoral anteversion. The femur has more internal rotation that results in the presentation. Genu varum is known as bowleg and genu valgum is known as knock-kneed.

Q 49.19: This common malignancy is diagnosed in patients younger than 15 years of age, has an incidence peak during early childhood (2 to 4 years old), and is seen more prominently in industrialized nations. What is the name of this malignancy? A Acute Lymphoblastic Leukemia B Acute Myelogenous Leukemia C Chronic Lymphocytic Leukemia D Chronic Myelogenous Leukemia E Lymphoma

The Correct Answer is: A Acute Lymphoblastic Leukemia is the most common malignancy diagnosed in patients younger than age 15, and has a peak incidence of 2 to 4 years of age. It is seen more often in males, and the pattern affected suggests a leukemogenic contribution from factors associated with industrialization.

Q 39.15: A newborn male is diagnosed with Christmas factor deficiency. What is the likelihood that he inherited this disorder from his father? A 0% B 25% C 50% D 75% E 100%

The Correct Answer is: A All daughters of a hemophilic male are carriers of hemophilia, whereas all sons are normal. Hemophilia B (or Christmas factor deficiency) is one of only two sex-linked pattern-bleeding disorders, and as such the disease occurs almost exclusively in males. Sons of carriers have a 50% chance of being affected and daughters of carriers have a 50% chance of being carriers themselves.

Q 35.1: A 3-year-old white male with low grade fever, lethargy, and fatigue for several weeks is seen on repeat visit. His mother states that nothing has helped. He has been trialed on a course of antibiotics without improvement. He has petechiae to his lower extremities and pallor throughout. What other physical finding is likely to be found in this patient? A Bone pain B Cranial nerve palsy C Epidural spinal cord compression D Painless enlargement of the scrotum E Subcutaneous nodules

The Correct Answer is: A All physical findings are possible in this patient, who has acute lymphoblastic leukemia (ALL). However, of those listed, bone pain is the most common. All other choices are extremely rare findings (usually less than 1%). In children presenting with ALL, the frequency of bone pain or limp can be more than 25% of cases.

Q 48.5: A 5-year-old girl presents to the office with her mother, who states the child is experiencing excessive tearing, itching, and redness of her eyes. On physical exam you note marked injection with chemosis without discharge. The patient lacks adenopathy. Which of the following is the most likely diagnosis? A Allergic conjunctivitis B Bacterial conjunctivitis C Inclusion conjunctivitis D Keratoconjunctivitis E Viral conjunctivitis

The Correct Answer is: A Allergic conjunctivitis (A) is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis. The absence of other viral symptoms (E) and discharge (B) make other diagnoses less likely. Preauricular adneopathy typically occurs in viral (E) or chlamydial conjunctivitis (C).

Q 47.10: You suspect that a 5-year-old patient has allergic conjunctivitis. Which of the following symptoms or signs would best support this diagnosis? A Itching B Fever C Preauricular adenopathy D Profuse discharge E Sore throat

The Correct Answer is: A Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis (A). Fever (B) and sore throat (E) are more likely to occur in viral or bacterial conjunctivitis. Preauricular adneopathy (C) typically occurs in viral or chlamydial conjunctivitis.

Q 47.3: A 10-year-old girl was recently diagnosed with type 1 diabetes. She appears to be adjusting well to her regimen of insulin and glucose monitoring, and follows a careful meal plan that she and her mother work on together. At a follow-up visit, she says that she will "die" if she can't participate on her summer swim team, but her mother is clearly concerned about her becoming hypoglycemic if she exercises that vigorously. In addition to reminding them that regular aerobic exercise is an important part of her overall well-being, which of the following is the most appropriate advice for them? A add an extra snack before exercising to the diet plan B ask the coach for a less-rigorous practice regimen C avoid dextrose-containing beverages during exercise D increase the amount of insulin on practice and competition days E try a less energy-intensive sport than swimming

The Correct Answer is: A Appropriate advice for children with type 1 diabetes is to have extra snacks before exercise. In addition, they should drink dextrose-containing fluids (C) during exercise and decrease insulin (D), while monitoring glucose before, during, and after exercise. Exercising less rigorously (B) and avoiding any particular sport (E) is usually not necessary with careful management of the diabetes.

Q 43.10: A 9-year-old child, who was diagnosed with a viral upper respiratory infection 2 weeks ago, returns to the clinic with a complaint of a 2-day history of drooping of one side of her mouth. She is afebrile with a blood pressure of 110/60 mm Hg. Her physical examination reveals an inability to completely close her left eye, inability to wrinkle her forehead, and the drooping of her mouth on the left side. Her smile is asymmetric. The remainder of her examination is otherwise normal. Which of the following is the MOST likely diagnosis? A Bell's palsy B botulism C brainstem glioma D Guillain-Barré syndrome

The Correct Answer is: A Bell's palsy is the acquired peripheral facial weakness (cranial nerve VII) of sudden onset and unknown etiology. It often follows a viral illness with notable improvement within 2 weeks and near complete recovery within 2 months. Prednisone therapy may promote recovery of facial strength. Guillain-Barré syndrome (acute idiopathic polyneuritis) generally presents with symmetrical weakness of the lower extremities, which may ascend rapidly to the arms, trunk, and face. Nonspecific respiratory or gastrointestinal symptoms may occur 5 to 14 days preceding the infection. Physical examination will yield symmetric flaccid weakness, which is usually proximal in distribution. Rarely, there is cranial nerve (III-VI, IX-XI) involvement. Botulism is most often caused by the ingestion of food containing the Clostridium botulinum toxin or rarely from an infected wound. Children will present with blurred or double vision, ptosis, or choking. Physical findings include a weak swallow paralysis of accommodation and eye movements. In this case, there was not a history of food ingestion or wound infection to support this diagnosis. Children with a brain stem tumor may present with facial and extraocular muscle palsies, hemiparesis, gait disturbances, and hydrocephalus (25%). Changes in personality such as lethargy, irritability, and aggressive behavior are particularly common findings. Speech and swallowing difficulties are not unusual. Later in the illness, patients will develop vomiting and headaches.

Q 49.9: A 5-year-old male child in the clinic is being evaluated for a firm, painful lump that is slightly reddened and approximately 3 cm in diameter, in his right axilla. His mother tells you the lump has been there for a couple of days. The boy does not look acutely ill. The mother informs you that they got a new kitten and puppy about a month ago but otherwise nothing else is new at home. Which of the following is the most likely etiology for his rash? A Bartonella henselae B parvovirus C Hodgkin disease D Osgood-Schlatter disease

The Correct Answer is: A Cat scratch disease (CSD) is caused by the gram-negative bacillus, Bartonella henselae. The disease is more common in the fall and winter months and more males than females are affected. Typically (approximately 90%), patients report handling a cat or kitten and up to 70% will report a scratch by a cat. The most common complication of CSD is encephalitis. About half of the patients with CSD will develop a primary cutaneous papule at the site of inoculation, most often (approximately 50%) on the hands or upper extremities, 3 to 10 days after the exposure. Regional lymphadenopathy will usually develop in about 1 to 7 weeks after the cutaneous lesions and will affect the nodes draining the site of the scratch or bite. The affected lymph nodes may be inflamed and are usually tender. Occasionally, the involved nodes may suppurate. The lymphadenopathy resolves in about 2 months, but may last as long as 4 to 8 months. Treatment is usually not indicated for this self-resolving disease. However, suppurative lesions may need to be aspirated for pain relief. It has been shown that 5 days of treatment with azithromycin has helped to speed recovery for some patients. Because Hodgkin disease involves the lymph nodes, it should be considered as a differential diagnosis when evaluating a child for CSD. However, it typically presents as a cervical lymphadenopathy. Fifth disease (erythema infectiosum) is a childhood disease caused by the human parvovirus. This common community-acquired disease does not usually require treatment, but respiratory isolation is recommended for 7 days following the onset of symptoms. The initial stage of the disease presents as red cheeks that appear to be "slapped" or "slapped cheeks" with circumoral pallor. Osgood-Schlatter disease is an orthopedic problem in children. It is the result of repetitive microtraumas to the patellar ligament at its point of insertion into the tibial tubercle. Usually, rest and anti-inflammatory medications are helpful in alleviating the pain associated with this condition.

Q 47.2: A 3-year-old girl is being followed by the neurologist to evaluate her motor spasticity that resulted from anoxia during labor and delivery. Which of the following is the most likely cause of this patient's spasticity? A cerebral palsy B congenital hypothyroidism C meningitis D multiple sclerosis

The Correct Answer is: A Cerebral palsy is caused by perinatal injury to the nervous system and results in motor spasticity. The history of perinatal anoxia is consistent with cerebral palsy. Congenital hypothyroidism is typically asymptomatic at birth and diagnosed through routine screening tests. Neonatal meningitis may result in anoxia, but this patient's anoxia is attributed to the birthing process. Multiple sclerosis is caused by inflammation, demyelination, and scarring.

Q 37.5: Examination of a female newborn demonstrating cyanosis after feeding reveals a systolic ejection click that is heard best at the third left intercostal space, and a short grade III/VI systolic ejection murmur that is heard best at the second left intercostal space. Given this patient's physical exam findings, which of the following is the most likely finding on an echocardiogram? A Pulmonic stenosis B Aortic stenosis C Mitral regurgitation D Aortic regurgitation E Mitral stenosis

The Correct Answer is: A Choice A, pulmonic stenosis, is the most likely finding on echocardiogram, as severe pulmonic stenosis frequently presents with a newborn infant presenting with cyanosis after feeding, and a systolic ejection murmur heard best at the second left intercostal space. Congenital pulmonic stenosis occurs in 1 in 10 patients with congenital heart disease. Most patients demonstrate only mild to moderate pulmonary stenosis and are asymptomatic, but infants with critical stenosis require intervention with balloon valvuloplasty. Choice B, aortic stenosis, if critical, would present with pulmonary congestion and heart failure within the first few weeks of birth, with a lack of peripheral pulses and no murmur. Choice C, mitral regurgitation, would not present with a cyanotic infant; however, in more severe mitral regurgitation, failure to thrive, frequent respiratory infections, and heart failure can occur. It would also present with a holosystolic blowing murmur, heard best at the apex. Choice D, mitral stenosis, would present with symptoms of failure to thrive and dyspnea, and an accentuated S1 and loud pulmonary closure sound. A presystolic crescendo murmur can be heard best at the apex.

Q 35.2: A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following is the most appropriate management for this patient? A Cataract surgery within the next 6 weeks B Cataract surgery within the next year C Observation every 3 months D Observation every 6 months E Observation every year

The Correct Answer is: A Congenital cataracts that are large and affect visual acuity (e.g., central) must be surgically corrected within the first two months of life (A) to avoid the development of deprivation amblyopia. Observation (C, D, and E) or delayed surgery (B) may result in permanent deprivation amblyopia.

Q 44.5: A 4-year-old female is brought in by her parents due to an increased nightly cough and low grade temperature. The x-ray shown reveals a classic finding for which of the following diagnoses? A Croup B Epiglottitis C Foreign body aspiration D Peritonsillitis E Tracheal carcinoma

The Correct Answer is: A Croup, also known as laryngotracheobronchitis, is associated with upper tracheal narrowing and edema, which is visible on an anteroposterior soft tissue neck x-ray. This is termed the "steeple sign." Epiglottitis is associated with a thickened epiglottis on a lateral soft-tissue neck x-ray, termed the "thumb" sign. Foreign body aspiration and tracheal carcinoma may have x-ray findings based on the location, size, and components present. Peritonsillitis is best visualized on physical exam. If assessing for a potential peritonsillar abscess, a contrasted CT is recommended.

Q 43.8: A neonate presents with meconium ileus that is successfully unobstructed. The infant returns at her 4-month appointment with signs of failure to thrive. Which of the following is the most likely diagnosis for this patient? A cystic fibrosis B Wilson disease C intussusception D volvulus

The Correct Answer is: A Cystic fibrosis (CF) is a major cause of gastrointestinal and pulmonary morbidity in children due to mutations in the CF genes. The mutations lead to a deficiency in cystic fibrosis transmembrane conductance regulator protein that controls movement of salt and water into and out of epithelial cells and results in production of abnormally thick mucus. About 15% of patients with CF present with meconium ileus at birth. This is typically treated with enema for disimpaction and rarely surgery. Approximately half of the infants with CF will present with failure to thrive, which is diagnosed by lack of growth for 2 consecutive months in patients younger than 6 months of age. They may also present with respiratory compromise. However, not all patients present in childhood. Diagnosis of CF is confirmed by a sweat chloride level above 60 meq/L or with genetic testing. Treatment for patients with CF is mainly symptomatic therapy for obstructions of the digestive and respiratory tract. In addition, there is pancreatic enzyme supplementation to aid in digestion and vitamin and calorie supplementation for deficiencies in the diet. Gene therapy is now being looked at for future treatment. Intussusception (telescoping of the small intestine) typically presents in an infant with paroxysmal abdominal pain, vomiting, and diarrhea that may progress into bloody stools. Volvulus is normally the result of intestinal malrotation that causes occlusion of the superior mesenteric artery and eventual bowel necrosis. Infants typically present within 3 weeks of life with bile-stained vomiting and bowel obstruction. Wilson's disease is the defect in the ability to excrete copper in the bile that results in accumulation of copper in the liver.

Q 34.1: At 12 hours of age, a physical examination is performed on a neonate who has intrauterine growth retardation. He is noted to have microcephaly, jaundice, and hepatosplenomegaly. Which of the following is the MOST likely congenital viral infection in this neonate? A cytomegalovirus B herpes simplex virus C rubella D syphilis

The Correct Answer is: A Cytomegalovirus (CMV) is one of the congenital neonatal TORCH infections (toxoplasmosis, other [syphilis, varicella-zoster, and parvovirus in this list], rubella, cytomegalovirus, and herpes simplex/hepatitis/HIV). CMV is the most common congenital infection. The disease-specific manifestations for CMV include microcephaly with periventricular calcifications, neonatal jaundice with direct hyperbilirubinemia, and hepatosplenomegaly. Other associated manifestations include intrauterine growth retardation, thrombocytopenia, and purpura. Disease-specific manifestations for herpes simplex virus include skin/eye/mouth vesicles, encephalitis, respiratory distress, and sepsis. Disease-specific manifestations of rubella include congenital heart lesions (patent ductus arteriosus, pulmonary artery stenosis, aortic stenosis, ventricular defects), thrombocytopenic purpura characterized by purple macular lesions ("blueberry muffin" appearance), cataracts, retinopathy, and sensorineural deafness. Disease-specific manifestations of syphilis include mucocutaneous lesions (snuffles), periostitis, osteochondritis, and hemolytic anemia. Often, these babies are stillborn. Syphilis is caused by a spirochete, Treponema pallidum, not a virus.

Q 35.9: Which of the following is the most common etiologic agent of bacterial meningitis in the pediatric population of the United States? A Streptococcus pneumoniae B Haemophilus influenzae type B C Listeria monocytogenes D Neisseria meningitides

The Correct Answer is: A Despite the increase in vaccination of infants in the United States, Streptococcus pneumoniae remains the most common etiologic agent for bacterial meningitis in the pediatric population. Haemophilus influenzae type B is the second most common, but has gone down significantly due to the widespread vaccination of children. Neisseria meningitides has approximately 2,400 to 3,000 cases a year. Meningitis due to Listeria monocytogenes is typically seen in the neonatal period due to transmission from the mother. It is present in normal fecal matter in around 10% of the population. Its rates have gone down due to strict guidelines for the food industry, resulting in less than 1,000 cases per year.

Q 46.4: Which of the following are predictive or diagnostic of anorexia nervosa? A having a weight that is 85% less than predicted normal weight B homosexual orientation in females C promiscuity D menorrhagia

The Correct Answer is: A Diagnostic criteria for anorexia nervosa include a weight loss to 85% of the required body weight. Homosexual orientation in men, not women, is considered a predisposing factor. Anorexia is associated with amenorrhea and decreased interest in sex.

Q 34.9: A 3-day-old infant has bilateral copious, yellow-green eye discharge and conjunctival inflammation. A Gram stain of this discharge reveals gram-negative intracellular diplococci. Which of the following antibiotics is the drug of choice for this infection? A ceftriaxone B cephalexin C erythromycin D gentamicin

The Correct Answer is: A Gonococcal ophthalmia neonatorum presents as a unilateral or bilateral serosanguineous discharge and then within 24 hours the discharge becomes mucopurulent, followed by conjunctival injection and edema of the eyelids. The usual incubation period for Neiserria gonorrhea is 2 to 5 days; however, the infection may be present at birth or delayed greater than 5 days if there has been instillation of silver nitrate prophylaxis. A presumptive diagnosis is made by the demonstration of gram-negative intracellular diplococci on Gram stain. Definitive diagnosis is made by culture. Following a positive Gram stain and pending culture results, treatment should be promptly initiated with ceftriaxone (50 mg/kg/24 hours IV or IM for one dose not to exceed 125 mg), a third-generation cephalosporin with good coverage for gram-negative bacteria. An alternate drug is cefotaxime (100 mg/kg/24 hours IV or IM every 12 hours for 7 days or 100 mg/kg as a single dose), which is also a third-generation cephalosporin. Although erythromycin drops (0.5%) are used prophylactically for N gonorrhea, this is not an effective treatment. Gentamicin would be used for Pseudomonas, and Chlamydia is treated with erythromycin. Cephalexin as a first-generation cephalosporin does not have coverage for gram-negative bacteria.

Q 38.10: A 5-year-old child presents for her kindergarten checkup. The clinician notes that over the past couple of years, her height decreased from the 50th percentile to the 5th percentile. On examination, the clinician also notes truncal adiposity. Her CBC and lead levels were normal. Which of the following is the most likely diagnosis? A growth hormone deficiency B Cushing disease C congenital hypothyroidism D congenital adrenal hyperplasia

The Correct Answer is: A Growth hormone (GH) deficiency is defined as a decreased growth velocity, delay in skeletal maturation, absence of other explanations for poor growth (lack of intake), and laboratory tests demonstrating decreased GH secretion. Etiology of GH deficiency can be congenital, genetic, acquired, or idiopathic, which is the most common. Infants usually have a normal birth weight and may have a slightly decreased length. In addition, most infants present with other endocrine deficiencies like hypoglycemia, hypothyroidism, and/or adrenal insufficiency. Children may present with truncal adiposity because growth hormone promotes lipolysis. Serum GH or intrinsic growth factor levels may or may not be decreased. In patients who do not have a demonstrated decrease in these hormones, a trial period with GH is indicated. These patients and positive GH-deficient patients receive a once-daily subcutaneous injection of recombinant human GH. Congenital hypothyroidism typically presents with short stature (typically noted after the 4-month newborn visit), delayed epiphyseal development, delayed closure of fontanelles, and retarded dental eruption in addition to other signs of hypothyroidism. Cushing disease typically presents with truncal adiposity with thin extremities, muscle wasting, decreased growth rate, and moon facies. Laboratory results show elevated adrenocorticosteroids both in urine and serum, hypokalemia, eosinopenia, and lymphocytopenia. Typically, in patients younger than the age of 12, Cushing disease is secondary to administration of ACTH or glucocorticoids. Congenital adrenal hyperplasia typically presents with pseudohermaphroditism in females or salt-losing crisis in males with or without isosexual precocity. There is an increased linear growth and advanced skeletal maturation.

Q 39.14: A 9-year-old girl is brought to the office by her mother who has noticed that the child's neck looks "odd." The girl states that it feels "like something is there," indicating the base of the neck, but that she has no difficulty swallowing. A thorough examination reveals only a firm, nontender, and diffusely enlarged thyroid with no thrills or bruits. All parameters on a thyroid function panel are within normal limits. Low levels of thyroid antibodies are present. What is this child's most likely diagnosis? A Chronic lymphocytic thyroiditis (Hashimoto thyroiditis) B Graves disease C Papillary carcinoma of the thyroid D Pituitary tumor E Subacute thyroiditis (deQuervain thyroiditis)

The Correct Answer is: A Hashimoto thyroiditis, the most common thyroid disorder in the United States, is an autoimmune disease. In children, girls 8-15 years of age are most commonly affected. Graves disease is most common in women ages 20-40. The thyroid enlargement is diffusely enlarged but may be asymmetric and may be accompanied by a bruit. In addition, the patient will have signs and symptoms of hyperthyroidism. Thyroid antibodies and hormones are elevated and TSH suppressed. Thyroid carcinoma is also more likely in women and papillary carcinomas are the post common. They present as a firm nodule in the gland, most often between 10 and 40 years after exposure to radiation. Thyroid-hormone-secreting pituitary tumors (rare) usually present with signs and symptoms of hyperthyroidism without enlargement of the gland and normal or high serum TSH levels. DeQuervain thyroiditis presents with signs and symptoms of hyperthyroidism and an enlarged tender gland.

Q 35.5: A patient presents with hyperleukocytosis (WBC 100,000). The bone marrow is consistent with T-cell ALL. The uric acid is less than 7.0 mg/dl. Prior to starting chemotherapy, what is the best therapy to initiate on this patient? A Allopurinol and IV fluids B Aluminum hydroxide and calcium carbonate C Glucocorticoids and vincristine D Leukapheresis and cranial irradiation E Sevelamer and mercaptopurine

The Correct Answer is: A Hyperuricemia is often a finding in patients with hyperleukocytosis. The optimal treatment is to start IV fluids, due to numbers of circulating white cells and allopurinol, to treat hyperuricemia. The use of aluminum hydroxide is appropriate if they have hyperphosphatemia, and calcium carbonate if they have a low serum calcium concentration. Glucocorticoids and vincristine are used with hyperleukocytosis of >400,000. Leukapheresis and cranial irradiation are used for patients with extreme leukocytosis of >400,000. Sevelamer is used to treat hyperphosphatemia, and mercaptopurine is a byproduct produced during production of leukemic cells.

Q 44.8: A 16-year-old female has tried topical clindamycin and tretinoin. In addition, she recently finished a six-month course of doxycycline 100 mg bid. She has not noticed much improvement in her acne. The patient continues to complain of large, painful lesions, as well as numerous comedonal lesions. What is the next appropriate step in treatment? A isotretinoin 0.5 mg/kg/day B clotrimazole cream bid C keflex 500 mg bid D elidel cream bid

The Correct Answer is: A Isotretinoin is indicated for nodulocystic acne, as well as acne that is resistant to topical treatments and oral antibiotics. Clotrimazole is an antifungal medication that is indicated for the treatment of cutaneous candidiasis and tinea. Keflex is a first generation Cephalosporin. It is not a first line treatment for acne. Elidel is indicated as a second line treatment for atopic dermatitis in patients over two years of age. It does not treat acne.

Q 49.20: A 4-year-old boy presents with 5 days of fever, conjunctivitis, strawberry tongue, red lips, and injected throat. He has large, swollen, slightly tender lymph nodes in his neck and a peeling rash in the palms and soles. The most likely cause is A Kawasaki syndrome B respiratory syncytial virus C coxsackievirus D fifth disease

The Correct Answer is: A Kawasaki syndrome occurs throughout the world, primarily in children. It is thought to be infectious but the etiologic agent has never been isolated. The syndrome is composed of fever and four of five of the following symptoms: bilateral conjunctivitis, some type of mucous membrane change, a peripheral extremity change, transverse grooves on the nails, a polymorphous rash, and cervical lymph nodes >1.5 cm. It can be complicated by arteritis. Treatment may include aspirin, immune globulin, plasmapheresis, or corticosteroids.

Q 37.11: Which physical exam finding differentiates acne rosacea from acne vulgaris? A The absence of comedones B The absence of telangiectasias C The presence of erythema D The presence of inflammatory papules

The Correct Answer is: A The characteristic lesions of acne rosacea are small papules, papulopustules, and telangiectasias with flushing. There are no comedones present in acne rosacea.

Q 47.6: A woman brings her 13-year-old daughter to clinic, concerned about the fact that she has not yet had her first menstrual cycle. The patient is PMH negative, Social Hx negative, FMH: mothers' age of menarche was 13. Physical exam reveals the child to be a well-developed, well-nourished female, height and weight at the 50% for age and gender. Thelarche is present and has sparse pubic hair. The remainder of her physical exam is normal for age. The most appropriate course of action is? A Reevaluation in 6 months B Thyroid evaluation C Pelvic exam D Pelvic ultrasound E hCG

The Correct Answer is: A The child is in the expected age for puberty, and she shows signs of hormonal changes.

Q 36.7: An 8-year-old male with a history of atopic dermatitis presents with a localized rash, consisting of vesicles and eroded lesions. He has a low-grade fever, but no other symptoms. What is the appropriate treatment? A Oral acyclovir for 5 to 10 days B Oral keflex for 7 to 10 days C Topical aclometasone ointment for 10 to 14 days D Topical mupirocin ointment for 7 to 10 days

The Correct Answer is: A The classic lesion of eczema herpeticum is described as a "punched out" lesion, which refers to vesicles that have become eroded. Mild cases of eczema herpeticum can be treated on an outpatient basis with oral acyclovir. More severe cases must be treated on an inpatient basis with IV acyclovir and oral antibiotics if superinfected.

Q 36.2: These lesions are visible on a 14-year-old female's forehead. What medication is this disorder best treated with? A topical retinoids B topical erythromycin C topical Benzoyl peroxide and erythromycin D oral Doxycycline 100 mg bid

The Correct Answer is: A The lesions are comedones (open and closed). Optimal treatment should be with topical retinoids such as tretinoin and adapalene, as these are comedolytic. Topical erythromycin is indicated in inflammatory acne, not comedonal acne as pictured. Benzoyl peroxide only has mild comedolytic activity and erythromycin has none. This combination medication would be more appropriate for inflammatory acne. Doxycycline has no comedolytic activity.

Q 46.9: A 2-month-old female presents for a well child check. The mother has no concerns and feels that the child is doing well. On exam, there is no evidence of cyanosis and the peripheral pulses are normal and equal. However, there is a fixed and widely split S2, a right ventricular heave, and a systolic ejection murmur present. The murmur is heard best at the left sternal border second intercostal space. What is the most likely diagnosis? A Atrial septal defect B Coarctation of the aorta C Patent ductus arteriosus D Tetralogy of fallot E Aortic stenosis

The Correct Answer is: A The patient in this scenario is exhibiting the classic signs of an atrial septal defect. Coarctation of the aorta has absent or diminished femoral pulses and a blowing systolic murmur. A patent ductus arteriosus (PDA) is not associated with cyanosis, and the description of this murmur is classically described as a rough machinery systolic murmur. Tetralogy of fallot can have associated cyanosis with hypoxemic spells during infancy, easy fatigability, and dyspnea on exertion. Tetralogy of fallot also has the presence of a right ventricular lift and a rough, systolic ejection murmur, present along the left sternal border in the third intercostal space that radiates to the back. Aortic stenosis has a harsh systolic ejection murmur present at the right sternal border, and associated thrill in the carotid arteries.

Q 36.3: A 1 day-old boy develops progressing abdominal distension, bilious vomiting and failure to pass a meconium stool. Abdominal radiographs show dilated loops of small bowel. Which of the following is the most likely diagnosis in this patient? A Cystic Fibrosis B Hypothyroidism C Imperforate anus D Intussusception E Pyloric Stenosis

The Correct Answer is: A The patient presents with a meconium ileus consistent with a diagnosis of cystic fibrosis (A). Pyloric stenosis (E) typically presents between 3 and 6 months of age, while intussusception (D) presents later (6 to 24 months). Imperforate anus (C) presents at birth, but infants typically lack acute abdominal distention and bilious vomit. Other common causes of intestinal obstruction in a newborn include meconium plug syndrome, Hirschsprung Disease, Intestinal Atresia, and Midgut Volvulus.

Q 50.1: A 1 day-old boy develops progressing abdominal distension, bilious vomiting and failure to pass a meconium stool. Abdominal radiographs show dilated loops of small bowel. Which of the following is the most likely diagnosis in this patient? A Cystic Fibrosis B Hypothyroidism C Imperforate anus D Intussusception E Pyloric Stenosis

The Correct Answer is: A The patient presents with a meconium ileus consistent with a diagnosis of cystic fibrosis (A). Pyloric stenosis (E) typically presents between 3 and 6 months of age, while intussusception (D) presents later (6 to 24 months). Imperforate anus (C) presents at birth, but infants typically lack acute abdominal distention and bilious vomit. Other common causes of intestinal obstruction in a newborn include meconium plug syndrome, Hirschsprung Disease, Intestinal Atresia, and Midgut Volvulus.

Q 37.7: A 24-month-old infant presents for his routine physical examination. The parents state that he has been following all of his developmental milestones. On examination, the clinician hears a grade II/VI murmur along the left sternal border, which radiates into the left axilla and the left side of the back. The child also has decreased femoral pulses bilaterally. The clinician orders a chest X-ray. Which of the following is the expected finding on X-ray based on the presentation? A notching or scalloping of the ribs B boot-shaped heart—right ventricular hypertrophy C "egg on string"—narrowed mediastinum D absence of the main pulmonary artery

The Correct Answer is: A The patient's presentation is consistent with findings of coarctation of the aorta. The pathognomonic finding in coarctation is decreased or absent femoral pulses. However, the majority of children show no signs of coarctation in infancy and develop signs and symptoms during childhood, most notably unequal pulses and blood pressure between arms and legs (arms greater than legs). In addition, a grade II/VI ejection murmur is heard at the aortic area and left sternal border that radiates into the left axilla and left back. Chest X-ray shows a normal-sized heart, a prominent aorta, indents at the level of the coarctation, and a dilated poststenotic segment resulting in the "figure 3" sign. Scalloping or notching of the ribs is due to enlargement of the intercostal arteries. Echocardiography is used to directly visualize the coarctation and estimate the obstruction. Asymptomatic infants and children are encouraged to have corrective surgery prior to age 5, after which they are at increased risk for myocardial dysfunction and hypertension, and require exercise testing prior to participation in aerobic activities. The boot-shaped heart is seen in patients with tetralogy of Fallot secondary to right ventricular hypertrophy; the narrowed mediastinum finding with "egg on a string" is typically seen in patients with transposition of the great vessels.

Q 38.12: A two-year-old male presents with a nodule on the side of his index finger. His mother states that he has had this nodule on one prior occurrence during infancy, and it resolved on its own. What is the most likely diagnosis? A Digital fibroma B Juvenile xanthogranuloma C Molluscum contagiosum D Verruca vulgaris

The Correct Answer is: A This child has a recurrent digital fibroma. It is a smooth, firm, pink nodule that occurs on the fingers and toes up through early childhood. Surgical excision is recommended so that the function of the digit is not impaired.

Q 45.6: A 2-week-old male infant presents for a routine checkup. The mother complains that he nurses every hour, but vomits (nonbilious) after every time he eats. He has only had three bowel movements since he has been home. On examination, the infant has not gained any weight since leaving the hospital, and the clinician notes gastric peristaltic waves. Which of the following is the treatment of choice for this patient? A pyloromyotomy B metoclopramide C laparotomy D omeprazole

The Correct Answer is: A This infant is presenting with signs and symptoms of pyloric stenosis. Infants typically have vomiting (projectile at times) after every feeding and it normally starts between the age of 2 and 4 weeks. The infant nurses fervently and is hungry. In addition, there may be dehydration, constipation, weight loss, and apathy. Abdomen may be distended with gastric peristaltic waves. Occasionally, an olive-sized mass can be felt in the right upper quadrant with deep palpation after the child has vomited. Vomitus is typically nonbilious. Diagnosis is confirmed by an upper gastrointestinal series with delayed gastric emptying, enlarged pyloric muscle, and characteristic semilunar impressions on the gastric antrum. In addition, an ultrasound is needed to verify the hypertrophic muscle. The treatment of choice for these patients is pyloromyotomy, which can be done laparoscopically. These patients make full recoveries and have an excellent prognosis.

Q 39.20: A mother presents with her four-month-old infant for a well child check. While examining the child, you notice ill defined bluish macules on the back and lumbosacral regions. What is the appropriate next step? A reassure the parent that these frequently spontaneously resolve in early childhood B call Child Protective Services on suspicion of abuse C educate the parents that there may be an increased risk of melanoma in the lesions D educate the parents that the only effective treatment is laser therapy

The Correct Answer is: A This is a common presentation of hypermelanosis, sometimes commonly referred to as Mongolian spots. These usually occur in patients with more pigmented complexions. They usually spontaneously resolve prior to the child entering grade school. Hypermelanosis can sometimes be mistaken for child abuse by an inexperienced practitioner; however, hypermelanosis is a common benign condition that occurs in patients with pigmented skin. There is no increased incidence associated with hypermelanosis, and no treatment is required or available.

Q 45.5: A 3-year-old male on laboratory examination has a hemoglobin of 6 (9.5 to 15.0), platelet count of 43,000 (150,000 to 450,000), and Leukocyte count of 9.6 (4.5 to 11.0). Blasts are noted in peripheral smear and on marrow examination. What other laboratory examination is essential in this child? A Cerebrospinal fluid examination B Coagulopathy studies C MRI of the chest D Skeletal roentgenography E Urinalysis

The Correct Answer is: A This patient has acute lymphoblastic Leukemia (ALL). Examination of the CSF is essential to rule in/out CNS leukemia. A chest x-ray is adequate to determine if there is enlargement of the thymus or mediastinal nodes. An MRI would not be indicated at this point. Severe bleeds is uncommon and bleeding times are not typically effected. Skeletal roentgenography is not necessary for management of this patient, even if abnormalities are detected. A urinalysis may show microscopic hematuria and the presence of uric acid crystals, but is not essential in the diagnostic workup of this patient.

Q 41.6: A 9-year-old male presents with an acute onset of petechiae, ecchymoses, and gingival bleeding. He has pallor, fatigue, and bony pain. A pancytopenia is noted on CBC. Ebstein-Barr is negative. Lymphoblasts are noted on smear. Vitals reveal a temperature of 100.8F, HR 74, and RR 20. A few shoddy cervical nodes are noted. What is the most likely diagnosis? A Acute lymphoblastic leukemia B Aplastic anemia C Infectious lymphocytosis D Infectious mononucleosis E Lymphoma

The Correct Answer is: A This patient has acute lymphoblastic leukemia (ALL). While all the diseases would be in the differential, only ALL fits all the findings. Infectious mononucleosis is excluded with a negative EBV. Infectious lymphocytosis would not have a pancytopenia or increased blasts on smear. Aplastic anemia would have a pancytopenia but not bony pain. Lymphoma typically does not have a pancytopenia associated with the disease.

Q 38.9: An 8-year-old male with a history of atopic dermatitis presents with a widespread rash consisting of vesicles and eroded lesions. What is the causative organism? A Herpes simplex virus B Human papilloma virus C Staphylococcus aureus D Varicella zoster virus

The Correct Answer is: A This patient has eczema herpeticum. This is caused by the herpes simplex virus. Transmission can occur innocuously via the parent. Atopic dermatitis is a risk factor for eczema herpeticum, secondary to the impaired barrier function of the skin. This impaired barrier function allows the virus to spread rapidly.

Q 39.10: A 1-year-old boy is brought to the emergency department by his parents, who state that the child refuses to walk or crawl and begins crying when they stand him. Swelling to his right knee is noted; it is also warm to the touch and pain response is noted. His parents state that it seemed to start a couple of days ago and has gotten worse. They don't recall a trauma, but state that he seems to bruise easily. The child's mother states that she also bruises easily. Vitals are as follows: Temp: 38.0°C, HR: 70, RR: 15. What laboratory finding would you expect? A Prolonged aPTT (activated partial thromboplastin time) B Prolonged bleeding time C Prolonged PT (prothrombin time) D Prolonged thrombin clotting time E Thrombocytopenia

The Correct Answer is: A This patient has hemophilia A. Patients with severe hemophilia A have a prolonged aPTT; all of the other tests should be within the normal range.

Q 46.5: A 4 year-old girl presents to the clinic due to severe allergic rhinitis and recurrent asthma exacerbations. Which of the following leukotriene pathway inhibitors is indicated for use in this child? A Beclomethasone B Montelukast C Salmeterol D Zafirlukast E Zileuton

The Correct Answer is: B Montelukast (B) is indicated for use in children 1 year of age or older, zafirlukast (D) is indicated for children > 5 years of age, and zileuton (E) is indicated for children > 12 years of age. Beclomethasone (A) is an inhaled corticosteroid and salmeterol (C) is an inhaled long-acting beta-2 agonist.

Q 37.3: A 4 year old male presents with a fever for 5 days. His highest temperature was 39.4C. His mother brings him to the ED because she noticed this morning that his palms and soles were red. Now, there is blotchy erythema on the trunk with bulbar conjunctivitis and diffuse erythema on the tongue and prominent papillae. CBC shows leukocytosis. What is the appropriate management of this patient? A Hospitalization and IvIg B Hospitalization ad IV antibiotics C Outpatient antibiotics x 10 days D Outpatient symptomatic treatment

The Correct Answer is: A This patient is exhibiting classic signs and symptoms of Kawasaki Disease. Complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, myocardial ischemia or infarction, and stroke. Recommended treatment is hospitalization to monitor for complications and administration of IvIg with aspirin.

Q 38.5: A 14-year-old female presents with a 24-hour history of episodic outbreaks on her hands and feet. She describes the outbreaks as beginning on the sides of her fingers and toes, with small intensely pruritic vesicles. What should be the next step in treatment? A bacterial culture and KOH B punch biopsy and viral culture C viral culture and shave biopsy D shave biopsy and KOH

The Correct Answer is: A This patient is experiencing probable dyshidrotic eczema. It is necessary to rule out a secondary bacterial infection, so a bacterial culture is necessary. It is also necessary to rule out a fungal infection or parasitic by performing a KOH. This does not have any features of a viral infection, so a viral culture is not necessary. A punch biopsy is also not necessary because it can be diagnosed with a non-invasive procedure. A shave biopsy is not indicated because non-invasive techniques can be used to diagnose. Shave biopsies are not indicated when vesicles are present.

Q 37.9: A 7-year-old child is brought into the office by her mother who states that the child "is still wetting the bed at night." The child has already decreased liquid intake and uses the bathroom before going to bed. The mother is worried that there is something wrong with the child. Upon examination there is no abnormality. Urinalysis is negative. Which of the following is the treatment of choice for this disorder? A bed-wetting alarm B desmopressin acetate (DDAVP) C imipramine D amitriptyline

The Correct Answer is: A This patient is presenting with signs and symptoms of primary nocturnal enuresis, which is the wetting only at night during sleep without any sustained period of dryness. It is mainly considered a parasomnia occurring in deep sleep. The incidence of enuresis is higher in boys, is typically related to a developmental delay, and most children become continent by adolescence. Patients need to be tested for structural abnormalities and infections, in addition to neurologic diseases, diabetes mellitus and insipidus, and seizure disorders. Treatment includes limiting liquids at bedtime and routine bathroom training during the day. If these are unsuccessful, the next option is a bed-wetting alarm. This device is attached to the child's undergarment and vibrates when the child is wet to arouse the child to be aware of their need to urinate. If the alarm is unsuccessful, then the next step is medication—DDAVP (desmopressin acetate) or imipramine.

Q 38.17: A 15-year-old obese male presents with annularly configured lesions in a generalized distribution. They are asymptomatic. What can these lesions be associated with? A Diabetes mellitus B Hyperlipidemia C Hypertension D Systemic lupus erythematosus

The Correct Answer is: A This patient presents with a generalized form of granuloma annulare (GA). Generalized GA can be associated with diabetes mellitus.

Q 38.14: A 15 year old male presents with lesions on his palms, dorsum of his hands and lower arm. They began as red macules that developed a central vesicle over a few days. The lesions are pruritic with no other symptoms. What is the most common etiology? A Herpes simplex infection B Insect bites C Psoriasis vulgaris D Atopic dermatitis

The Correct Answer is: A This patient presents with the classic iris or target lesion of erythema multiforme (EM). The most common cause of recurrent EM is herpes simplex outbreak which usually precedes EM by a few days.

Q 45.10: A 16-year-old male complains of a recurrent rash that is noticed each year during the summer. He states that the rash is asymptomatic but is spreading. A physical exam shows small hypopigmented macules with fine scale. A KOH exam shows budding yeast. What is the most likely diagnosis? A tinea versicolor B atopic dermatitis C post inflammatory hypopigmentation D tinea corporis

The Correct Answer is: A Tinea versicolor is a yeast infection that primarily affects teens and young adults. The area of infection is usually the upper back, upper chest, and lower face. It occurs in warm, humid environments and can recur yearly. The appearance of the infection can be hypo- or hyper-pigmented, slightly scaling macules. The characteristic microscopic appearance on a KOH is described as "spaghetti and meatballs," due to the shortened hyphae and spores of the yeast. Atopic dermatitis in a teen patient would normally be described as red scaling plaques that affect the flexural surface. Atopic dermatitis is also described as being pruritic. Post inflammatory hypopigmentation occurs following an inflammatory reaction on the skin. The hypopigmentation is not scaling and will have a negative KOH. Tinea corporis can be hypopigmented and scaling, but usually exhibits central clearing and pruritis. It does not recur seasonally and affects exposed surfaces. A KOH will show branching hyphae and spores.

Q 39.29: A 16-year-old boy is seen for a sports physical prior to starting football. On auscultation, a grade II/IV holosystolic murmur is appreciated at the apex. Which of the following maneuvers would be the most appropriate to choose to increase the intensity of the murmur for better identification? A Isometric hand grip exercise B Listening with the bell at the apex, with the patient in the left lateral decubitus position C Inspiration, followed by the patient holding his/her breath D Valsalva maneuver E Having the patient lie flat with the knees bent

The Correct Answer is: A Utilizing isometric hand grip exercises, the murmur increases in intensity and may be heard radiating to the axilla. Isometric hand grip exercises increase the intensity of the murmur of mitral regurgitation by increasing arterial and left ventricular pressure, which increases the flow across the mitral valve, thereby increasing the murmur's intensity. Choice B is best used when listening to the murmur of mitral stenosis. Choice C will increase the AP diameter, making it more difficult to hear the murmur. With the Valsalva maneuver, choice D, the murmur decreases in intensity. Choice E is the best position for the abdominal exam, especially in males.

Q 34.4: A 13-year-old female is seen for the first time to establish care. She is known to carry the diagnosis of beta-thalassemia major and has been maintained on regular transfusions for her anemia. She is short for her age and has not achieved menarche. Her glucose level is elevated and she has developed signs of diabetes mellitus. These findings are consistent with which of the following? A End stage thalassemia B Inadequate iron chelation C Inadequately transfused anemia D Stage 3 thalassemia E Untreated thalassemia

The Correct Answer is: B *Inadequate iron chelation in patients with thalassemia major results in the absence of a pubertal growth spurt and failure of menarche. These patients may also develop diabetes mellitus, as well as other endocrine disturbances. * There is no staging to thalassemia, and untreated or inadequately transfused anemia results in increased infections early in life, usually causing death, spontaneous fractures, and other deformities. Additionally, thrombocytopenia and leucopenia may develop.

Q 35.4: A mother presents with a 2-month-old infant with a concern of bald spots in the child's scalp. She states that there were ulcerated areas present at birth that healed within a few days. What is the most likely diagnosis? A Alopecia areata B Aplasia cutis congenita C Epidermolysis bullosa D Seborrheic dermatitis

The Correct Answer is: B Aplasia cutis congenita is a rare condition that is present at birth, and presents as asymptomatic ulcerations of the scalp. These ulcerations heal with scarring in a matter of weeks. The cause is believed to be incomplete neural tube closure or cessation of skin development of the embryo.

Q 43.9: A 6-year-old male child presents to the clinic for a cough that occurs only after he has been running, according to his mother. She says she first noticed this about 6 months ago, after he had had one of his usual winter colds, and his cough persisted for about a week. On the basis of this history, what is the most likely diagnosis? A airway foreign body B asthma C cystic fibrosis D laryngomalacia

The Correct Answer is: B Asthma, in this case exercise-induced, is the most likely cause of this problem. The symptoms commonly associated with acute exacerbations of asthma include wheezing, cough, dyspnea, and chest pain. Some symptoms that might be suggestive of asthma include exercise-induced cough, nighttime cough, cough after cold air exposure, and cough after laughing. Airway foreign bodies, though not common, are an acute problem that may present as sudden cough, choking, and wheezing. Cystic fibrosis (CF) is the most common, lethal, genetic disease affecting the Caucasian population. Up to 50% of patients with CF are diagnosed in infancy, but others may not be diagnosed until adolescence or adulthood. Chronic or recurrent cough should be an indicator for consideration of CF as a differential diagnosis. Laryngomalacia is the most common cause of stridor in infants. It is the incomplete development of the cartilaginous support of the laryngoglottic structures. This congenital condition is usually self-limiting and occurs most commonly in infants at or just after birth. The inspiratory collapse of the epiglottis or arytenoid cartilages is heard as stridor.

Q 39.24: A 12-year-old boy presents to the clinic for follow-up regarding his recently diagnosed partial seizures. He reports no seizures or side effects since starting carbamazepine (Tegretol) 1 month ago. What study should be ordered to monitor this patient's treatment? A blood glucose B complete blood cell count C electroencephalogram D vitamin B12 E urinalysis

The Correct Answer is: B Carbamazepine is an anti-epileptic drug that potentially causes blood dyscrasias and requires CBC monitoring. Disorders of carbohydrate metabolism, vitamin B 12 deficiency, or renal toxicity are not commonly reported. EEG is used to help establish a diagnosis of a seizure disorder.

Q 39.13: At a 2-month-old well-child checkup, a female infant is noted to have the following physical findings: widely open anterior and posterior fontanels, large protruding tongue, coarse facial features, low-set hair line, and an umbilical hernia. In the newborn period, there was a prolongation of physiologic icterus. The results of the newborn screening test are abnormal. Which of the following is the MOST likely diagnosis? A congenital adrenal hyperplasia B congenital hypothyroidism C Crigler-Najjar syndrome D galactosemia

The Correct Answer is: B Congenital hypothyroidism is one of the most common disorders tested for in newborn screening tests, revealing an elevated TSH (thyroid stimulating hormone) and a decreased T 4 (thyroxine). Symptoms suggestive of congenital hypothyroidism in the neonate include hypotonia, coarse facial features, hirsute forehead, large fontanels (anterior and posterior), widely open sutures, umbilical hernia, protruding/large tongue, hoarse cry, distended abdomen, and prolonged jaundice. Signs of congenital hypothyroidism include lethargy or hypoactivity, poor feeding, constipation, mottling, and hypothermia. Congenital adrenal hyperplasia (CAH) is not universally screened for in the newborn screening test, as it is included in only 14 of the 50 states. In females with CAH, there may be virilization with abnormalities of the external genitalia varying from mild enlargement of the clitoris to complete fusion of the labioscrotal folds. Signs of adrenal insufficiency (salt loss) may present in the first few days of life. Crigler-Najjar syndrome is not one of the disorders tested for in the standard newborn screening tests. It is an inherited disease producing congenital nonobstructive, nonhemolytic, unconjugated severe hyperbilirubinemia. The physical findings in this infant do not correlate with Crigler-Najjar syndrome. Galactosemia is tested for in the newborn screening test in nearly all 50 states. The infant may have symptoms of cataract, hepatomegaly, and prolonged jaundice. Often, these neonates have Escherichia coli sepsis, leading to death in the first 2 weeks of life if not treated promptly.

Q 44.3: A couple presents to the office seeking genetic counseling advice regarding their child's potential risk of being born with Cystic Fibrosis. Both parents are identified as carriers for the cystic fibrosis gene mutation. Which of the following genetic inheritance patterns should be used to predict the probability of their child being affected by Cystic Fibrosis? A Autosomal dominant B Autosomal recessive C Mitochondrial inherited D X-linked dominant E X-linked recessive

The Correct Answer is: B Cystic fibrosis has an autosomal recessive (B) genetic inheritance pattern. In this case their children have a 25% chance of being affected, 50% chance of being a carrier, and 25% chance of lacking inheritance of the genetic trait.

Q 38.3: A 4-year-old boy presents to the outpatient clinic for a well child visit. Developmental assessment is normal. Upon visual acuity testing his vision is noted to be 20/30 right eye, 20/40 left eye, and 20/30 with both eyes. Which of the following is the most appropriate management of this child's vision? A Re-assess his vision in 3 months B Re-assess his vision in one year C Re-assess his vision prior to enrolling in kindergarten D Refer to an optometrist E Refer to a pediatric ophthalmologist

The Correct Answer is: B Pediatric ophthalmology referral criteria for 3- to 5-year-old children include visual acuity of less than 20/40 in either eye or greater than a two line difference between eyes, so referral to an optometrist (D) or pediatric ophthalmologist (E), which is preferred by the American Academy of Pediatrics, is not warranted and his vision can be re-assessed at his next well child visit in one year (B).

Q 49.18: A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked swelling is noted externally to the left eye. There was no loss of consciousness. Upon physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this information, what is the most likely diagnosis? A Zygomatic arch fracture B Orbital blowout fracture C Le Fort I fracture D Le Fort II fracture E Le Fort III fracture

The Correct Answer is: B Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve. A Le Fort I fracture describes a transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum. A Le Fort II fracture describes a pyramidal through the central maxilla and hard palate. Movement of the hard palate and nose occurs, but not the eyes. A Le Fort III fracture describes a craniofacial disjunction, wherein the entire face is separated from the skull due to fractures of the frontozygomatic suture line, across the orbit and through the base of the nose, and ethmoids. The entire face shifts, with the globes held in place only by the optic nerve.

Q 47.8: A 10 year old male presents with bright red, well-demarcated petechiae and palpable purpura located on bilateral lower extremities. He also complains of abdominal pain and mild joint pain. His mother report the child had an upper respiratory infection about a week ago. Punch biopsy shows IgA immunoreactivity around post-capillary venules. What is the most likely diagnosis? A Toxic Epidermal Necrolysis B Henoch Schonlein purpura C Erythema multiforme D Fixed Drug eruption

The Correct Answer is: B Henoch Schonlein purpura (HSP) is commonly described as palpable purpura. It is precipitated by an upper respiratory infection and can also be associated with abdominal pain and joint pain.

Q 44.12: Two and a half weeks after a camping vacation in upstate New York, a 12-year-old boy develops a fever and generalized headache. He complains that any light hurts his eyes, that he aches all over, and that he "just can't get warm." On examination he has a diffuse erythematous macular rash that spares the palms and soles, mild cervical lymphadenopathy, and slight hepatomegaly. He does not remember a tick bite, but his mother reports warning signs about ticks in the restrooms of the campground. Of the following tick-borne diseases, which is most likely? A Babesiosis B Human granulocytic ehrlichiosis C Lyme disease D Rocky Mountain Spotted Fever

The Correct Answer is: B Human granulocytic ehrlichiosis is commonly found in the upper Midwest and Northeast and has this clinical presentation. The incubation period is 5-21 days. Babesiosis and Lyme are spread by the same tick vector as HGE so must be considered. The incubation period for Babesiosis is 1-3 weeks and it is most common in coastal New England, northern California, and Washington State and around the lakes of the upper Midwest. Symptoms are similar, but usually include dark urine. Hepatosplenomegaly is rare. (A) The incubation period and distribution of Lyme disease are similar to HGE, but the rash is more typically that of erythema chronicum migrans. Early symptoms range from none to nonspecific low-grade fever, headache and myalgias. (C) Rocky Mountain spotted fever is more common along the eastern seaboard and the southeastern and south-central states. Its incubation period is 3-12 days and its rash tends to involve the palms, soles, and extremities and spread centrally. The headache is typically retroorbital. (D)

Q 40.6: A 4-year-old is diagnosed with severe thrombocytopenia, causing spontaneous bleeding two weeks after having influenza. The child has no evidence of anemia, neutropenia, or anything else that raises a suspicion for an alternate diagnosis, and there are no atypical findings on the blood film. What is the most likely diagnosis? A Autoimmune hemolytic anemia B Immune thrombocytopenic purpura C Thalassemia D Thrombotic thrombocytopenic purpura E Von Willebrand's disease

The Correct Answer is: B In children with no other potential causes, the most likely diagnosis is immune thrombocytopenic purpura. The disease must be distinguished from acute lymphoblastic leukemia in this population prior to finalizing the diagnosis. Autoimmune hemolytic anemia would present with an anemia. Thalassemia is an inherited hematologic disorder, von Willebrand is a bleeding disorder typically with normal platelet counts, and thrombotic thrombocytopenic purpura typically has an associated anemia and a lack of bleeding.

Q 38.18: A 4-month-old male presents for a well child check. He is healthy and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur that is heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely finding on ECG? A Left ventricular hypertrophy B Normal ECG C Right axis deviation D Supraventricular tachycardia E Sick sinus syndrome

The Correct Answer is: B In this scenario the patient most likely has a small left-to-right shunt of a ventricular septal defect, given the clinical exam findings. The ECG is most frequently normal in a patient with a small ventricular septal defect. If the patient had a large left-to-right shunt left ventricular hypertrophy would be a possibility. The other choices are not commonly seen on ECG when a ventricular septal defect is present.

Q 48.4: A 1400-gram preterm infant has a symptomatic patent ductus arteriosus. What medication has the best chance of closing the patent ductus arteriosus in this patient? A Acetaminophen B Indomethacin C Propranolol D Ranitidine E Sildenafil

The Correct Answer is: B Indomethacin is an NSAID and inhibits prostaglandin synthesis, allowing for closure of the patent ductus arteriosus in preterm infants. None of the other medications listed play a role in closure of a patent ductus arteriosus.

Q 39.8: A mother presents with her 6-year-old child who has a rash on his arm. The rash which is a discrete, red or flesh-colored, flat-topped, thickened area that is linear in nature with papules with scale has remained unchanged despite the use of topical steroids for one month. The lesion is asymptomatic. What is the most likely diagnosis? A Atopic dermatitis B Lichen striatus C Morphea D Verruca vulgaris

The Correct Answer is: B Lichen striatus is a benign rash consisting of linearly configured, shiny, and flat lesions that occur on any skin surface. This rash occurs suddenly and resolves on its own in several weeks. The etiology is unknown.

Q 50.3: A 4-year-old boy presents to the outpatient clinic for a well child visit. Developmental assessment is normal. Upon visual acuity testing his vision is noted to be 20/30 right eye, 20/40 left eye, and 20/30 with both eyes. Which of the following is the most appropriate management of this child's vision? A Re-assess his vision in 3 months B Re-assess his vision in one year C Re-assess his vision prior to enrolling in kindergarten D Refer to an optometrist E Refer to a pediatric ophthalmologist

The Correct Answer is: B Pediatric ophthalmology referral criteria for 3- to 5-year-old children include visual acuity of less than 20/40 in either eye or greater than a two line difference between eyes, so referral to an optometrist (D) or pediatric ophthalmologist (E), which is preferred by the American Academy of Pediatrics, is not warranted and his vision can be re-assessed at his next well child visit in one year (B).

Q 35.6: A 6-year-old female child presents with neck pain and fever for 2 days. Her remote history consists of 2 to 3 days of diarrhea and vomiting. She attends a local daycare where other kids had similar nausea/vomiting, but recovered. The LP was positive for gram-negative bacilli, decreased glucose, increased protein, and increased neutrophils. Which of the following is the most likely etiologic agent? A rotavirus B Salmonella species C Corynebacterium diphtheria D Clostridium botulinum

The Correct Answer is: B Salmonella species are gram-negative bacilli that are classified as Enterobacteriaceae, along with E Coli. While extremely uncommon as an etiology for meningitis, salmonella can cause lethal meningitis infections and must be watched. While there is typically no treatment for mild to moderate diarrhea from salmonella infections, these patients should be monitored for complete resolution. Viral meningitis typically does not have a positive Gram stain, unless there is contamination. Corynebacterium and clostridium are gram-positive bacilli.

Q 43.2: Which of the following is the initial treatment step in an adolescent who presents to the emergency department with status epilepticus? A IV glucose B stabilize airway C arterial blood gas D IV diazepam therapy

The Correct Answer is: B Status epilepticus is a medical emergency and is defined as seizure activity that lasts a minimum of 30 minutes. This results in hypoxia, acidosis, cerebral edema, and structural damage. In addition, fever, respiratory depression, hypotension, and death may occur. There are both convulsive and nonconvulsive types of status epilepticus. Because of its emergency status and potential complications, the clinician needs to initiate the ABCs (airway, breathing, circulation). Therefore, the first line of treatment is to establish and maintain an airway, oxygen is next, and then circulation, which encompasses pulse, blood pressure, and IV access. Once the IV is established, the orders should be for administering glucose-containing fluids and IV drug therapy with diazepam, lorazepam, or midazolam as well as administer phenytoin and phenobarbital. Arterial blood gases should be ordered and any abnormalities should be corrected appropriately. Finally, the clinician should determine the underlying cause: trauma, structural disorder, infection, lactic acidosis, toxins, and uremia. Maintenance drug therapy is necessary until the underlying cause is determined and rectified.

Q 40.9: The Centers for Disease Control and Prevention recommend the first lead screening for children living in high risk areas in the United States at which age? A 6 months B 9 months C 15 months D 24 months

The Correct Answer is: B The CDC recommends that there are two age ranges for testing lead in children in the United States: 9 to 12 months and again at 24 months. These high-risk areas include poverty-stricken areas, use of lead paint pottery, lead painted homes (peeling or cracking), industrial exposures, and use of diarrhea remedies in Mexico. The CDC recommends using questions to screen all children between 6 months and 6 years of age.

Q 39.17: What is the peak incidence of age for a patient who presents with acute rheumatic heart disease? A <5 years old B 5 to 15 years C 20 to 35 years D 40 to 55 years E >55 years old

The Correct Answer is: B The bulk of the cases of acute rheumatic fever are within the pediatric population. It is rare in younger children, as well as in adults over the age of 40.

Q 35.8: An 8-year-old boy began vomiting earlier in the day and complained of "feeling terrible." His mother says he has slept most of the day and is hot to the touch, although she has not taken his temperature. He is also complaining of a sore throat and that his neck is sore. On examination, his temperature is 103F and he appears unwell. His pharynx is beefy red, the tonsils are enlarged, and covered with a thick exudates. His anterior cervical nodes are tender and markedly enlarged. What additional physical finding is most consistent with this presentation? A bloody diarrhea B circumoral pallor C diffuse rales D petechiae on the distal extremities E vesicular skin lesions with a honey-colored crust

The Correct Answer is: B The clinical picture is that of a Group A Streptococcal infection which, in this age group, presents with fever, malaise, repeated vomiting, a sore throat with tonsillar exudates, and tender, enlarged anterior cervical nodes. Additional physical findings include petechial lesions on the soft palate and mucosal surfaces, circumoral pallor, and a coated tongue. Diarrhea is not common in streptococcal infections. (A) Localized or diffuse rales are characteristic of a pneumococcal pneumonia in this age group (C) and petechial rashes on the extremities and trunk of meningococcal disease. (D) Vesicular lesions that rupture and become covered with a honey-colored crust are typical of streptococcal impetigo. (E)

Q 37.6: A 3-year-old boy presents complaining of left ear pain since early this morning. The mother states he has had cold symptoms for 3 days and awoke crying, with left ear pain, and a temperature of 102.6˚ F. Which of the following physical exam findings most accurately establishes the anticipated diagnosis? A Fever greater than 101.5˚ F B Immobile or hypo-mobile tympanic membrane C Post-auricular adenopathy D Tenderness with palpation of the external ear E Tympanic membrane erythema

The Correct Answer is: B The diagnosis of acute otitis media is best established through the use of pneumatic otoscopy demonstrating decreased tympanic membrane mobility (B). Fever (A), pain with palpation of the auricle (D), and tympanic membrane erythema (E) are all non-specific findings.

Q 47.4: Which of the following is the causative agent in patients with Fifth disease? A herpesvirus 6 (HHV-6) B human parvovirus B19 C paramyxovirus D varicella-zoster virus (VZV) E none of the above

The Correct Answer is: B The disease is caused by parvovirus B19. It appears sporadically, but often in epidemics in communities. Children are infectious during the prodromal stage, which is unapparent or mild and usually indistinguishable from an upper respiratory infection. The rash is an immune-mediated phenomenon that occurs after the infection, so children with the rash are not infectious and should not be restricted from school or other activities.

Q 37.13: The most common cause of nephrotic syndrome in children is A post-streptococcal glomerulonephritis B minimal change disease C diabetes mellitus D NSAIDs E polycystic kidney disease

The Correct Answer is: B The most common cause of nephrotic syndrome in children is minimal change disease. Diffuse injury to the capillaries is the underlying cause, resulting in significant proteinuria, edema, hypoalbuminemia, and hyperlipidemia. It accounts for 65% of cases of nephrotic syndrome in children; however, 10% of adults with nephrotic syndrome have minimal change disease. Treatment is with corticosteroids for 2 to 4 weeks, dietary sodium restriction, and sometimes diuretics to reduce the edema. Relapse and lack of response to corticosteroids can occur. If the latter occurs, renal biopsy is indicated to rule out other causes of the nephrotic syndrome, such as focal glomerulosclerosis and membranoproliferative glomerulonephritis.

Q 39.28: Which of the following is the recommended treatment for a 4-year-old child with presumed bacterial meningitis? A cefotaxime or ceftriaxone plus ampicillin B cefotaxime or ceftriaxone plus vancomycin C gentamicin plus ampicillin D ampicillin plus chloramphenicol

The Correct Answer is: B The most common etiologic organisms for bacterial meningitis in children are S pneumoniae, N Meningitidis, and H influenzae. Because of an increase in resistant S pneumoniae, coverage with vancomycin and a third-generation cephalosporin such as cefotaxime or ceftriaxone is needed for best coverage. Gentamicin can be used but, as with all aminoglycosides, caution is needed regarding toxicity. Ampicillin, rifampin, and chloramphenicol are alternative treatments if necessary. (

Q 49.3: The mother of a four-month-old brings her son in for evaluation of cyanosis. The mother noted the cyanosis in the last two days, and it is most evident when he is feeding or crying. He was previously healthy, with no medical problems. On physical examination, a grade III/VI systolic ejection murmur is present at the left sternal border in the third intercostal space, and radiates to the back. Which of the following diagnostic studies will best help you in establishing the diagnosis? A Electrocardiography B Echocardiography C Angiocardiography D Chest x-ray E Serial cardiac enzymes

The Correct Answer is: B The most likely diagnosis, given the history and physical examination, is tetralogy of fallot. Echocardiography usually establishes the diagnosis by visualizing the large ventricular septal defect, the right ventricl infundibular stenosis, and the enlarged aorta. Electrocardiography may reveal right ventricular hypertrophy, but cannot establish the diagnosis of tetralogy of fallot. Angiocardiography will show the anomalies in the coronary arteries, but this alone cannot be used to establish the diagnosis. Chest x-ray may reveal a boot-shaped heart, but alone cannot be used to establish the diagnosis. Serial cardiac enzymes are measured when there is a concern for a myocardial infarction, but are not used in diagnosing tetralogy of fallot.

Q 39.19: A 2-year-old boy presents to the clinic for his routine well child visit. On physical exam of his mouth and dentition you observe the following. Which of the following is the most likely diagnosis? A Dental abcess B Dental caries C Dental contusion D Periodontitis E Stomatitis

The Correct Answer is: B The patient is noted to have whitish discoloration at the gingiva margin consistent with the early demineralization of a dental carie (B).

Q 40.4: A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following should be ordered to confirm the suspected diagnosis? A Arterial blood gas B Inspiratory and forced expiratory chest x-rays C PA and lateral chest x-ray D Peak expiratory flow rate E Spirometry

The Correct Answer is: B The patient most likely has aspirated a foreign body. This is best evaluated through the demonstration of inspiratory localized hyperinflation and expiratory mediastinal shift (B) on chest x-ray. ABG (A) results will vary depending on the severity of airway obstruction. PA and lateral chest x-rays (C) are typically normal. PEFR (D) and Spirometry (E) are not typically able to accurately assess this localized airway obstruction.

Q 38.2: An 8-year-old male with hair loss, pruritus, and posterior cervical lymphadenopathy has a + culture on dermatophyte test medium (DTM). Which of the following is the most appropriate treatment? A ketoconazole shampoo daily x 2 weeks B oral griseofulvin x 8 weeks C oral Keflex x 2 weeks D desonide foam qd x 6 weeks

The Correct Answer is: B The positive DTM confirms the diagnosis of tinea capitis. The only approved treatment for tinea capitis is griseofulvin. In tinea capitis, the dermatophyte invades the hair shaft and topical treatment is not effective. An antifungal shampoo is often used as an adjunct to treatment. Keflex is an oral antibiotic, which will not help treat the fungal infection. Desonide is a topical steroid that will worsen the fungal infection.

Q 39.27: A six-month-old infant presents to the primary care provider with complaints of a spreading rash. The physical exam shows multiple yellow-brown macules and plaques that urticate when stroked. What would an appropriate treatment regimen include? A referral to child protective services B patient education to avoid NSAIDS and extremes of temperature C reassure the parents that it will resolve spontaneously within a week D prescribe ketoconazole cream bid x 2 week

The Correct Answer is: B This condition is consistent with urticarial pigmentosa, and it will resolve over time. However, certain things such as NSAIDS, codeine, and scopolamine, as well as extreme temperatures, can cause such reactions as anaphylaxis. This condition is frequently mistaken for child abuse, as the lesions can look like small finger sized bruises. It is consistent, however, with urticaria pigmentosa, which is an accumulation of mast cells in the skin, as indicated by urtication of the lesion after gentle stroking. Urticaria pigmentosa will resolve; however, it will take longer than a week to resolve. Ketoconazole cream is an antifungal that is used to treat fungal infections.

Q 34.5: A 12-year-old male presents with hyperkeratotic papules located on both hands. What is the causative organism? A Herpes simplex virus B Human papilloma virus C Parvovirus B19 D Varicella zoster virus

The Correct Answer is: B This patient has verruca vulgaris or the common wart. The causative organism is the human papillomavirus (HPV). They can affect patients of any age and can occur on any skin surface. There is a predilection for the hands and fingers.

Q 45.4: A 6-year-old male presents with crusted erythematous lesions on the nose, mouth, and chin. He has a history of atopic dermatitis. Which of the following should be part of an appropriate treatment regimen? A hydrocortisone 2.5% ointment bid x 2 weeks B topical mupirocin ointment bid x 7-10 days C lotrisone cream bid x 2 weeks D ketoconazole cream bid x 7 -10 days

The Correct Answer is: B This patient is suffering from impetigo. Impetigo is easily treated with a topical antibiotic, such as mupirocin. Hydrocortisone is a topical steroid and may worsen the infection. Lotrisone is a combination medication that includes an antifungal and a topical steroid, neither of which is indicated in this patient. Ketoconazole cream is used to treat fungal infections, not bacterial infections.

Q 41.4: An 8-year-old male child presents with brown, nonpruritic, annular lesions on the back of his hands and feet. Intradermal nodules are seen on the extensor surfaces of the elbows and knees that have been present for several months. At today's visit, the lesions are essentially unchanged since his last visit about a month ago. What is the best treatment for this suspected disorder? A excision and biopsy B no treatment C topical steroids D wet to dry dressings

The Correct Answer is: B This presentation is typical for granuloma annulare, which is a benign skin disorder, and treatment is not warranted. It is most commonly seen in children aged 6 to 10. The red to brown lesions are annular or circinate. These asymptomatic lesions are often confused with tinea corporis. The lesions will disappear on their own over a couple of years.

Q 38.13: First-time parents present to the clinic with their 2-week old infant for a well-child visit. Which of the following strategies should be recommended to parents to help prevent sudden infant death syndrome (SIDS)? A Avoid pacifier use B Encourage tummy time while awake C Increase room temperature D Place infant on side for sleep E Use home monitors

The Correct Answer is: B Tummy time (B) helps infants develop strength to avoid situations that compromise breathing. Pacifiers (A) are recommended to help avoid bottle feedings as a sleep aid since they are associated with an increased risk of SIDS. Excess warmth (C) and prone or side (D) sleeping positions also increase the risk of SIDS. Home monitors (E) are not effective in the prevention of SIDS.

Q 36.4: A 1-year-old female is having a 2-day history of fever (102 0 F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non-toxic appearing, has a rectal temperature of 100.2 0 F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x-ray has no specific findings. Based on these findings, what is the initial ancillary test to confirm the diagnosis? A Acid fast bath test B Viral nasal washings C Sputum culture and sensitivity D Blood cultures E Throat culture

The Correct Answer is: B Viral nasal washings are the best choice for determining RSV infection that causes bronchiolitis. Sputum and blood cultures do not grow the agents that would typically cause the infection to occur, and you are obtaining a sample from a different part of the respiratory tract and blood.

Q 38.20: The majority of cases of halitosis in young children can be traced to which of the following causes? A dental caries B nasal foreign body C poor dietary habits D upper respiratory tract infection

The Correct Answer is: B While halitosis can be caused by pharyngitis, sinusitis, and poor hygiene, the most common cause of halitosis in children is a nasal foreign body. Seeds and beads are the leading objects inserted into the nose. If not promptly removed, they can cause nasal obstruction, infection, rhinorrhea, bleeding, halitosis, or a foul smell. They are usually easy to remove, but if there is difficulty in removing the foreign body, the child should be referred to an otolaryngologist for definitive care. Tobacco use in adolescents is a common cause of halitosis. Dental disease is the most common cause of halitosis in adults.

Q 44.9: A 28-week-premature infant is noted to have increasing tachypnea and difficulty breathing, with diffusely decreased breath sounds on exam shortly after delivery. A chest x-ray reveals diffuse, bilateral atelectasis and air bronchograms. Which of the following is the most likely diagnosis? A Acute asthma exacerbation B Hyaline membrane disease C Meconium aspiration D Pleural effusion E Spontaneous pneumothorax

The Correct Answer is: B Premature infants, due to a lack of surfactant, develop marked atelectasis and decreased lung compliance, with acute respiratory distress. This is termed hyaline membrane disease and is the most common cause of respiratory distress in preterm infants. Meconium aspiration is more likely in full-term or near-term infants who experience fetal distress, and the x-ray may demonstrate hyperexpansion and irregular infiltrates. Spontaneous pneumothorax can occur at birth. Exam findings will include decreased breath sounds on the affected side, and x-ray findings should indicate the pneumothorax or pneumomediastinum. Pleural effusion may be present in hydropic infants, or it may be due to an underlying disorder or chylothorax. The x-ray would reveal opacity of the affected side, with blunting of the costophrenic recess. Asthma exacerbation should involve airway hyperresponsiveness in relation to a trigger exposure, and would demonstrate bilateral hyperinflation with diaphragm flattening on x-ray.

Q 48.6: A 2-year-old child presents to the emergency department via ambulance due to a seizure lasting approximately 2 minutes with jerking and somnolence. En route in the ambulance her vital signs are: temperature 39°C rectal; pulse 120/min; respirations 32/min; blood pressure 110/64 mm Hg. Upon further questioning, her mother claimed she had a runny nose yesterday. On physical examination, she is sleepy but arousable with negative Kernig and Brudzinski signs. Which of the following seizures is the MOST likely diagnosis? A absence seizure B complex partial seizure C febrile seizure D simple partial seizure

The Correct Answer is: C A febrile seizure is a brief (less than 15 minutes), generalized, symmetric, tonic-clonic seizure associated with a febrile illness (temperature greater than 38.8°C) without any central nervous system infection or neurologic cause. An absence (petit mal) seizure is a brief (2 to 25 seconds) loss of consciousness that can occur multiple times per day. There is no loss of tone, and frequently the only observable behaviors are staring or minor movements such as lip smacking and semipurposeful movements of the hands. There is no postictal period. Complex partial seizures (psychomotor) have varied symptoms including alterations in consciousness, unresponsiveness, and repetitive complex motor activities that are purposeless. Often, at the beginning of the attack, there is a psychoillusory phenomenon such as hallucinations, visual distortions, visceral sensations, or feelings of intense emotions. Simple partial seizures include focal motor, adversive, and somatosensory seizures. Manifestations of these seizures are varied including hallucinatory, psychoillusory, or complex emotional phenomena. Children will interact normally with their environment, with the exception of those limitations imposed by the seizure. Following the seizure (minutes to hours), there may be transient paralysis of the affected body part.

Q 34.2: A 2-week-old male infant is being seen in the clinic for a profuse mucoid discharge from both eyes, with some associated tearing. On examination, you notice both eyes are hyperemic and the eyelids are red and swollen. Which of the following is the most likely cause of this patient's ophthalmia neonatorum (conjunctivitis in the newborn)? A allergic B gonococcal C chlamydial D viral

The Correct Answer is: C Chlamydial infections are the most common cause of conjunctivitis in newborns in developed countries. Other causes of ophthalmia neonatorum include reactions to silver nitrate prophylaxis, other bacterial infections such as gonococcal or staphylococcal, or viral organisms such as adenovirus or echovirus. Chlamydia trachomatis causes conjunctivitis and pneumonia in neonates. Treatment for chlamydial conjunctivitis should be with systemic erythromycin to treat the conjunctivitis and as prophylaxis against pneumonia.

Q 38.11: The American Academy of Pediatrics (AAP) recommends which of the following treatments for a two-year-old child with an acute otitis media who has a fever of 103.7˚F, had an ear infection two months ago, and in whom you suspect penicillin-resistant strep bacteria? A Amoxicillin 45 mg/kg, divided into BID-dosing and administered for 10 days. B Amoxicillin 90 mg/kg, divided into BID-dosing and administered for 10 days. C Amoxicillin-clavulanate 45 to 90 mg/kg, divided into BID dosing and administered for 10 days D Cephalexin 20 mg/kg, divided into QID-dosing and administered for 10 days E Ceftriaxone 50 mg/kg, IM daily for three days.

The Correct Answer is: C AAP recommends consideration of amoxicillin as a first-line anti-infective for antibiotic naïve patients, and those at low risk. For patients who have received antibiotics in the previous 90 days, or those who have been exposed in day care or a medical facility, escalating antibiotics to cover penicillin-resistant streptococcus bacteria—such as amoxicillin-clavulanate—and a higher dose should be a consideration.

Q 35.7: A 5-year-old girl presents to the office with her mother, who states the child is experiencing excessive tearing, itching, and redness of her eyes. On physical exam you note marked injection with chemosis without discharge. The patient lacks adenopathy. Which of the following is the most appropriate treatment? A Azithromycin 1 gram by mouth B Observation and reassurance C Olopatadine 0.1% ophthalmic solution twice daily D Sulfacetamide 10% ophthalmic solution three times a day for 5 days E Valacyclovir 500 mg by mouth twice daily for 10 days

The Correct Answer is: C Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis and is treated with antihistamines/mast cell stabilizers (C). Azithromycin (A) is indicated for the treatment of conjunctivitis caused by chlamydia and antibiotic drops (D) are indicated for bacterial conjunctivitis. Observation and reassurance (B) is indicated for viral conjunctivitis. The patient lacks symptoms of herpes infection (E).

Q 36.6: A seven-week-old male infant is believed to have had a febrile seizure. The mother states that he has had rhinorrhea and fever x 2 days, and this afternoon he had a witnessed generalized tonic-clonic seizure for approximately two minutes. There is no history of seizures, trauma, new medications, or rash. A physical exam reveals an irritable infant with an elevated temperature of 102.4˚F, an erythematous bulging left tympanic membrane, and clear rhinorrhea with mucosal swelling. Which of the following is the most appropriate next management step for this infant? A Anticonvulsant medication B Electroencephalogram C Lumbar puncture D Skull x-rays E Watchful waiting

The Correct Answer is: C Although febrile seizures are common in the pediatric population, newborns and young infants with irritability, seizure activity, and fever should be evaluated for bacterial meningitis, according to the American Academy of Pediatrics. This requires a lumbar puncture. A single simple seizure, occurring in the presence of temperature greater than or equal to 100.4˚F (38˚C), lasting less than 15 minutes, and occurring in a child between six months and five years of age that is nontoxic appearing, does not require blood work, lumbar puncture, or imaging, but a source should be identified when possible. Anticonvulsant therapy is not indicated, as the medication risks outweigh the risks of another simple seizure and the primary target is to find and address the cause while addressing the fever. EEG is recommended for new onset afebrile seizures, or in the presence of recurrent seizures. Emergent neuroimaging with CT or MRI should be pursued if trauma is suspected.

Q 37.12: A 16-year-old girl is brought to the emergency department by ambulance after reportedly ingesting "a bottle of aspirin." Vital signs are temperature 37.8°C oral; pulse 94/min; respirations 30/min; blood pressure 100/68 mm Hg. What would you expect the blood gases to show that would confirm she had swallowed the aspirin? A anion gap metabolic acidosis with respiratory acidosis B nonanion gap metabolic acidosis with respiratory alkalosis C anion gap metabolic acidosis with respiratory alkalosis D nonanion gap metabolic acidosis with respiratory acidosis

The Correct Answer is: C An acute salicylate overdose (greater than 150 mg/kg) will produce symptoms of salicylate intoxication. Chronic salicylate intoxication occurs with ingestion of greater than 100 mg/kg/day for at least 2 days. Salicylates affect most organ systems, leading to various metabolic abnormalities. Because salicylates are a gastric irritant, symptoms of vomiting and diarrhea occur soon after the overdose, which may contribute to the development of dehydration. Salicylates stimulate the respiratory center leading to hyperventilation and hyperpnea resulting in respiratory alkalosis and compensatory alkaluria. A characteristic feature of salicylate intoxication is the coexistence of a respiratory alkalosis with a widened anion gap metabolic acidosis.

Q 38.1: What is a commonly shared feature of bipolar disorder and ADHD in pediatric patients? A disruptive B obsessed with ideas C behavior problems D impaired concentration E insomnia

The Correct Answer is: C Behavior problems are a commonly shared feature of pediatric ADHD and bipolar disease. Disruptive and impulsive behaviors are a shared feature of conduct disorder. Disruptive behavior and being annoying to others can be found with oppositional defiant disorder; impaired attention and concentration can be found in major depression. Bipolar patients are obsessed with ideas while ADHD and conduct disorder patients are not.

Q 49.7: An 8-month-old female is diagnosed with respiratory syncytial virus bronchiolitis while in the emergency department. Which of the following strongly indicates a need for admission to the hospital and continued monitoring? A Age of 8 months B Birth at 38 weeks C Feeding difficulty with decreased oxygen saturation D Oxygen saturation of 96% E Respiratory rate of 45bpm

The Correct Answer is: C Brochiolitis patients must be considered at risk of developing severe disease and/or apnea when certain criteria are present, thus requiring admission. This includes, but may not be limited to, the following: birth <37 weeks gestation, age <12 weeks, witnessed apnea, underlying cardiopulmonary disease, immunodeficiency, tachypnea based on expected respiratory rate per age, decreased oral intake or feeding difficulty with associated decreased oxygen saturation, decreased oxygen saturation with varying ranges based on source (most being <95%), a history of previous intubation, and a caregiver ability to adequately provide care and monitoring.

Q 38.16: A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following diagnostic studies should be performed as a result of this finding? A Fasting blood glucose B MRI of the eye and orbit C Rapid plasma reagin (RPR) D Serum cortisol level E Serum thyroid stimulating hormone level

The Correct Answer is: C Congenital cataracts may result from transmission of maternal infections such as herpes simplex virus, cytomegalovirus, toxoplasmosis, or syphilis and require further evaluation for potential systemic infection. A quantitative RPR (C) should be performed to assess for congenital syphilis. Endocrine disorders such as diabetes (A), Cushing's syndrome (D), or hypothyroidism (E) aren't common causes of congenital cataracts.

Q 48.2: While seeing a 12-week-old baby girl for her well-child checkup, it is noticed that she has tearing from her left eye. There is a small reddened area that is swollen and she cries when it is touched. The swollen area is just below the medial inferior eyelid. There is also constant tearing from this same eye. Her mother says it just started about 2 days ago and is getting worse. What is the most likely cause of this problem? A blepharitis B conjunctivitis C dacryocystitis D anterior uveitis

The Correct Answer is: C Dacryocystitis, whether acute or chronic, is usually secondary to bacterial infections. It presents as an acutely inflamed swelling and tender area over the lacrimal sac just medial and inferior to the inner canthus of the eye. Because the lacrimal sac is inflamed and blocked there is tearing and usually purulent discharge from the eye. There may also be an orbital cellulitis. Treatment consists of oral and topical antibiotics and warm compresses, and surgical drainage may also be indicated. After the acute episode and for chronic cases, surgical correction of the nasolacrimal obstruction is required. Anterior uveitis typically presents with pain, photophobia, blurred vision, and injection without exudates. Blepharitis is an inflammation of the lid margin that presents with crusty debris along the lashes. Unless there is a concomitant conjunctival infection, there is typically no injection noted.

Q 36.1: Which of the following daily maintenance fluid requirements is the closest approximation for a 24-kg child who is refusing to eat? A 1,080 mL B 1,200 mL C 1,580 mL D 2,000 mL

The Correct Answer is: C Dehydration is a common pathophysiologic alteration in fluid balance in children. The body has a maintenance fluid requirement to replace daily normal losses that occur through the skin, kidney, intestines, and respiratory tract. The following formula can be used to calculate the usual amount of fluid a healthy child requires by mouth to maintain hydration: 100 mL/kg for the first 10 kg of body weight 50 mL/kg for the next 10 kg of body weight 20 mL/kg for the weights above 20 kg For this question, a 24-kg child would require: 100 mL/kg × 10 kg = 1,000 mL for the first 10 kg 50 mL/kg × 10 kg = 500 mL for the next 10 kg 20 mL/kg × 4 kg = 80 mL for the next 4 kg Total = 1,580 mL 24 kg

Q 45.8: The eggs of this parasite are detected by microscopic examination of clear adhesive tape that has been pressed to the child's anus in the morning, prior to bathing. What parasite is most likely to be identified by this test method? A Ancylostoma duodenale (hookworm) B Ascaris lumbricoides (ascaris) C enterobiasis (pinworm) D trichuriasis (whipworm)

The Correct Answer is: C Enterobiasis or pinworms is a worldwide infection that affects people of all ages and socioeconomic levels. It especially affects children. The classic manifestation of this problem is nocturnal anal pruritis and sleeplessness. The sleeplessness may be secondary to the migration of female worms to the perianal area to lay eggs, during which the tape may pick up the larvae. Transmission of the worms occurs when children ingest the eggs that are present on their hands (from scratching), in the bedclothes, or in house dust. After hatching in the stomach, the larvae migrate to the cecum where they mature into adults. The treatment of choice for pinworms is pyrantel pamoate or mebendazole. Albendazole may also be used. For eradication of this parasite, often the entire family must be treated at once. Ascaris is a helminthiasis infection that is ingested and excreted in the stool. Diagnosis is made by stool examination for the characteristic eggs. Hookworms are found in warm, damp soil and penetrate the skin. From there the infection can spread to the lungs where they ascend into the trachea to be swallowed and live in the intestine. Diagnosis is made by stool examination for the eggs. Whipworm is ingested from the soil and lives in the intestine; detection is also made by egg in the feces.

Q 38.7: A 2-day-old infant presents with numerous red macules with central vesicles and pustules. The rash spares only the palms and soles. The infant has no fever and is nursing normally. What is the most likely diagnosis? A Acne neonatorum B Congenital herpes simplex C Erythema toxicum D Milia

The Correct Answer is: C Erythema toxicum is a benign rash seen in newborns. The cause of the rash is unknown and resolves spontaneously. The rash appears as erythematous macules, which may develop central vesicles within 24 to 48 hours. The palms and soles are spared.

Q 45.9: A 2-year-old child presents to the pediatric office for a well child visit. The presence of which of the following risk factors places this child at high-risk for dental caries? A Child receives fluoride varnishes B Maternal smoking C Parents are of low socioeconomic status D Single parent home E Use of fluoridated water

The Correct Answer is: C Factors that place children at high-risk for dental caries include the presence of white spots, cavities, or fillings on exam; mother/primary care giver having cavities; mother/primary caregiver being of low socioeconomic status (C); frequent between-meal sugar-containing snacks/beverages; or being put to bed with a bottle that contains sugary beverage. Fluoride (A) and fluoridated water (E) are protective. Maternal smoking (B) and single parenting (D) are not validated risk factors for dental caries.

Q 38.19: An Rh-negative, 5-year-old male child presents with acute onset of petechiae and purpura after an acute viral illness. In addition, he has episodes of epistaxis. Which of the following is a treatment option if his platelet count falls below 20,000/mm 3 , but he is not actively bleeding? A platelet transfusions B IV anti-D (WinRho SD) 50-70 mg/kg/dose C prednisone 2.4 mg/kg/24 hours × 2 weeks D splenectomy

The Correct Answer is: C In patients with idiopathic thrombocytopenic purpura, treatment options should be initiated when platelet counts *fall below 20,000, *regardless of whether there is active bleeding or not. Without active bleeding the treatment options include prednisone 2-4 mg/kg/24 hours for 2 weeks; IV immunoglobulin 1 g/kg/24 hours for 1 to 2 days, or IV anti-D 50-75 μg/kg/dose for Rh-positive patients. Splenectomy is indicated for life-threatening bleeding. There is currently no indication for platelet transfusion and none of the above treatments are considered optimal, because in the majority of children, it will resolve on its own within 6 months.

Q 49.13: A 20-month-old boy is brought into the emergency department by his parents. They state he has not been feeling well for 2 days and this morning noted he was "shaking all over" and was not responding to commands. This went on for less than 10 minutes and has never happened before. His current rectal temperature is 100.7°F. The seizures are characteristic of A absence seizures B Lennox-Gastaut syndrome C febrile seizures D infantile spasms E juvenile myoclonic epilepsy

The Correct Answer is: C Febrile seizures can occur in children younger than 5 years when accompanied by a fever. They are characterized by a brief generalized motor seizure. Absence seizures are generalized seizures characterized by a loss of consciousness without motor involvement, typically seen in older children. Lenox-Gastaut syndrome presents in childhood as well but is usually associated with developmental delay and seizures of akinetic and myoclonic nature (referred to as drop attacks). Infantile spasms occur without relation to systemic illness and are massive myoclonic events with bending at the waist. Juvenile myoclonic epilepsy evolves in the teenage years and is characterized by repeated episodes of myoclonic seizure activity.

Q 48.7: A 5-year-old child with no known drug allergies is diagnosed in your clinic with bilateral acute otitis media. Which of the following is the drug of choice? A levofloxacin B nitrofurantoin C amoxicillin D doxycycline E gentamicin

The Correct Answer is: C First choice antibiotic treatment for acute otitis media includes a 10-day course of amoxicillin (80 to 90 mg/kg/day in two divided doses) or a combination of erythromycin (50 mg/kg/day) and a sulfonamide (150 mg/kg/day). Reasons for amoxicillin therapy include spectrum of activity including both susceptible and intermediate resistant S pneumoniae, safety, cost, and tolerability.

Q 39.5: A 16-year-old high school boy presents to the emergency department 4 hours after sustaining an abrasion to his knee after a fall while rollerblading on the school playground. His school immunization record reveals that his last diphtheria, tetanus, and pertussis (DTaP) booster was administered at age 4. In this situation, which of the following is the MOST appropriate plan? A administer tetanus toxoid B administer adult tetanus and diphtheria toxoid (Td) C administer diphtheria, tetanus toxoid, and acellular pertussis (Tdap) vaccine D administer tetanus immune globulin

The Correct Answer is: C Generalized tetanus (lockjaw) is a neurologic disease caused by Clostridium tetani. Although any open wound is a potential source for contamination with C tetani, those with dirt, soil, feces, or saliva are at increased risk. Tetanus-prone wounds contain devitalized tissue, especially those caused by punctures, frostbite, crush injury, or burns. Recommendations for tetanus prophylaxis in a child with a laceration or abrasion depend upon the number of previous vaccinations, occurrence of last booster, type of wound (clean or tetanus-prone), and age of child. In this case, the patient is older than 7 years and had all of his previous immunizations; however, his most recent booster was greater than 10 years ago. Thus, he should receive an adult-type diphtheria and tetanus toxoid with acellular pertussis. In most cases, when tetanus toxoid is required for wound prophylaxis in a child older than 7 years, the Td instead of tetanus toxoid alone is recommended so that diphtheria immunity is maintained. If tetanus immunization is not up to date at the time of wound treatment, then the immunization series should be completed according to the primary immunization schedule. If a child is younger than 7 years, then the diphtheria, tetanus, acellular pertussis (DTaP) booster is indicated, unless there is a contraindication for pertussis, in which case the diphtheria and tetanus (DT) booster should be administered. Tetanus immune globulin (TIG) is recommended for treatment of tetanus. Under special circumstances, a patient infected with the human immunodeficiency virus (HIV) with a tetanus-prone wound should also receive TIG in addition to the prophylactic vaccine. (Ogle and Anderson, 2009, pp. 1144-1147; Centers for Disease Control and Prevention, 2009a) Ogle JW , Anderson MS. Infections: bacterial & spirochetal. In: Hays WW , Levin MJ , Sondheimer JM, et al., eds. Current Diagnosis & Treatment: Pediatrics. 19th ed. New York: McGraw-Hill; 2009. Centers for Disease Control and Prevention (2009a). Summary of recommendations for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) and tetanus and diphtheria toxoids (Td) use among adolescents aged 11-18 years .

Q 46.6: A 10-year-old male who plays soccer presents with annularly configured dermal papules that are skin colored and shiny, and are located on his shins. His mother states that the lesions started as nodules, and have since enlarged. There is no scale present and they are asymptomatic. No one else in his home has similar findings. What is the most likely diagnosis? A Atopic dermatitis B Contact dermatitis C Granuloma annulare D Tinea corporis

The Correct Answer is: C Granuloma annulare (GA) is a self-limited condition that may appear as solitary lesions or in a more generalized distribution. They begin as small, shiny skin colored dermal papules that enlarge over time with central clearing. There are no epidermal manifestations. GA commonly occurs over bony surfaces, such as the shins or dorsa of the hands. It is frequently misdiagnosed as tinea corporis; however, the absence of epidermal scaling helps rule out this diagnosis.

Q 49.10: A 15-year-old boy suddenly collapses on the basketball court; his sports physical conducted at the beginning of the year did not elicit any abnormal findings. Basic life support initiated at the scene, however, is unsuccessful in resuscitation. Which of the following is the most likely etiology of his sudden death? A mitral valve prolapse B surgically corrected aortic stenosis C hypertrophic cardiomyopathy D rheumatic heart disease

The Correct Answer is: C Hypertrophic cardiomyopathy in adolescence is typically due to familial hypertrophic cardiomyopathy with an incidence of 1:500. Many patients are asymptomatic until a sporting event, which may cause symptoms, specifically sudden cardiac death. Examination may demonstrate a palpable or audible S 4 , an LV (left ventricular) heave, systolic ejection murmur (may need to stimulate cardiac activity), and/or a left precordial bulge. Echocardiography is the gold standard for diagnosis but family history should be assessed. Stress testing is indicated to assess for ischemia and arrhythmias. Strenuous activities are prohibited for these patients. The other cardiomyopathies (dilated and restrictive) are next but are not as common. Congenital structural abnormalities of the coronary arteries are the next most common cause. Valvular disorders, including surgically repaired aortic stenosis, are typically not causes of sudden death, but these patients should be screened for symptoms and stress tested as necessary.

Q 49.14: A 5-year-old male presents with a first-time, one-week history of a cough, nasal congestion, and a temperature of 101˚ F orally. Upon physical exam, you note a distended, erythemic right tympanic membrane that has decreased mobility, with pneumatic otoscopy. There are no known drug allergies. What is the first line antibiotic indicated for this condition? A Ciprofloxacin B Moxifloxacin C Amoxicillin D Clindamycin E Cefaclor

The Correct Answer is: C In cases of non-resistant otitis media, amoxicillin, erythromycin, or a sulfonamide are first line antibiotics. Flouroquinolones, like ciprofloxacin or moxifloxacin, are contraindicated in children.

Q 39.30: In a 6 year old non-bleeding child with a platelet count of 20,000, and a new diagnosis of immune thrombocytopenic purpura, what is the best clinical intervention? A Glucocorticoids B Immunization against pneumococcus C No therapy D Splenectomy E Weekly transfusions of platelets

The Correct Answer is: C In non-bleeding children with platelet counts of 20,000, no therapy is indicated. More than two-thirds of children diagnosed with ITP will resolve in less than six months, and more than 80% after one year. Immunization against pneumococcus is appropriate if a splenectomy is planned. Glucocorticoids are useful, but may be avoided as an initial intervention and avoidance of side effects. Splenectomy is used only after one year of diagnosis, and when the child is at least five years old. Transfusion of platelets is not needed in non-bleeding individuals.

Q 44.6: An aspirated peanut that is causing a partial obstruction of the trachea in a child is most likely to cause which of the following physical exam findings? A Aphonia B Inability to cough C Stridor D Progressive cyanosis E Rhonchi

The Correct Answer is: C Incomplete airway obstruction due to a foreign body will cause turbulent air flow in the airway and an inspiratory wheeze sound, known as stridor. Attempts should be made to remove the foreign body, leaving the patient with a partial obstruction to utilize the cough reflex to remove the foreign body. If unsuccessful, or if findings such as aphonia, an inability to cough, progressive cyanosis, or unconsciousness occur, a complete obstruction is present and definitive intervention must convene. Age appropriate measures, utilizing back blows and chest compressions in infants younger than the age of one and abdominal thrusts in children over the age of one, should be attempted.

Q 44.7: A mother brings in her 20-month-old female child to the office because she noticed pubic hair growing. On examination, the clinician notices that the clitoris is enlarged; the rest is unremarkable. Which of the following is an expected laboratory finding on this patient? A increased aldosterone B increased estrogen C increased androstenedione D increased luteinizing hormone

The Correct Answer is: C Infant girls presenting with signs of precocious puberty need to be screened for congenital adrenal hyperplasia (CAH). CAH most commonly presents with pseudohermaphroditism in females—urogenital sinus, enlarged clitoris, or other signs of virilization. In males, there tends to be isosexual precocity in older males and salt-losing crisis in infant males. Both children show increased linear growth and skeletal maturation. The most common type of CAH is a deficiency in the enzyme 21-hydroxylase and laboratory tests demonstrate increased urinary and plasma androgens (DHEA, androstenedione). There may be elevated progesterone, but typically there is no effect on estrogen. There is also decreased aldosterone and elevated urinary ketosteroids. There is also no effect on the levels of leuteinizing hormone or follicle-stimulating hormone. Treatment usually involves glucocorticoids, mineralocorticoids, and reconstructive surgery, if needed.

Q 38.15: A 12-year-old female presents with a complaint of dry flaking skin that becomes fissured and painful. Her skin has always had dark plate-like scales. What is the most likely finding in the patient's history? A Her skin forms blisters with minimal contact B She was premature C There was a membrane present at birth D There were no symptoms present until the age of six

The Correct Answer is: C Lamellar ichthyosis is a condition in which a baby is born with a collodion membrane. Within a few weeks, this membrane is shed and replaced by large gray scales. These plate-like scales persist with no improvement over time. Painful fissures on the hands and feet are common.

Q 47.5: Which agent is most responsible for croup infections? A Parvovirus B Adenovirus C Parainfluenza D Bocavirus E Streptococcus

The Correct Answer is: C Laryngotracheobronchitis, or croup, is mostly caused by the parainfluenza virus. Other agents that can cause this are respiratory syncytial virus (RSV), human metapneumovirus, influenza virus, rubeola virus, adenovirus, and Mycoplasma pneumoniae.

Q 40.10: A 12-year-old male presents with a rash, consisting of erythematous macules and papules involving the face, trunk, and extremities. He also complains of cough, coryza, and non-purulent conjunctivitis. The described exanthema and associated enanthem is pathognomonic for what disorder? A Erythema infectiosum B Hand, foot, and mouth disease C Measles virus D Varicella virus

The Correct Answer is: C Measles is one of the few exanthemas where the primary lesions are both macules and papules. These lesions may coalesce to become confluent. The pathognomonic lesion of measles is the Koplik spot, which is a blue-white papule with surrounding erythema appearing on the oral mucosa.

Q 40.7: A 6-year-old girl presents to the emergency department with abdominal distension of 1-day duration. She has not had a bowel movement or passed flatus in 72 hours. Examination reveals markedly diminished bowel sounds with tympany to percussion. She has also passed bloody mucus from her rectum. There is no evidence of hernia, and surgical history is negative. Which of the following is the most likely diagnosis? A Regional enteritis B Pyloric stenosis C Meckel diverticulum D Acute appendicitis

The Correct Answer is: C Meckel diverticulum is prevalent in 2% of the population, has a 2:1 male:female predominance, and is usually located 2 ft from the ileocecal valve. The most common clinical presentations are bleeding, intestinal obstruction, and inflammation. Bright red or maroon bleeding is the most frequent complication in children younger than 2 years of age. Obstruction may develop secondary to a volvulus that occurs at the site of the diverticulum or from an intussusception with the diverticulum acting as the lead point. An air contrast barium enema may be able to reduce intussusceptions in children.

Q 34.6: A 6-year-old female presents with small erythematous papules grouped around the mouth. The mother reports that she tried to treat with over-the-counter hydrocortisone 1% cream. The condition has worsened. What is the best step in management of this condition? A hydrocortisone valerate cream B keflex 500 mg bid C metronidazole 0.75% gel bid D clotrimazole cream bid

The Correct Answer is: C Metronidazole 0.75% gel bid is a first line treatment for perioral dermatitis. Topical steroids, such as hydrocortisone valerate cream, will actually worsen perioral dermatitis and create a granulomatous condition. Oral antibiotics, like Keflex 500 mg bid, are frequently used to treat perioral dermatitis. However, Keflex is not indicated for perioral dermatitis. Clotrimazole is an antifungal cream that is not used in perioral dermatitis.

Q 48.10: Which of the following is the most common childhood nutritional disorder in the United States? A binge eating disorder B folate deficiency C obesity D rickets

The Correct Answer is: C Obesity is the number one nutritional disorder in children in the United States. In 2004, 17% of American children aged between 9 and 19 were considered obese. Risk factors for obesity include other obese family members and infants born to diabetic mothers. Associated environmental factors include sedentary lifestyle, total caloric intake, television watching, and computer games. All are considered contributory factors in childhood obesity. Binge eating disorder is a relatively new eating disorder category. It is most frequent in overweight or obese individuals. This disorder includes recurrent episodes of binge eating (eating more than most individuals would in a 2-hour period) and a sense of lack of control over the impulse to eat, marked distress over the episode at least 2 days a week, and is not associated with regular compensatory activity such as purging or fasting. Folate deficiency anemia (megaloblastic) can occur in infants within a few weeks after birth. This deficiency may be a result of malabsorption, low dietary intake such as with goat's milk or home-prepared formulas that have been sterilized by heating, or formulas based on pasteurized milk. Infants who are breastfed or given supplemented cows' milk formulas do not have a problem with folate deficiency. In children, rickets is most commonly a result of poor dietary intake of vitamin D and inadequate exposure to direct sunlight. Vitamin D sources include milk, cheese, and baby formula. Vitamin D in humans is produced by activation of its inactive precursors in the skin after exposure to ultraviolet light.

Q 49.17: Which of the following is indicated for treatment of oral thrush? A Prednisone B Penicillin C Nystatin D Cephalexin E Acyclovir

The Correct Answer is: C Oral candidiasis, also referred to as oral thrush, is most commonly seen in infants and immunocompromised patients. It can also occur in asthma patients being treated with a metered dose steroid inhaler. The antifungal treatment of choices is nystatin suspension. Other agents that can be used are fluconazole and clotrimazole oral troches.

Q 45.7: A 2-year-old male presents with a 10-day history of fever, cough, and decreased appetite and fluid intake. He is normally healthy. On examination, the child appears ill, has a temperature of 102.2 0 F, a pulse rate of 122, and a respiratory rate of 36. On auscultation of the lungs there are rhonchi heard on the right lung fields, as well as a small amount of wheeze. A chest x-ray is ordered, which reveals the presence of pneumatoceles. Based on these findings, what is the most likely pathogen causing this patient's infection? A Streptococcus pneumoniae B Hemophilus influenza C Staphylococcal aureus D Pseudomonas aeurginosa E Chlamydia pneumoniae

The Correct Answer is: C Pneumatoceles, pyopneumothorax, and empyemas are frequently encountered in pediatric Staphylococcal aureus pneumonias.

Q 44.10: What is the most serious complication of the influenza B virus? A Multi-lobar pneumonia B Encephalitis C Reye's syndrome D Renal failure E Hepatitis

The Correct Answer is: C Reye's syndrome, while rare, is a very serious complication related to influenza B virus infections. There is a 30% mortality rate, which primarily affects the pediatric population. Hepatic failure and encephalopathy are events that occur in this fatal disease.

Q 39.22: A 1-year-old female is having a 2-day history of fever (102 0 F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non-toxic appearing, has a rectal temperature of 100.2 0 F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x-ray has no specific findings. What is the initial treatment of choice for this patient with these symptoms? A Antibiotics B Oxygen therapy C Supportive care D Antiviral medications E Plasmaphoresis

The Correct Answer is: C The choice for treatment of acute bronchiolitis is supportive care. Oxygen therapy is only reserved for those patients who are hypoxic, and antiviral medications have not proven to be effective in shortening or eradicating the infection.

Q 40.8: Which of the following childhood exanthems is characterized by a 10-day incubation period followed by 3 days of fever, runny nose, and conjunctivitis giving way to a maculopapular rash starting on the head, progressing to the trunk, and accompanied by white spots on the buccal mucosa? A herpes simplex infection B coxsackie virus C measles D rubella

The Correct Answer is: C The description best fits that of measles. It has a 7- to 10-day incubation period followed by 3 days of coryza, fever, and conjunctival involvement. The prodrome dissipates as the characteristic rash develops first on the head and face and then the trunk. Koplick spots are the pathognomonic white spots that occur on the buccal mucosa in measles' infection. Herpes simplex infection can present as painful vesicles on the mouth and lips (HSV-1) or genitalia (HSV-2). It is preceded by fever and a tingling or burning sensation at the site where the vesicle will develop. Coxsackievirus causes hand, foot, and mouth disease with lesion distribution in those three areas. Rubella has a longer incubation period (2 to 2.5 weeks) and is less contagious than measles. It is sometimes asymptomatic or produces a milder course than measles.

Q 43.7: A mother brings her 11-month-old son to you for a fever and rash. He had four days of fever worsening each day until last night when it measured 104.5°F taken orally before being given acetaminophen. When he awoke this morning, his fever was 100.4°F but he had developed a maculopapular rash to his trunk and extremities that blanches. Which of the following is the probable etiology? A Fifth disease B varicella C roseola D rubella E scarlet fever

The Correct Answer is: C The most prominent historical feature is the abrupt onset of fever, often reaching 40.6˚C, which lasts up to eight days (mean, four days) in an otherwise mildly ill child. The fever then ceases abruptly, and a characteristic rash may appear. Roseola occurs predominantly in children aged six months to three years, with 90% of cases occurring before the second year. Herpesvirus 7 (HHV-7) infection tends to occur somewhat later in childhood. These viruses are the most common recognized cause of exanthematous fever in this age group and are responsible for 20% of emergency department visits by children aged six to 12 months.

Q 38.4: A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following is the most effective treatment option for the patient's suspected diagnosis? A Albuterol B Azithromycin C Bronchoscopy D Chest physiotherapy E Prednisone

The Correct Answer is: C The patient has most likely aspirated a foreign body. The most effective treatment is removal of the foreign body through bronchoscopy (C). Supportive therapy includes bronchodilators for wheezing/airway obstruction (A), antibiotics for associated infections (B), and chest physiotherapy (D) to promote recovery after removal of the foreign body.

Q 43.6: A 15-year-old male presents to the outpatient clinic complaining of a sore throat and fever that developed over the last week after feeling fatigued for two to three weeks. The patient appears non-toxic with a temperature of 39.0˚ Celsius. Physical exam reveals pharyngeal and tonsillar erythema with exudates and tonsillar hypertrophy, posterior cervical adenopathy, and splenomegaly. Which of the following laboratory tests is most likely to confirm the expected diagnosis? A HIV antibody testing B Liver function tests C Monospot D Rapid strep test E Rapid plasmin reagin (RPR)

The Correct Answer is: C The patient presentation is consistent with infectious mononucleosis (IM) and can be confirmed through a monospot test (C). The time course of the symptoms and presence of posterior cervical adenopathy makes IM more likely than strep pharyngitis (D). HIV antibody testing (A) is ineffective at diagnosing acute retroviral syndrome during its initial presentation. Liver function tests (B) may be elevated in IM, but are not confirmatory of the diagnosis.

Q 34.8: A 4-year-old male has been experiencing a significant cough for the last 12 to 14 days, and initial episodes of coughing are characterized as frequent outbursts of 5 to 10 spastic coughs in a row. The patient does not report any fever, but does note that the coughing is worse at night. On examination, the patient is alert, awake, and oriented. His temperature is 97.7 0 F, pulse rate is 89, respiratory rate is 25, and blood pressure is 110/56. The HEENT is unremarkable, and lung sounds are clear to auscultation. You suspect that the patient may have an acute case of pertussis. Based on the history and physical exam findings, which is the test of choice for confirming a diagnosis of pertussis? A Complete blood count (CBC) B Throat culture C Chest x-ray D Nasopharyngeal culture E Sputum gram stain and culture

The Correct Answer is: D A special medium culture plate (such as a Bordet-Gengou agar) is required for the nasopharyngeal swab for the diagnosis of pertussis. Throat culture, chest x-rays, and complete blood counts are helpful in ruling out other disease patterns.

Q 35.10: A 17-year-old boy high school wrestler is brought into the emergency department after he collapsed at a wrestling match. He spent time fully clothed in a hot sauna prior to the match to try to "make weight." Labs are ordered, and results come back as follows: Which IV fluid regimen would most effectively treat this patient's hypernatremia? A quarter normal (hypotonic) saline B half-normal saline C isotonic (normal) saline D dextrose 5% in water E lactated Ringer's

The Correct Answer is: C The patient presents with a combination of inadequate fluid intake and excessive losses due to perspiration, resulting in hypovolemia and hypernatremia. The most common causes of hypernatremia are inadequate fluid intake resulting in hemoconcentration and diabetes insipidus (DI), resulting in excessive renal fluid losses. Normal urine osmolality is 500 to 850 mOsm/kg but can range from 50 to 1,200 mOsm/kg depending on the patient's fluid intake. Urine osmolality >400 mOsm/kg indicates that the renal fluid-conserving mechanism is intact, as the kidneys are working to preserve volume. A lower urine osmolality would be consistent with DI, characterized by a lack of response to anti-diuretic hormone (ADH), resulting in excessive urinary losses of water with worsening hypernatremia. Treatment is directed at the cause. If the patient is dehydrated, restoring fluid volume is the goal. If the patient has DI, treating the underlying disease will lower the serum sodium level. For this dehydrated patient, the treatment would be to administer isotonic (normal) saline, which contains 0.9% sodium, because of the large free water deficit. Quarter-normal saline contains 0.25% sodium, half-normal saline contains 0.45% sodium, and lactated Ringer's solution is similar to half-normal saline in its sodium content. Dextrose 5% in water (D5W) contains no electrolytes. Isotonic saline is the appropriate choice because it treats not only the volume deficit but the serum osmolality as well. Its osmolality (308 mOsm/kg) is often lower than the plasma osmolality because of the hypovolemic state and, therefore, helps restore normal serum osmolality. Once serum osmolality becomes more normal, the isotonic saline can be replaced by D5W to replace the remaining free water deficit. If the free water deficit were less dramatic, initial IV fluid treatment could be half-normal saline, followed by D5W.

Q 37.4: A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What imaging study is the best initial test to obtain in this patient? A Abdominal plain film B Barium enema C Barium upper GI series D CT scan of the abdomen E Upper GI endoscopy

The Correct Answer is: C The suspected diagnosis is pyloric stenosis. An upper GI series with barium is the best test to obtain in this instance. A barium enema is a good choice in suspected intussusception cases. An upper GI endoscopy is best used when a gastric or duodenal ulcer is suspected. An abdominal plain film or CT could be ordered, but aren't the best initial tests to obtain in this patient's presentation.

Q 49.8: A 12-year-old female presents with linearly distributed light brown papules on her arm. They are asymptomatic and have been present for several years. The mother states that they appear to grow as the child grows. What treatment is necessary? A Cryotherapy B Laser ablation C No treatment is necessary D Shave excision with biopsy

The Correct Answer is: C This condition is consistent with a linear epidermal nevus. They can appear at any age, but are usually present at or shortly after birth. The pigmented papules are arranged linearly and can occur on any skin surface. They are not symptomatic and will grow with the child. There is no treatment necessary.

Q 34.7: A 6-year-old male presents with multiple lesions on his shins. The lesions are annular dermal plaques with a central depression. There are no epidermal changes. He states the lesions are asymptomatic. The child has no other medical problems and is a normal active child. What is the most likely diagnosis? A necrobiosis lipoidica B tinea corporis C granuloma annulare D atopic dermatitis

The Correct Answer is: C This is the classic distribution of granuloma annulare. These lesions commonly occur over bony surfaces and are thought to be secondary to minor trauma (such as playing soccer, normal play activities, or insect bites). The lesions will spontaneously resolve and no treatment is indicated. The distribution in this patient is similar to that of classic necrobiosis lipoidica; however, the dermal changes are classic for granuloma annulare. Necrobiosis lipoidica starts as brown-red plaques that evolve to become waxy appearing. They are commonly misdiagnosed as tinea corporis; however, there are no epidermal changes such as scaling. The lesions are completely dermal. Atopic dermatitis in a 6-year-old child is most commonly distributed on the flexural surfaces and consists of red scaling plaques that are pruritic.

Q 41.5: A 21-day-old male is brought to the pediatric clinic for concern of irritability, sweating with feeds, and fatigue. Upon examination, there is a discrepancy in the pulse between the arms and legs. The femoral pulses are diminished when compared to the brachial pulses. A murmur is present, and heard in the left axilla and the left back. An EKG is obtained, which show right ventricular hypertrophy. Echocardiography shows a localized narrowing of the aortic arch, just distal to the origin of the left subclavian artery. What is the best definitive treatment for this patient? A Intravenous infusion of normal saline B Placement of a pericardial patch C Balloon angioplasty of the abnormality D Long-term use of propranolol E Performing an atrial switch operation

The Correct Answer is: C This patient has coarctation of the aorta. Balloon angioplasty of the abnormality is the correct answer, and is a corrective repair. IV infusion of normal saline is not appropriate in this child, who is presenting with heart failure. Placement of a pericardial patch is performed for ventricular septal defects. Long-term use of porpranolol is an effective treatment in mitral valve prolapse. An atrial switch operation is performed with transposition of the great arteries.

Q 48.9: A mother presents with a four-month-old male infant complaining of a dry, itchy rash that never seems to completely resolve. There are days when it appears to improve. She currently uses baby wash and baby lotion to care for his skin. She recently discontinued the lotion because he screams when it is applied. Which of the following is this condition exacerbated by? A warm and humid environments B use of petroleum based moisturizers C frequent bathing and soap based cleansers D soap free cleansers and topical steroids

The Correct Answer is: C This patient has the classic presentation of infantile atopic dermatitis. There are numerous factors that can irritate this condition including frequent (more than once a day) or long baths, soap based cleansers, cold dry environments, illness, stress, itchy clothing, and allergies. Lotions may sting, especially if the skin is dry and the skin barrier is broken. Atopic dermatitis usually improves in warm, humid environments. Petroleum based moisturizers are an important part of the treatment of atopic dermatitis. Soap free cleansers are recommended for patients with atopic dermatitis, as they are less irritating and drying. Topical steroids are the first line treatment of atopic dermatitis.

Q 49.12: A two-week-old female is being evaluated, and on examination she is noted to have bounding pulses with a widened pulse pressure. There is a murmur present at the second left intercostal space, and it is described as a rough machinery murmur. Cyanosis is not present. What is the most likely diagnosis in this patient? A Atrial septal defect B Coarctation of the aorta C Patent ductus arteriosis D Tetralogy of fallot E Ventricular septal defect

The Correct Answer is: C This patient is exhibiting signs of a patent ductus arteriosus. Atrial septal defects may not have a murmur associated with them early in the infant's life, but may develop four to six weeks after birth and present as a nonspecific systolic murmur. The signs and symptoms of coarctation of the aorta consist of decreased or absent femoral pulses, with a murmur present in the left axilla and the left back. Tetralogy of fallot presents with cyanosis, easy fatigability, dyspnea on exertion, and variable digital clubbing. Ventricular septal defect presents with a holosystolic murmur at the lower left sternal border and a right ventricular heave, but presentation depends on the size of the defect and the pulmonary vascular resistance. The patient with a ventricular septal defect may also present with features of heart failure, failure to thrive, and diaphoresis with feedings.

Q 36.8: An 8-year-old male presents with hair loss and scalp pruritus with scaling. The mother states it has been present for approximately two weeks. On physical exam, posterior cervical lymphadenopathy is found to be present. What would be the best diagnostic test to perform at this stage? A cbc with diff B Wood's lamp examination C culture on dermatophyte test medium D thyroid function test

The Correct Answer is: C This presentation is classic for tinea capitis. Tinea capitis is extremely common in school aged children. It presents with a scaling, pruritic scalp and lymphadenopathy. There is often hair loss that is described as black dot alopecia. The diagnosis is confirmed by culture of dermatophyte test media (DTM). A cbc will not help diagnose a fungal infection. Only 10% of tinea infections will fluoresce with Wood's lamp examination; therefore, it is not effective for diagnosing tinea capitis. A thyroid function test will not help with a tinea infection.

Q 39.18: Which of the following is the most common congenital heart malformation? A atrial septal defect B tetralogy of Fallot C ventricular septal defect D transposition of the great vessels

The Correct Answer is: C Ventricular septal defect, a hole between the two ventricles, can be cyanotic or acyanotic based on the size of the defect, and accounts for 30% of cases of congenital heart disease. Atrial septal defect occurs in approximately 10% of congenital heart disease cases. Transposition of great vessels is an embryonic malformation resulting in the aorta arising from the right ventricle and the pulmonary artery arising from the left ventricle. It is responsible for about 10% of all congenital malformations. Tetralogy of Fallot, consisting of a ventricular septal defect, overriding aorta, pulmonic/subpulmonic stenosis, and right ventricular hypertrophy, accounts for 10% of congential heart disease. (

Q 34.3: An 8-year-old girl is rushed to the emergency department by her parents because she has become delirious. The child was diagnosed with influenza three days prior. Her parents say that she had begun vomiting yesterday, almost nonstop, and has not been able to hold down fluids. They also note that she has been breathing rapidly. Your exam reveals a tachypneic, disoriented female with hyperreflexia, a positive babinski reflex, and liver enlargement. CSF analysis reveals a normal protein and cell count. What is the most likely diagnosis? A Bacterial meningitis B Guillain Barre syndrome C Measles encephalitis D Reye's syndrome E Viral meningitis

The Correct Answer is: D *Although rare, Reye's syndrome is associated with viral infections, salicylate use during illness, and metabolic disorders. Illness is associated with liver fat deposition and degeneration, intractable vomiting, and mental status changes, which may progress to seizures, delirium, and coma. Cerebral edema contributes to these changes and other neurologic findings.* Meningeal signs are more consistent with meningitis. Measles encephalitis typically presents days to weeks after the pathognomic measles exanthem and clinical findings. Guillain Barre has been associated with influenza infection, and signs and symptoms would include evolving weakness with ascending paralysis and extremity dysesthesias.

Q 45.2: A 3-month-old infant had a mild microcytic, hypochromic anemia at birth and the screen was negative for sickle cell disease/trait. She was started on iron therapy and presents today for follow up. The hemoglobin (Hgb) electrophoresis laboratory results are: Hemoglobin 8.8 mg/dL (normal: 10.5-14.0) Hematocrit 25% (normal: 33-42) Mean corpuscular volume (MCV) 60 fL (normal: 70-90) Mean corpuscularhemoglobin concentration (MCHC) 32 g/dL (normal: 33-37) Hgb A 2 27% (normal: 1.5%-4%); Hgb A 1 30% (normal: 76%-99%); HgF (fetal hemoglobin) 50% (normal: 0%-20%); Bart Hgb 0% (normal: 0%) Which of the following is the MOST likely diagnosis? A heterozygous alpha thalassemia B homozygous alpha thalassemia C beta thalassemia major D beta thalassemia minor

The Correct Answer is: D *The typical hemoglobin electrophoresis for beta thalassemia minor has an elevated level of hemoglobin A2. In a normal infant there is mainly HgF and HgA 1 with minimal amounts of A2.* Bart hemoglobin is diagnostic for the alpha thalassemias after the neonatal period is over. Beta thalassemia major will only have fetal hemoglobin on electrophoresis. Because of the high incidence of false-negatives in hemoglobin screenings in the neonatal period, it is important for the provider to do a full work-up of microcytic, hypochromic anemias to ensure proper diagnosis.

Q 35.3: A 12 year old male presents with lesions on the palmar surface. They have been present for less than a week. Prior to the lesion appearing there was a small lesion that was assumed to be a bug bite. The lesion bleeds profusely with minimal provocation. What is the most likely diagnosis? A Glomus tumor B Hemangioma C Spider Angioma D Pyogenic granuloma

The Correct Answer is: D A pyogenic granuloma (PG) occurs at the site of minor trauma such as a bug bite or scratch. The PG grows rapidly forming a popular lesion with a collarette of scale. It will bleed profusely with minimal provocation. The only effective treatment is shave excision with curetting and ablation of the blood vessels that form the base of the PG.

Q 41.2: Which of the following indicates a poor prognosis for someone diagnosed with schizophrenia? A acute onset B co-morbid mood disorder C obvious precipitating event D younger age at diagnosis

The Correct Answer is: D A younger age of onset/diagnosis along with an insidious onset, social isolation, family history of schizophrenia, and negative symptoms (affective flattening, alogia, apathy, anhedonia) all portend a poor prognosis. To the contrary, acute onset, late diagnosis, positive symptoms (hallucinations, delusions, disordered thought processes, etc.), and a concomitant mood disorder actually lend to a better prognosis.

Q 43.4: A 4-year-old child swallows several tablets of a medication that he found in his parent's bathroom cabinet underneath the sink. Approximately 2 to 3 hours after ingesting the tablets, there were no symptoms other than nausea and vomiting. Thirty hours after ingesting the tablets, elevated aminotransferase levels were detected followed by jaundice, hepatic encephalopathy, renal failure, and death. What did the child most likely swallow? A diazepam B aspirin C oxycodone D acetaminophen E phenobarbital

The Correct Answer is: D Acetaminophen toxicity may result from a single toxic dose, from repeated ingestion of large doses of acetaminophen (eg, 7.5 to 10 g daily for 1 to 2 days), or from chronic ingestion of the drug. Dose-dependent hepatic necrosis is the most serious acute toxic effect associated with overdose and is potentially fatal. Acetaminophen is the second most common cause of liver failure requiring transplantation in the United States.

Q 46.3: A 9-year-old male child presents with a painful rash of his upper extremity. His mom states it started 4 days ago and seems like it is spreading. Physical examination demonstrates a vesicular rash across the right upper arm and chest but does not cross the midline. Which of the following prescriptions would be most appropriate for this patient at today's visit? A hydration B nonsteroidal anti-inflammatory drugs (NSAIDs) C Varicella-Zoster immunoglobulin (VZIG) D oral acyclovir

The Correct Answer is: D As this patient is presenting with signs and symptoms of herpes zoster within the appropriate time frame for antiviral treatment, the treatment for this patient would be oral acyclovir. NSAIDs may help with the pain associated from zoster but will not hasten the length of the course of the virus as acyclovir will. Varicella-Zoster immunoglobulin (VZIG) is indicated for prophylaxis in exposed individuals who are immunocompromised

Q 50.2: A 9-year-old male child presents with a painful rash of his upper extremity. His mom states it started 4 days ago and seems like it is spreading. Physical examination demonstrates a vesicular rash across the right upper arm and chest but does not cross the midline. Which of the following prescriptions would be most appropriate for this patient at today's visit? A hydration B nonsteroidal anti-inflammatory drugs (NSAIDs) C Varicella-Zoster immunoglobulin (VZIG) D oral acyclovir

The Correct Answer is: D As this patient is presenting with signs and symptoms of herpes zoster within the appropriate time frame for antiviral treatment, the treatment for this patient would be oral acyclovir. NSAIDs may help with the pain associated from zoster but will not hasten the length of the course of the virus as acyclovir will. Varicella-Zoster immunoglobulin (VZIG) is indicated for prophylaxis in exposed individuals who are immunocompromised.

Q 48.1: A premature infant is born with the inability to produce adequate amounts of pulmonary surfactant. Which of the following is the primary function of pulmonary surfactant? A increase the solubility of carbon dioxide in the alveoli B increase the solubility of oxygen in the alveoli C prevent infectious organisms from infiltrating the alveoli D prevent the collapse of small lung alveoli E stimulate the unloading of carbon dioxide from hemoglobin

The Correct Answer is: D Because of their small size, many lung alveoli are prone to collapse. Pulmonary surfactant contains a high concentration of amphipathic phospholipid molecules, which lowers the surface tension of alveoli. According to the law of Laplace, a reduction of surface tension reduces the collapsing pressure on small alveoli and allows them to remain open. Pulmonary surfactant production does not typically begin until the 24th week of gestation; hence, an infant born before this time is at great risk for having collapsed alveoli.

Q 44.13: An extremely heavy 12-year-old girl comes to the practice with her grandmother for new patient evaluation, bringing old records with her. Her blood pressure today is mildly elevated. Which of the following parameters will help determine whether her overweight and elevated blood pressure are due to Cushing syndrome (adrenocortical hyperfunction) rather than exogenous obesity? A advanced skeletal maturity B heavy thighs and legs C pinkish striae D short stature E slightly increased growth rate

The Correct Answer is: D Children with Cushing syndrome typically have short stature, while those who are obese due to exogenous factors have normal or tall stature. Likewise, they tend to have delayed skeletal maturity (A), truncal obesity with thin extremities (B), purplish striae (C), and a slowed growth rate (E), while obese children have advanced maturation, heavy extremities, pinkish striae, and an increased growth rate.

Q 48.3: An 8-year-old girl is brought in to the emergency department with abdominal cramps, nausea, and vomiting since early this morning. She has had two loose stools but denies melena or hematochezia. She has had a low-grade fever. In the past hour, her vision has become blurry and she feels increasingly weak. Her mother has had similar but milder symptoms. Twenty-four hour dietary recall includes only chicken broth today. Last night for dinner they had meatloaf (fully cooked), mashed potatoes, and green beans. Her mother cans all their vegetables. Her medical history is unremarkable. She takes no medications. No known drug allergies. Examination reveals a temperature of 99°F, clear lungs, and mildly tachycardic heart with no murmur audible. Abdomen-bowel sounds present, soft with mild diffuse tenderness, no guarding. Neurologic examination is significant for decreased visual acuity and decreased motor strength (2/5) in the upper and lower extremities. The most likely etiology is A enterotoxic E coli B cholera species C pinworms D Clostridium botulinum

The Correct Answer is: D Clostridium botulinum produces a neurotoxin that can lead to life-threatening illness including respiratory paralysis. Botulism infection is caused by the spore-forming bacteria that lives in soil and can be foodborne. In the latter case, home-canned foods are often the cause. After a 12-hour to 3-day incubation period, botulism begins with classic symptoms of abdominal pain, nausea, vomiting, and mild diarrhea and, if unchecked, evolves into a progressive neurologic disorder marked by double vision, motor weakness, and ptosis. Respiratory muscle involvement may occur ultimately and result in death. Because of the virulence of the neurotoxin it has been used as an agent of bioterrorism. Cholera and enterotoxigenic E. coli cause a foodborne diarrheal illness that can result in significant morbidity and mortality, but they do not have neurologic manifestations. Pinworm infection is usually found among younger children, is marked by severe anal itching, and fecal-oral transmission.

Q 49.6: A 12-year-old boy presents to the urgent care center complaining of burning pain in his lower extremities with weakness. On examination, the clinician notes symmetric weakness with severely decreased active range of motion of the lower extremities. In addition, there is decreased position and vibratory sensation in the distal portions bilaterally. Upon further questioning, the patient admits to being diagnosed with mononucleosis 2 weeks ago. Which of the following is the most likely diagnosis? A poliomyelitis B botulism C Tick-bite paralysis D Guillain-Barré syndrome

The Correct Answer is: D Guillain-Barré syndrome is most likely due to a delayed hypersensitivity with T-cell-mediated antibodies to mycoplasma and viral infections (CMV, EBV, hepatitis B, campylobacter jejuni). The patients may mention a nonspecific respiratory or gastrointestinal infection 1 to 2 weeks prior to symptoms. Complaints may be paresthesias, weakness in bilateral lower extremities with occasional ascension into the arms, trunk, and face, and rarely ataxia and ophthalmoplegia in the Miller-Fisher variant. Examination findings demonstrate symmetric flaccid weakness, with impairment of position, vibration, and touch in the distal portions of the extremities. If a spinal tap is performed, it may show few polymorphonuclear neutrophils with high protein and normal glucose. EMG is positive for decreased nerve conduction. Laboratory tests may show high titers of suspected infections or active infection of hepatitis/bacterial pathogens. Guillain-Barré is normally a self-limiting disorder within a few weeks, unless there are issues with respiratory depression. Poliomyelitis is secondary to polioviruses and presents with fever, paralysis, meningeal signs, and asymmetrical weakness. Botulism secondary to infection with Clostridium botulinum in older children presents with blurred vision, diplopia, ptosis, choking, and weakness. In infants, botulism presents as constipation, poor suck and cry, apnea, lethargy, and choking. Tick-bite paralysis presents with rapid onset with ascending flaccid paralysis reaching upper extremities in a couple of days of onset and patients often present with paresthesia and pain. Finding of a tick is usually confirmatory for these patients.

Q 47.12: What is the appropriate first line treatment of lyme disease in a non-pregnant adult female with erythema migrans and no other symptoms of lyme disease and no known drug allergies? A Erythromycin 150 mg qid B Ceftriaxone 1g IM C Amoxicillin 500 mg q 8 hours D Doxycycline 100 mg bid

The Correct Answer is: D In patients over the age of 9 exhibiting skin or joint manifestations of lyme disease, the first line treatment is Doxycycline 100 mg bid. Patients less than 9 or those who are allergic to Doxycycline should be treated with amoxicillin. Erythromycin is fourth line treatment for all age groups. Ceftriaxone is first line for patients with nervous system involvement.

Q 43.3: A 2-year-old baby girl is brought to the ED with a history of abdominal pain and diarrhea. Mother states that the child was playing normally and then "doubled over" with what appears to be abdominal pain. The abdomen appears slightly distended and is tender to palpation. While in the ED the child has a bloody, diarrheal bowel movement. Which of the following is the most likely diagnosis? A pyloric stenosis B mesenteric ischemia C Crohn disease D intussusception E Hirschsprung disease

The Correct Answer is: D Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. The patient develops paroxysms of pain followed by bloody bowel movements. Pyloric stenosis typically presents prior to the age of 6 months with vomiting but not with diarrhea. Hirschsprung disease results from an absence of ganglion cells in the colon and typically presents early in life with failure to pass meconium, followed by vomiting and abdominal distension. The typical age of onset is later in adolescence in Crohn disease and in the elderly in mesenteric ischemia.

Q 43.1: A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What laboratory finding is most consistent with the suspected diagnosis? A Decreased hematocrit B Elevated amylase C Hyperkalemia D Hypochloremic alkalosis E Hyponatremia

The Correct Answer is: D Laboratory findings that are consistent with the suspected diagnosis of pyloric stenosis include hypochloremic alkalosis with potassium depletion. An elevated hemoglobin and hematocrit can also be present, and are due to dehydration. Changes in amylase or serum sodium are not present in cases of pyloric stenosis.

Q 38.8: A 6-year-old female child presents with complaints of chronic hip pain so severe that she has not been able to walk to the school bus. Examination shows severe tenderness at the left hip with markedly decreased active and passive range of motion. Radiologic examination demonstrates joint effusion with widening. Which of the following is the most likely diagnosis? A osteochondritis dissecans B slipped capital femoral epiphysis C septic hip arthritis D Legg-Calvé-Perthes disease

The Correct Answer is: D Legg-Calvé-Perthes disease is also known as avascular necrosis of the proximal femur. It typically occurs in children between 4 and 8 years old and persistent hip pain is the main symptom. On examination, the clinician notices a limp and/or limitation of motion of the affected hip. Radiologic examination demonstrates the necrosis with effusion and joint space widening with a negative aspirate. Treatment involves surgical hip replacement. Slipped capital femoral epiphysis (SCFE) is due to the displacement of the proximal femoral epiphysis owing to disruption of the growth plate. The head is normally displaced medially and posteriorly relative to the femoral neck. It typically occurs in adolescence, specifically obese males, and can also be associated with hypothyroidism. SCFE usually occurs after direct trauma to the hip or a fall. Patients complain of vague symptoms at first that progress into pain of the hip or of the knee. On examination, there is decreased internal rotation of the hip that can be confirmed by lateral X-ray of the hip. Septic hip arthritis is not common in children between the age of 5 and 12 years. The legs are held in external rotation to minimize pain and will have a positive aspirate. Osteochondritis dissecans typically presents in the knee, elbow, and talus and is characterized by a wedge-shaped necrosis of bone.

Q 46.7: Upon performing a newborn examination, the clinician notes a widened pulse pressure, paradoxical splitting of S 2 , and a "machine"-like murmur heard best at the second intercostal space, left sternal border, and inferior to the clavicle. Which of the following is the most likely diagnosis? A tetralogy of Fallot B ventricular septal defect C atrial septal defect D patent ductus arteriosus

The Correct Answer is: D Patent ductus arteriosus (PDA) is an isolated abnormality that occurs in infants. The ductus arteriosus is a normal fetal vessel that joins the aorta and the pulmonary artery and spontaneously closes after 3 to 5 days. Lack of closure results in the audible murmur that is "machine-like" and maximal at the second intercostal space (ICS), at the left sternal border (LSB), and inferior to the clavicle. It is typically a pansystolic murmur with bounding pulses and a widened pulse pressure. There is also a paradoxical splitting of S 1 and S 2 . Echocardiography confirms the PDA, the direction and degree of shunting, and the presence of lesions for which the PDA is needed to keep. If there are no other cardiac malformations requiring the PDA, then if the PDA is large, surgery should be completed before 1 year of age. Symptomatic PDAs that are relatively small may be closed with indomethacin in preterm infants. The murmur heard in atrial septal defect (ASD) usually is an ejection type, systolic murmur heard best at the LSB, second ICS with a wide, fixed S 2 and normal pulses. Ventricular septal defect (VSD) presents with a harsh, pansystolic murmur heard best at the third and fourth ICS. With increasing size of the VSD, heaves, thrills, and lifts are present along with radiation throughout the chest. Tetralogy of Fallot presents with a rough ejection, systolic murmur heard best at the LSB and the third ICS with radiation to the back.

Q 39.1: A mother presents with a 10-year-old female with a complaint of thinning hair. On physical exam there are no areas of alopecia, broken hairs, scaling, or erythema. A hair pull produces 12 to 14 hairs. Examination under microscopy indicates that the follicles are intact and normal in appearance. What is the most likely diagnosis? A Tinea capitus B Anagen dysplasia C Alopecia areata D Telogen effluvium

The Correct Answer is: D Telogen effluvium is a condition of hair thinning that can occur at any age. It is a reaction to a physical or mental stressor. A normal scalp has 10 percent to 15 percent of hairs in the telogen phase at any time, resulting in a normal shedding of 50 to 100 hairs per day. Increased shedding of hairs occurs in telogen effluvium. This results in more hairs being shifted into the telogen phase more quickly. A hair pull with microscopy is the diagnostic test that will indicate an increase in hairs in the telogen phase.

Q 49.1: Which of the following is a common adverse effect associated with the use of stimulants such as methylphenidate for attention-deficit hyperactivity disorder (ADHD)? A diarrhea B hypoglycemia C hypotension D paresthesias E reduced appetite

The Correct Answer is: E Stimulants (eg, amphetamines, methyl-phenidate) are considered first-line therapy in the majority of cases of ADHD. Both amphetamines and methylphenidate block dopamine and norepinephrine reuptake, while amphetamines also stimulate norepinephrine release. Elevated levels of CNS norepinephrine have been associated with an anorexigenic effect, leading to reduce caloric intake.

Q 41.1: The mother of a four-month-old brings her son in for evaluation of cyanosis. The mother noted the cyanosis in the last two days, and it is most evident when he is feeding or crying. He was previously healthy with no medical problems. On physical examination, a grade III/VI systolic ejection murmur is present at the left sternal border in the third intercostal space, and radiates to the back. What is the most likely diagnosis? A Atrial septal defect B Patent ductus arteriosus C Mitral valve prolapse D Tetralogy of fallot E Transposition of the great arteries

The Correct Answer is: D Tetralogy of fallot is the correct answer. The epsiodes of cyanosis described by the mother represent "tet spells." Atrial septal defect is incorrect, as it is not associated with cyanosis; while the murmur may be located at the left sternal border, it is most often heard in the second intercostal space and is associated with a widely split S2. Patent ductus arteriosus (PDA) is incorrect, as this does not lead to cyanosis, and the description of this murmur is classically described as a rough machinery systolic murmur. PDA murmur may radiate to the anterior lung fields, but does not radiate well to the posterior lung fields. Mitral valve prolapse is incorrect, as it is not associated with cyanosis and the murmur is described as a systolic click. Transposition of the great arteries is incorrect, as there is typically no significant murmur present and they present as neonates with profound cyanosis.

Q 47.9: A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following is the most likely diagnosis? A Asthma B Bronchiectasis C Epiglottitis D Foreign body aspiration E Vocal cord dysfunction

The Correct Answer is: D The acute onset of symptoms and their localization to the right lower lobe are consistent with foreign body aspiration (D). Asthma (A) presents with diffuse wheezing. Bronchiectasis is less common in this age group and typically presents with a copious amount of sputum production. Epiglottis (C) and vocal cord dysfunction (E) present with upper airway symptoms.

Q 39.21: An 18 month old female is brought to the pediatricians office with a history of cough, fever of 102, and decreased fluid intake. Her immunizations are not up to date as the family just moved to the United States from out of the country. On physical exam she is drooling and sitting up in a "tripod position" with mild stridor. What is the most appropriate treatment indicated for this condition? A Humidified air B Albuterol nebulizer C Budesonide nebulizer D Recemic epinephrine nebulizer E Ipratropium nebulizer

The Correct Answer is: D The clinical presentation suggests epiglotitis. This is an emergent airway condition. The anesthesiologist , or the pediatric otolaryngologist must be called to stand by to intubate or insert a tracheostomy if the patients airway closes. Racemic epinephrine via nebulizer relieves much of the edema to the upper airway in a patient with epiglotitis. It is a stabilizing measure until definitive care can be arranged. Oxygen and antibiotics should administered emergently also. No x-rays are indicated when the presentation is classic. Albuterol is a beta-agonist used for treatment of asthma. Budesonide,a steroid and ipratropium, an anticholinergic agent are most often used in combination with albuterol for treatment emphysema and asthma.

Q 39.12: A 12-month-old female presents with bilateral lichenification, scaling, and excoriations in the antecubital fossae and popliteal fossae. Which of the following should treatment include? A clotrimazole/betamethasone diproprionate cream bid to affected areas B topical ketoconazole cream bid-tid to affected areas and po hydroxyzine C petroleum jelly bid-tid to affected areas and po augmentin D triamcinolone 0.1% ointment bid to affected areas and po hydroxyzine

The Correct Answer is: D The first line treatment for atopic dermatitis is a topical steroid, such as triamcinolone ointment. Oral hydroxyzine is an antihistamine that is used to control pruritis in atopic dermatitis. Clotrimazole/betamethasone diproprionate cream is a combination antifungal and topical steroid. There are no clinical indications for this medication. An antifungal such as ketoconazole is not indicated. The oral hydroxyzine is an antihistamine that is used to help control pruritis. Petroleum jelly is an excellent emollient; however, augmentin is not indicated unless there is a secondary infection. No infection is present in this patient.

Q 49.11: Which of the following is the first sign of puberty in a normal male? A appearance of axillary hair B appearance of pubic hair C deepening of the voice D enlargement of the testes

The Correct Answer is: D The first sign of pubertal development in boys is the enlargement of testicular size and occurs at the mean age of 11.6 years. Genital stages accelerate before pubic hair development, which occurs, on average, at 13.4 years of age. The deepening of the voice and the development of chest and axillary hair usually occurs in midpuberty or 2 years after the growth of pubic hair.

Q 46.2: A 12-year-old female presents with a cough, fever, and severe right ear pain for two days. Her mother states that she was crying last evening with severe pain, but then she seemed to rapidly improve. There was some bloody drainage in the ear canal. The child is currently swimming for her middle school swim team. Other children on the team have been ill also. Her temperature is 101˚F. During physical exam, you notice the following finding. What is the diagnosis? A Otitis externa B Suppurative otitis media C Bullous myringitis D Otitis media with perforation E Otorrhea

The Correct Answer is: D The image shows an erythemic tympanic membrane with a perforation. Otitis externa won't have tympanic membrane involvement, and will have tragal tenderness upon palpation. Bullous myringitis is often caused by mycoplasma, and shows multiple bubbles or blisters on the TM.

Q 40.5: A 5-year-old male child presents to the office for his kindergarten physical examination. Assuming that the patient's immunizations have been up to date, which of the following are the immunizations that the patient should receive at the end of today's visit? A hepatitis B, inactivated poliovirus (IPV), diphtheria, tetanus, acellular pertussis (DTaP), measles, mumps, rubella (MMR), varicella B IPV, DTaP, MMR, pneumococcal (PCV) C IPV, DTaP, MMR, Haemophilus influenzae type B (Hib) D DTaP, IPV, MMR, varicella

The Correct Answer is: D The immunization schedule is developed biannually by the Centers for Disease Control and Prevention. Assuming that the child has had the appropriate immunizations at the regularly scheduled examinations, the recommended immunizations at the 4- to 6-year-old range are the DTaP (diphtheria, tetanus, acellular pertussis), IPV (inactivated polio), and the MMR (measles, mumps, and rubella). The hepatitis series should have been completed by the age of 6 months and the Haemophilus influenzae type B (Hib) should be completed by the age of 12 to 15 months. Varicella is given from 12 to 18 months and again from 4 to 6 years; the PCV (pneumococcal) should be finished by 12 to 15 months.

Q 34.10: A 12-year-old girl presents with complaints of intermittent pain and stiffness involving her hands. This pain has been progressively worsening over the past 3 years. She relates that for the past 2 months she has been feeling increasingly tired and has experienced swelling and stiffness of her hands, which appears worse in the morning and is relieved as the day progresses. The physical examination shows she has a low-grade fever. There are multiple symmetrical joint swelling of the proximal interphalangeal and metacarpophalangeal joints with associated warmth, tenderness, and effusion. Initial laboratory findings include a CBC that reveals mild anemia, an elevated erythrocyte sedimentation rate, a positive rheumatoid factor, and a negative antinuclear antibody (ANA) test. X-rays of the hands and wrists show soft tissue swelling and periarticular osteopenia. Which of the following is the most likely diagnosis? A reactive arthritis B infectious arthritis C systemic juvenile rheumatoid arthritis D polyarticular juvenile rheumatoid arthritis E pauciarticular juvenile rheumatoid arthritis

The Correct Answer is: D The most likely diagnosis in this patient is polyarticular juvenile rheumatoid arthritis (JRA). This form of JRA is seen in approximately 35% of patients with JRA. It is characterized by symmetrical involvement of five or more joints. Two subsets of the disease exist that are distinguished by the presence or absence of rheumatoid factor. A positive rheumatoid factor is most commonly seen in girls with later disease onset (at least 8 years old). An antinuclear antibody (ANA) test may be positive but is more likely to be positive with the pauciarticular form. In the early stage of the disease, the x-ray may be normal or show soft tissue swelling and periarticular osteopenia. In addition to the positive ANA of pauciarticular JRA patients, the arthritis must be present in four or fewer joints. Early onset disease is commonly seen in girls aged 1 to 5 years and has a positive ANA; up to 30% of patients will also have eye involvement. Late onset disease is more common in male patients, with involvement of the large joints. Systemic JRA, also known as "Still disease," is seen in about 10% to 15% of children with JRA. It is characterized by daily intermittent fever spikes and a transient, nonpruritic, pale pink, blanching macular, or maculopapular rash found on the trunk. A positive rheumatoid factor is rare in this form of JRA. Reactive arthritis is usually associated with a recent viral or bacterial infection. Infectious arthritis more commonly presents as monarticular and is usually acute in onset.

Q 47.7: A 2-month-old female presents for a well child check. The mother has no concerns and feels that the child is doing well. On exam, there is no evidence of cyanosis and the peripheral pulses are normal and equal. However, there is a fixed and widely split S2, a right ventricular heave, and a systolic ejection murmur present. The murmur is heard best at the left sternal border second intercostal space. What is the most common abnormality present on an ECG? A Atrioventricular heart block B Atrial fibrillation C Bifasicular block D Right axis deviation E Supraventricular tachycardia

The Correct Answer is: D The most likely diagnosis is an atrial septal defect, which usually shows right axis deviation on ECG. The other ECG abnormalities listed do not commonly occur with an atrial septal defect.

Q 39.4: A 16-year-old boy is seen for a sports physical prior to starting football. On auscultation, a grade II/IV holosystolic murmur is appreciated at the apex. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the axilla. With the Valsalva maneuver, the murmur decreases in intensity. Given the patient's physical exam findings, which of the following is the most likely diagnosis? A Aortic stenosis B Aortic regurgitation/insufficiency C Mitral stenosis D Mitral regurgitation/insufficency E Tricuspid regurgitation

The Correct Answer is: D The murmur of mitral regurgitation can be described as a holosystolic murmur, usually heard best at the apex, so choice D is the most appropriate answer. Isometric hand grip exercises increase the intensity of the murmur of mitral regurgitation by increasing arterial and left ventricular pressure, which increases the flow across the mitral valve, thereby increasing the murmur's intensity. The murmur of mitral regurgitation is heard best at the apex. Radiation, if it occurs, is frequently to the axilla. Choice A is incorrect, as the murmur of aortic stenosis is usually described as a crescendo-decrescendo or systolic ejection murmur that is heard best at the right upper sternal border. Choice B is incorrect as the murmur of aortic regurgitation is usually described as a high-frequency decrescendo early diastolic murmur that is heard best at the left upper sternal border or at the right upper sternal border. Choice C is incorrect, as the murmur of mitral stenosis is described as a low-frequency rumbling diastolic murmur that is decrescendo in early diastole, but may become crescendo up to the first heart sound with moderately severe mitral stenosis and sinus rhythm. Choice E is incorrect, as the murmur of tricuspid regurgitation is described as a holosystolic descrescendo murmur.

Q 49.5: A two-week-old female is being evaluated in the clinic, and on examination she is noted to have bounding pulses with a widened pulse pressure. There is a rough, machinery sounding murmur present at the second left intercostal space. Cyanosis is not present. Which of the following diagnostic tests would be the most useful in confirming the suspected diagnosis in this patient? A Cardiac catheterization B Chest x-ray C ECG D Echocardiography E Nuclear stress test

The Correct Answer is: D The suspected diagnosis is a patent ductus arteriosus. The most useful test in confirming the diagnosis is echocardiography. This test provides direct visualization, and confirms the direction and degree of shunting. Cardiac catheterization is not required for diagnosis, but the catheterization lab is used to perform the surgical procedure to close the patent ductus arteriosus. A chest x-ray may be normal in cases of a small shunt. ECG may also be normal if the size of the shunt is small. A nuclear stress test is not used in evaluation of a patent ductus arteriosus.

Q 37.2: A 5-year-old boy presents with a tense, fluid filled blister on his fingertip. What organism is most likely to be found when the lesion is cultured? A Herpes simplex virus B Parvovirus B19 C Pseudomonas aeruginosa D Staphylococcus aureus

The Correct Answer is: D This child has blistering distal dactylitis. This is a form of impetigo, and is caused by either streptococcus pyogenes or staphylococcus aureus.

Q 39.3: A 2-year-old girl has developed a "barking" cough and a low-grade fever. She has some runny nose and her voice is somewhat raspy and hoarse. When approached by the PA, she becomes somewhat upset and exhibits mild inspiratory stridor. She appears otherwise well and has no drooling or dyspnea. What is the most likely etiology of this child's illness? A Adenovirus B Coxsackievirus C Cytomegalovirus D Parainfluenza virus E Respiratory syncytial virus

The Correct Answer is: D This child has the classic presentation for croup. Sixty-five percent of croup is caused by a parinfluenza virus infection. Adenoviruses tend to cause severe pharyngitis/tonsillitis with tender, enlarged cervical nodes (A), while Coxsackievirus is commonly associated with hand-foot-and-mouth disease. (B) Cytomegalovirus causes an infectious-mononucleosis-like picture. (C) RSV is more typically associated with bronchiolitis. (E)

Q 46.8: An 8-year-old female presents with numerous discrete, skin colored papules with a central umbilication. The lesions are mildly pruritic. What is the most likely diagnosis? A herpes simplex virus B varicella zoster virus C comedonal acne D molluscum contagiosum

The Correct Answer is: D This is classic presentation of Molluscum contagiosum. Molluscum primarily affects younger children, from infancy through elementary age. Lesions appear as pearly, skin colored papules with a central umbilication. They can be pruritic. Herpes simplex virus is described as a vesicle that crusts after a few days. Neurogenic pain is associated with the outbreak. The varicella zoster virus is chicken pox. These lesions are described as "a dew drop on a rose petal," due to the characteristic vesicle on a red base. They occur in crops, with some being vesicular and some being crusted. There is no umbilication. Comedonal acne primarily affects teens. These lesions are located on the face, back, and chest.

Q 39.11: The parents of a four-month-old child present with concern regarding a birthmark on the child's scalp and left side of face. The lesion has been present since birth and is growing. It has an orange, pebbly appearance. What is the appropriate treatment? A CT scan with contrast to rule out underlying brain malformation B laser therapy C no treatment, as the lesion will spontaneously resolve D excision prior to puberty due to increased risk of basal cell carcinoma

The Correct Answer is: D This lesion is consistent with a nevus sebaceous. It will grow as the child grows. After puberty, the lesion becomes thicker with a warty appearance. There is a slight increase in incidence of basal cell carcinoma as the patient ages. It is recommended that the lesion be excised prior to puberty, when these changes occur in response to hormone secretion. It is confined entirely to the skin; therefore, a CT is not necessary. Laser therapy is not an effective treatment for a nevus sebaceous. It requires complete excision. It also has an increased risk of basal cell carcinoma. It will not spontaneously resolve.

Q 37.8: A six-month-old male has recurrent diaper rashes, which are not responding to ketoconazole cream or zinc oxide diaper creams. Physical exam shows well demarcated perianal erythema, with scattered red papules on the buttocks. A KOH is negative. What would appropriate management include? A hydrocortisone 2.5% ointment bid x 2 weeks B tretinoin 0.25% cream bid x 2 weeks C lotrisone cream bid until resolved D topical mupirocin bid until resolved

The Correct Answer is: D This rash is consistent with a perianal staph or strep infection. This bacterial infection is easily treated with topical mupirocin. If the rash does not resolve after two weeks of topical treatment, treatment with an oral antibiotic such as Keflex is usually successful. Treatment with a topical steroid may worsen the infection. Tretinoin is a topical retinoid indicated to treat acne, and is not appropriate for this patient. Lotrisone is a combination medication that includes an antifungal and a topical steroid, neither of which is indicated in this patient.

Q 47.11: A 6-year-old child with leukemia presents with a very painful vesicular rash as seen in Figure 8-2. This is the only dermatologic manifestation but is accompanied by fever and malaise. His medical history is significant for the leukemia, tonsillectomy, and adenoidectomy at age 3 and chicken pox 4 months later. He has had all his other childhood immunizations. The most likely diagnosis in this case is A measles B roseola C recurrent chicken pox D zoster E molluscum contagiosum

The Correct Answer is: D Varicella zoster outbreak (shingles) most often occurs in an elderly patient years after experiencing chicken pox as a child or who have received the immunization. The virus lies dormant in the spinal nerve root and later manifests as a very painful, skin-sensitive vesicular rash in a dermatomal distribution. Unlike chicken pox, a postherpetic neuralgia pain can persist for years and is at times, debilitating. Although most common in the elderly, zoster can occur in children in immunocompromised states such as those with malignancy or human immunodeficiency virus infection. Molluscum contagiosum presents with flesh colored, umbilicated papules and is typically not painful. Measles and roseola are maculopapular rashes.

Q 46.10: What is the most common pathogen in pediatric bronchiolitis? A Mycoplasma B Chlamydia C Parainfluenza D Respiratory syncytial virus (RSV) E Streptococcus

The Correct Answer is: D Viruses are by far the most common reasons for bronchiolitis to occur. RSV is the clear leader in causative agents.

Q 40.1: A 12-year-old presents with sharply demarcated depigmented macules on bilateral knees. The parents report that this began about one year ago, after the child fell and skinned his knees. After healing, he was left with these markings. What is the most likely diagnosis? A post inflammatory hypopigmentation B hypertrophic scar C pityriasis alba D vitiligo

The Correct Answer is: D Vitiligo is the most likely diagnosis. Vitiligo is an autoimmune disorder that affects the melanocytes. There is often a history of trauma that can precede an occurrence of vitiligo. The course for vitiligo is variable. Sometimes it will resolve spontaneously. Other times, it will continue to progress despite treatment. Post-inflammatory hypopigmentation are areas of lighter pigment, not complete depigmentation, which result from a resolved inflammatory process. The pigment will return over time. A hypertrophic scar is one which is enlarged but stays within the borders of the original injury. No pigment changes are associated with these scars. Pityriasis alba is a yeast infection of the skin, and usually appears on the face. It usually occurs in elementary school aged children, and is more apparent in late summer or early fall.

Q 44.11: A 12-year-old male exhibits prominent brown scaling on his neck, trunk, and extremities with involvement of flexural regions. The palms and soles are spared. What is the most likely diagnosis? A Epidermolysis bullosa simplex B Extensive keratosis pilaris C Lamellar ichthyosis D X-linked ichthyosis

The Correct Answer is: D X-linked ichthyosis is a recessive condition affecting males. The patient will have large scales that appear brown in color. This condition spares the palms and soles, and begins between the ages of two to six weeks.

Q 41.3: A 3-year-old male is brought to your office with a red, tearing right eye. The mother stated that the child was playing in another room with his 4-year-old brother. All she heard was the child beginning to cry. Upon physical exam, the child is intermittently crying, and his right eye is red and tearing. The child is continually rubbing the eye. The anterior chamber is clear and the pupil is equal and reactive. What is your next step in evaluating this patient? A Contact child protective services B Order a head CT scan C Perform a tonometry D Obtain a visual acuity E Perform a fluorescein stain

The Correct Answer is: E A corneal abrasion must be ruled out in a child with a red eye.

Q 39.16: A 4-year-old girl is brought to urgent care complaining of left ear fullness and difficulty hearing. The parents express concern that she put an elbow macaroni noodle into her ear. This concern is confirmed on otoscopic evaluation of the ear. Which of the following steps is most appropriate for removing this foreign body? A Administer general anesthesia B Anesthetize the ear canal with lidocaine solution C Irrigate the ear with warm water D Irrigate the ear with a hydrogen peroxide solution E Remove the noodle with a loop

The Correct Answer is: E A loop (E) or alternative instrument should be used to pull the noodle outward and away from the tympanic membrane. Organic material may swell when wet, and irrigation (C and D) or the insertion of anesthetic solution (B) is not recommended.

Q 49.15: A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. Appropriate imaging is obtained and confirms the suspected diagnosis. What is the treatment of choice in this patient? A Acid supression B Dilatation of the lower esophageal sphincter C Diverting colostomy D Ladd procedure E Pyloromyotomy

The Correct Answer is: E A pyloromyotomy involves an incision along the length of the pylorus, down to the mucosa, and is the treatment of choice in pyloric stenosis. Acid suppression is the treatment of choice in cases of peptic ulcer disease. Dilatation of the LES is performed in cases of achalasia of the esophagus. A diverting colostomy may be used in cases of Hirschsprung disease, after removal of the aganglionic section of colon. The Ladd procedure is used in surgical treatment of intestinal malrotation.

Q 39.7: What is the most common clinical cardiac abnormality that is associated with acute rheumatic heart disease? A Hypotension B Arrhythmia C Ischemia D Ventricular aneurysm E Carditis

The Correct Answer is: E Carditis is the most common finding in rheumatic heart disease. This can present with the sequelae of pericarditis, cardiomegaly, heart failure (either right or left sided), and either a mitral or aortic murmur.

Q 49.2: A 16-year-old boy is seen for a sports physical prior to starting football. He denies any symptoms. His physical examination is normal, except for a grade II/VI holosystolic murmur auscultated at the cardiac apex. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the axilla. With the Valsalva maneuver, the murmur decreases in intensity. Given the patient's physical exam findings, which of the following is the most appropriate next diagnostic study? A Chest x-ray B Transesophageal echocardiogram C Holter monitor D Treadmill exercise stress test E Transthoracic echocardiogram

The Correct Answer is: E Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool that can evaluate for the presence of valvulopathy or congenital heart disease in this young patient. Choice A might be able to give evidence of cardiomegaly, but would not be sensitive enough to detect valvulopathy. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient who has no symptoms. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate for valvulopathy.

Q 40.3: A 3-year-old girl presents to the otolaryngologist for evaluation of a persistent left ear infection and drainage that have failed to respond to multiple antibiotic regimens. Which of the following is the most likely causative organism for this patient's condition? A Aspergillus B Chlamydia pneumoniae C E. coli D Streptococcus pneumoniae E Staphylococcus aureus

The Correct Answer is: E Chronic otitis media is typically caused by P. aeruginosa, H. influenzae, S. aureus (D), Proteus species, Klebsiella pneumoniae, or Moraxella catarrhalis. Aspergillus (A) and E. coli (C) are associated with otitis externa and streptococcus pneumoniae (D) is the most common bacterial cause of otitis media.

Q 39.9: An 18 month infant with congenital heart disease is diagnosed with acute bronchiolitis secondary to respiratory syncytial virus. Which of the following therapies should be initiated? A Albuterol B Amoxicillin C Azithromycin D Prednisone E Ribavirin

The Correct Answer is: E High-risk infants (i.e., congenital heart disease) who develop RSV are eligible for treatment with ribavirin. Antibiotics (B, C) are indicated if secondary bacterial infections develop. Albuterol (A) and prednisone (D) haven't been shown to improve RSV-related bronchiolitis.

Q 45.1: A 10-year-old male patient has been seen in the clinic on several occasions, with complaints of fatigue and fevers of unknown origin. On prior CBC, he was noted to have a hypereosinophilia. Today's smear reveals multiple small lymphoblasts, with scanty, light-blue cytoplasm after being stained with Wright-Giemsa, and inconspicuous nucleoli. Initial therapy for the patient should include which of the following? A Bone marrow biopsy and repeat CBC B Hematologic support for thrombocytopenia C Immediate referral for radiation therapy D Placement of an indwelling catheter and IV fluids E Prevention of metabolic and infectious complications

The Correct Answer is: E Prevention of metabolic and infectious complications are the immediate therapies of choice in this patient with ALL. This is done to prevent complications of hyperuricemia, hyperphosphatemia, and infection. Bone marrow biopsy, while important, is not a therapy. Platelet transfusions are only used if there are signs of bleeding and a low platelet count (usually less than 20,000). There is no place for radiation therapy at this point in the patient's initial treatment. Placement of an indwelling catheter is important early in treatment, but is not necessary as an initial treatment.

Q 49.16: A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago, her son started vomiting after feeding and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What is the most likely diagnosis? A Duodenal atresia B Intestinal malrotation C Intussusception D Peptic ulcer disease E Pyloric stenosis

The Correct Answer is: E Pyloric stenosis is the result of muscular hypertrophy with gastric outlet obstruction. The patient's symptoms and signs are most consistent with this diagnosis. Children with duodenal atresia present with bilious vomiting and epigastric distention within a few hours of life. Intestinal malrotation presents with bilious vomiting, usually within the first three weeks of life. Intussusception presents in a thriving three- to 12-month-old child with recurring bouts of abdominal pain. Vomiting and diarrhea usually follow, and bowel movements may appear bloody and contain mucus. In a young child, peptic ulcer disease usually presents with vomiting and upper GI bleeding.

Q 46.1: What is the treatment of choice for rheumatic fever? A Macrolides B Cephalosporin C Fluoroquinolone D Aminoglycosides E Penicillin

The Correct Answer is: E The goal is to eradicate the Streptococcus bacteria. Penicillins are the drug of choice, with the dose being benzathine penicillin G, 1.2 million units intramuscularly every four weeks as the ideal regimen. Oral penicillin does not absorb as well and has a weaker effect. The alternative to those with penicillin allergies is erythromycin 250 mg BID. Other alternatives are azithromycin or sulfadiazine.

Q 40.2: An infant is born to an HIV-positive mother who received three-drug treatment during pregnancy. Which of the following, if positive, indicates HIV infection in the infant? A HIV ELISA and Western Blot on cord blood B HIV ELISA and Western Blot at 1 month of age C HIV ELISA and Western Blot at 6 months of age D HIV ELISA and Western Blot at 12 months of age E HIV ELISA and Western Blot at 24 months of age

The Correct Answer is: E The median age at which infants no longer show the maternal antibody for HIV is 10 months; by 18 months, they all do not. HIV ELISA and Western blot are not appropriate for testing pediatric patients until after that age. HIV nucleic acid, RNA in plasma, or DNA in blood cells can be detected earlier. Tests for these include polymerase chain reaction (PCR), branched DNA chain assay (bDNA), and nucleic acid sequence-based amplification (NASBA). (

Q 38.6: A 4-month-old male presents for a well child check. He is healthy, and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely diagnosis? A Atrial septal defect B Coarctation of the aorta C Patent ductus arteriosus D Tetralogy of fallot E Ventricular septal defect

The Correct Answer is: E The patient in this scenario is exhibiting the classic signs of a ventricular septal defect. An atrial septal defect has a fixed, widely split S2, with a right ventricular heave as well as a systolic ejection murmur, which is best heard at the left sternal border second intercostal space. Coarctation of the aorta has absent or diminished femoral pulses and a blowing systolic murmur. A patent ductus arteriosus murmur is classically described as a rough machinery systolic murmur, and there are bounding pulses with a widened pulse pressure. Tetralogy of fallot can have associated cyanosis, with hypoxemic spells during infancy, easy fatigability, and dyspnea on exertion. Tetralogy of fallot has the presence of a right ventricular lift and a rough, systolic ejection murmur that is present along the left sternal border in the third intercostal space that radiates to the back. Aortic stenosis has a harsh systolic ejection murmur present at the right sternal border, and associated thrill in the carotid arteries.

Q 39.26: A 1-year-old boy is brought to the emergency department by his parents, who state that the child refuses to walk or crawl and begins crying when they stand him. He seems calm while lying on the examination table. Vitals are as follows: Temp: 38°C, HR: 70, RR: 15. Bruising is noted in several places. His parents deny trauma, but have noticed that he bruises easily. What other physical finding would you expect? A Conjunctival hemorrhages secondary to shaken baby syndrome B Pain response over the wrists secondary to passive range of motion C Pain response with passive range of motion to the hip secondary to slipped epiphysis D Pharyngitis and sand paper rash secondary to a staph infection E Swelling and warmth over the knee secondary to hemarthroses

The Correct Answer is: E This patient has hemophilia A. Hemarthroses usually occur when an affected child begins to walk. Due to his hemophilia, easy bruising can occur. Hemarthroses can cause low-grade fevers without infection being present, so choice D is incorrect. Wrist joints are less involved then knees, ankles, and elbows.

Q 44.2: A 14-year-old boy is evaluated for headaches. When he greets the PA, his hands are sweaty and have a soft, doughy consistency and he has a remarkable low, husky voice for his age. He is extremely tall, much more so than either of his parents. His father says no one in either family has ever been this tall, and his mother says they can't find shoes wide enough for his feet locally and have to order online. His teeth have wide spaces between them. He has previously been healthy, although he has not had medical care since his pre-K physical examination. What is the most likely underlying cause of this condition? A Carney syndrome B hypothalamic tumor C lymphoma D McCune-Albright syndrome E pituitary adenoma

The Correct Answer is: E This presentation suggests acromegaly/gigantism, which is almost always caused by a pituitary adenoma. It rarely occurs due to ectopic secretion of GHRH or GH that is being secreted by a hypothalamic tumor (B) or lymphoma (C), or may be part of Carney (A) or McCune-Albright (D) syndromes.

Q 43.5: A 12-year-old boy who is 60" tall and weighs 190# is found on routine physical examination to have 2+ glucose and trace ketones in his urine. His fasting glucose is 140 mg/dL and hemoglobin A1C is 6.0%. What is the next step in this child's management? A Initiation of insulin treatment B Prescription of oral metformin C Referral for a glucose tolerance test D Watchful waiting E Weight loss and exercise

The Correct Answer is: E Treatment of type 2 diabetes and pre-diabetes in children varies with the severity of the disease. If the HbA1C is near normal and ketones are not significantly increased, the first line of treatment is lifestyle modifications, including nutrition counseling for the entire family, weight loss, and exercise. Insulin (A) is not indicated in early type 2 disease. If life style changes are not successful, addition of metformin (B) is the next step. Glucose tolerance tests (C) are rarely needed in children. Watchful waiting (D) is inappropriate as continued elevated glucose levels put the child at risk for micro- and macrovascular damage.

Q 37.10: A 9-year-old female child presents with tachycardia, tachypnea, shortness of breath, bibasilar rales, and distended jugular veins. Which of the following is the most likely cause for her signs and symptoms? A rheumatic heart disease B sickle cell anemia C viral myocarditis D patent ductus arteriosus

The correct answer is (D). This patient is presenting with signs of congestive heart failure. The most common causes of heart failure in children/adolescents are due to acquired heart disease. Congenital heart diseases, such as malformations of the heart—patent ductus arteriosus and ventricular septal defects, are the most common causes of heart failure in infants-toddlers, and are second to fluid overload in neonates.

Q 39.25: A 1-year-old adopted Chinese infant is brought into the pediatrician's office for a routine visit. The parents are concerned because they think the child is short for her age. They do not have very much information relating to the birth of the child, other than that she was considered slightly short at birth and she had a seizure at one month of age. The foster parents of the child were not concerned, since the infant was somewhat chubby and ate well. She has no history of hypotonia. Upon exam you note normal shaped eyes with mild nystagmus. The infant is less than the third percentile for weight and her limbs are in normal proportion to her height. Her lung and heart exam are normal. CBC is normal. What is the most likely cause of her short stature? A Congenital growth hormone deficiency B Sickle cell anemia C Prader-Willi syndrome D Osteochondrodysplasia E Cystic fibrosis

The correct choice is A, congenital growth hormone deficiency. Parents of children with this disorder typically become concerned when the child is between one and two years of age. This patient fits the characteristic picture of this disorder, with short stature, increased fat mass, and hypoglycemia due to relatively unopposed insulin action. This may have been the cause of her seizure. She may also have optic hypodysplasia as a cause of her nystagmus. Choice B, sickle cell anemia, can be associated with short stature. However, the CBC from this patient was normal. Choice C, Prader-Willi syndrome, is also associated with short stature. Children with this disorder commonly have almond shaped eyes and hypotonia at birth. Choice D, ostrochondrodysplasia, is a type of inherited skeletal abnormality that presents with short stature and abnormal body proportions. This patient doesn't have abnormal body proportions. Choice E, cystic fibrosis, can be associated with growth abnormalities, but this patient has no evidence of lung disease.

Q 39.6: A 5-year-old girl is seen in your office with a several week history of increased thirst, weight loss, and blurred vision. She has a positive family history for diabetes mellitus, hypertension, and stroke. Her urine dipstick chemical testing reveals positive glucose and negative ketones, protein, blood, and nitrites. Which of the following laboratory test results would support a diagnosis of diabetes mellitus in this patient? A random plasma glucose > 200 mg/dL B random urine glucose dipstick > 1+ C plasma hemoglobin A1c < 7% D fasting plasma glucose > 110 mg/dL E 2-hour postprandial plasma glucose > 135 mg/dL

The correct choice is A, random plasma glucose > 200 mg/dL. The most recent recommendations from the international committee of diabetes experts list the following as diagnostic criteria, which must be confirmed before use: 1) Symptoms of diabetes and a random plasma glucose > 200 mg/dL 2) Fasting plasma glucose > 126 mg/dL 3) Two-hour plasma glucose > 200 mg/dL during a standard 75 gram oral glucose tolerance test More recently, the American Diabetes Association has also included a hemoglobin A1c level equal to or greater than 6.5% as a diagnostic criteria as well. None of the other choices fit into this list of diagnostic criteria.

Q 44.4: A 4-year-old child is being worked up for type 1 diabetes mellitus. In addition to ordering a fasting plasma glucose and hemoglobin A1c, you would like to determine the presence or absence of any immunologic markers. Which of the following autoantibodies are common in patients with type 1 diabetes mellitus? A Anti-double stranded DNA antibodies B Antinuclear antibodies C Islet beta cell autoantibodies D Pancreatic polypeptide producing cell antibodies E Thyroid stimulating antibodies

The correct choice is C, islet beta cell autoantibodies. Islet cell autoantibodies are seen in greater than 75% of patients with type 1 diabetes. These include several different antibodies and serve as a marker of the autoimmune process in the disease. Choice A, anti-double stranded DNA antibodies, is a marker for certain connective tissue disorders, such as systemic lupus erythematosis. Choice B, antinuclear antibodies, are used as a screening test for many different connective tissue disorders, such as systemic lupus erythematosis and scleroderma. Choice D, pancreatic polypeptide producing cell antibodies, are similar to beta cells, but are not involved in the autoimmune process. Choice E, thyroid stimulating antibodies, are found in patients with hyperthyroidism caused by Graves' disease.

Q 36.5: A 12-month-old infant is being worked up for congenital growth hormone deficiency. Her length at birth was short and she has been consistently less than the third percentile on her height chart. Her past medical history is only significant for three seizures since birth. Upon exam you note that she has a full face and her body proportions are normal. The remainder of the exam is normal. What is the most likely cause of her seizures? A Abusive head trauma B Brain tumor C Arteriovenous malformation D Hypoglycemia E Cerebrovascular accident

The correct choice is D, hypoglycemia. Patients with growth hormone deficiency will not have the counter regulatory action of growth hormone against insulin. This will allow unregulated insulin action causing hypoglycemia and possible associated seizures. Choices A, abusive head trauma, B, brain tumor, C, arteriovenous malformation, and E, cerebrovascular accident, can all cause seizures. This patient does not show any signs or symptoms of any of these disorders.

Q 49.4: A young child and his parents have been adhering to the treatment plan for type 1 diabetes, as discussed with their health care provider. It includes a change in diet, as well as blood glucose and ketone monitoring. They noticed that the amount of insulin needed decreased after the first two weeks. What is this time period commonly called? A Postprandial control phase B Glucose tolerance time C Pre-diabetic period D Mature onset diabetes of youth E Honeymoon phase

The correct choice is E, honeymoon phase. During this time, some pancreatic beta cell function may recover, although within eight weeks to two years most patients will show absent or negligible pancreatic beta cell function. Choice A, postprandial control phase, choice B, glucose tolerance time, and choice C, pre-diabetic period, are not true time periods. Choice D, mature onset diabetes of youth, is a subgroup of autosomal dominant inherited disorders, characterized by diabetes in non-obese older children that are not ketosis prone and generally do not need insulin therapy to control their disease. This type of diabetes accounts for up to 5% of diabetes in North America and Europe.

Q 48.8: An 11-year-old boy has a history of early growth failure and cherubic features. His height velocity chart is shown. What is the most likely cause of the sharp increase in the growth curve at age six? (Figure 7-10, Greenspan's Basic and Clinical Endocrinology, 2007) A Pituitary adenoma resection B Glucocorticoid replacement C Insulin therapy D Ensure supplementation E Recombinant human growth hormone

The correct choice is E, recombinant human growth hormone. This patient had a classic presentation of growth hormone deficiency. Replacement of growth hormone will result in marked improvement in growth, especially during the first year of treatment. Replacement therapy in most cases can allow for heights reaching genetic potential. Choice A, pituitary adenoma resection, is the treatment of choice for acromegaly. Choice B, glucocorticoid replacement, is not indicated in this patient. Choice C, insulin therapy, could possibly worsen this patient's condition. Patients with growth hormone deficiency are at risk of hypoglycemia. Choice D, ensure supplementation, is helpful for patients needing nutritional supplementation. This patient's short stature is not nutritional in nature.

Q 39.2: A 10-year-old child is seen with his parents for a routine check up. During the review of symptoms, his parents mention that their son has been extremely thirsty and is going to the bathroom to urinate frequently. The patient agrees. The parents are concerned that their son has developed diabetes mellitus. The family history is negative for diabetes mellitus, but the mother has a history of familial hypothalamic diabetes insipidus. Screening blood work includes a CBC, hemoglobin A1c, and renal function tests, all of which are within the reference range. Which of the following serum analytes would you expect to be deficient? A Sodium B Glucose C Thyroxine D Prolactin E Vasopressin

The correct choice is E, vasopressin. The reader must first understand that the patient's symptoms are classic for diabetes insipidus, with the increased thirst, frequency, and polyuria. These symptoms are also seen in diabetes mellitus, but this would be less likely since the patient doesn't have a family history of diabetes mellitus, and his hemoglobin A1c is not elevated. Choice A, sodium, should be within range, as long as the boy is able to drink when thirsty; otherwise, he would become hypernatremic. Choice B, glucose, is incorrect. Although the signs and symptoms also fit the pattern of diabetes mellitus, the glucose would most likely be elevated in this disorder, and not low. Choice C, thyroxine, is under control of TSH from the anterior pituitary gland, and choice D, prolactin, is secreted from the anterior pituitary gland. Vasopression is secreted from the posterior pituitary gland.