Chapter 18

During the delivery of a male infant, you are there to assess the Apgar score. He was born through an intact pelvis and had no complications during labor or delivery. At 1 minute he is pink all over and grimaces. He is flexing his arms and legs occasionally. He is breathing well and his heart rate is 110. At 5 minutes he is still pink all over but now is crying vigorously, with active movement. His respiratory effort is good and his heart rate is 130.What is his Apgar score? A) 8 at 1 minute, 10 at 5 minutes B) 7 at 1 minute, 9 at 5 minutes C) 9 at 1 minute, 10 at 5 minutes D) 8 at 1 minute, 9 at 5 minutes

A) 8 at 1 minute, 10 at 5 minutes In checking the Apgar, five things are looked at during the 1-minute and 5-minute marks. The color, reflex irritability, muscle tone, respiratory effort, and heart rate are evaluated. In this case, at 1 minute he received 2 points for being pink all over, 1 point for grimacing, 1 point for flexion of the arms and legs, 2 points for strong respiratory effort, and 2 points for a heart rate over 100. This gives a 1-minute total of 8. At 5 minutes he was given 2 points for being pink all over, 2 points for vigorous crying, 2 points for active movement, 2 points for strong breathing, and 2 points for a heart rate over 100. This gives a 5-minute total of 10. These are normal, healthy Apgar scores.

Which of the following will help to optimize yield from a pediatric examination? A) Doing the examination out of order if necessary to take advantage of quiet periods for auscultation, etc. B) Being very orderly, so as not to miss a portion of the examination C) Using firmness as needed to make it through your examination D) Making sure to place the infant on the table during the examination while mom watchesclose by

A) Doing the examination out of order if necessary to take advantage of quiet periods for auscultation, etc. While order and routine are comforting to the examiner, children should be examined in an order which allows maximum yield. Many prefer to listen to the heart and lungs first while the child is quiet, in a parent's arms. Likewise, you may gain advantage to examining the mouth while the baby is crying. Most view the ENT examination as the most invasive for a child (especially the otoscopic examination), so many leave this for last.

An adolescent male comes to your clinic with a note from his mother stating it is okay for him to be seen today without her presence. He has come in for his annual sports physical required to play football. For his age his physical examination is unremarkable and you sign his school's physical examination form. You decide to take this opportunity to do some health education with him. He admits to wondering a lot lately if he is normal. Although he is in football he really enjoys science and computers more. He is worried that all his buddies will think he is a geek. He is convinced he also won't get a date for the Sadie Hawkins dance next week because the girls all think he is boring, too. He denies any experimentation with tobacco or alcohol, and he blushes when you mention sex. After hitting all the pertinent age-appropriate education points you give him his sports physical form and he leaves. The patient's concerns during the visit most resemble what developmental stage of adolescence? A) Early adolescence (10 to 14 years old) B) Middle adolescence (15 to 16 years old) C) Late adolescence (17 to 20 years old)

A) Early adolescence (10 to 14 years old) His concern with whether he is normal or not is often seen in the development of social identity in early adolescence. He is also concerned with the present (Sadie Hawkins dance) and not the distant future, as is seen with late adolescence. He also denies the experimentation often seen in middle adolescence.

A foster mother brings a 4-year-old child to see you for an evaluation. She has had custody of the girl for 2 weeks. She knows that the child was born in your state and that her maternal grandmother had custody for 6 months. She received good medical care during that time, but after her biologic mother obtained custody the child was abused and has had no further medical care. She says the child has had many behavioral problems and seems to be very behind on her developmental tasks. When you examine the child you notice short palpebral fissures, a wide nasal philtrum, and thin lips. Her cardiac, pulmonary, musculoskeletal, and abdominal examinations are normal. Her Denver Developmental Screening Test shows most of her milestones have occurred only through the 24th month. What form of congenital retardation is she most likely to have? A) Fetal alcohol syndrome B) Congenital hypothyroidism C) Down syndrome

A) Fetal alcohol syndrome The facial appearance in fetal alcohol syndrome shows short palpebral fissures, a wide and flattened philtrum, and thin lips. These children often have mild retardation even with good care, but with abuse they may have more profound retardation. This condition may occur with only modest alcohol consumption.

You are having trouble examining the abdomen of a school-aged child due to ticklishness. What should you do? A) Have the child press on your hand. B) Have the parent insist that the child allow you to examine her. C) Ask the parent to leave the room. D) Make the child realize that this is part of the examination and must be done.

A) Have the child press on your hand. By having the child participate in the examination and pressing on your hand, it will eliminate the ticklishness. Resistance to examination at this age is normal. The last three options only make the situation worse. The key is to have the child participate in the examination in a fun way.

A 38-week gestation, 2500-gram infant is placed on your service. How would she be described? A) Term, normal birth weight B) Term, low birth weight C) Preterm, normal birth weight D) Preterm, low birth weight

A) Term, normal birth weight Preterm is defined as less than 37 weeks; term, 37-42 weeks; and post-term, over 42 weeks of gestation. Birth weights have similar limits: extremely low birth weight, less than 1000 grams; very low birth weight, less than 1500 grams; low birth weight, less than 2500 grams; and normal birth weight, equal to or more than 2500 grams. These have prognostic implications and impact on how closely to watch and how aggressively to treat these infants.

A mother brings her 15-month-old daughter to your office for evaluation of a rash and fever. She says the rash started one day and the fever developed the next day. Her daughter has had all of her vaccinations up to 10 months. The mother sheepishly admits that she hasn't had time to bring her daughter in since her 10-month check-up. On examination you see a mildly sick-appearing toddler with a 102-degree temperature. Looking at her skin you see at least 100 of a variety of papules, vesicles, and ulcers in different stages of development. What illness prevented by proper vaccination does this toddler have? A) Varicella (chickenpox) B) Measles C) Smallpox

A) Varicella (chickenpox) Normally the first vaccine for varicella is given at 12 to 15 months. The characteristic rash in waves of lesions is in a pattern of papules, vesicles, ulcers, and scabs. Because of the number of persons who still get shingles (an outbreak of varicella in one dermatome following the original infection by years), there is still enough virus in the United States to easily get chickenpox without vaccination. This child is regarded as contagious to others until all of the lesions are "scabbed over." Smallpox would appear different in that all of the lesions would be in the same stage of development.

You are observing an infant who is able to pull to a stand, uses "mama" and "dada" specifically, and indicates his wants by vocalization and pointing. Where would you place this child's developmental age? A) 12 months B) 10 months C) 8 months D) 6 months

C) 8 months Assessing developmental milestones is of major importance during the first year and beyond. These accomplishments in the physical, cognitive/language, and social domains are normal for an 8-month-old infant.

A toddler is able to jump in place and balance on one foot as well. She can also speak infull sentences and feed herself. What is the approximate developmental age of this child? A) 2 years B) 3 years C) 4 years D) 5 years

B) 3 years These milestones are consistent with a physical, cognitive/language, and social and emotional developmental age of 3 years.

A 32-year-old white female presents to labor and delivery fully effaced and delivers a 5.8-lb (2,500-gram) infant female with Apgar scores of 6 and 8. The mother has had no prenatal care and in the nursery you perform the newborn examination. With the Ballard scoring system, the neuromuscular examination score is 15. Looking at physical maturity, you see superficial peeling and few veins on the skin. The lanugo hair has bald areas and the plantar surface of the foot has creases on two thirds of it. The areola is stippled with a 2-mm bud. The pinna is well curved, is firm, and has instant recoil. The labia majora and minora are equally prominent. Add the score of the neuromuscular components to your score of physical maturity to determine weeks of gestation. How many weeks of gestation has this child had? A) 34 weeks B) 36 weeks C) 40 weeks

B) 36 weeks Superficial peeling with few veins gives a score of 2 points; lanugo with balding areas gives a score of 3 points; the plantar surface being covered by two thirds gives a score of 3 points; the stippled areola with a 2-mm bud gives a score of 2 points; the well-formed pinna with instant recoil gives a score of 3 points. The equal labia majora and labia minora give a score of 2 points. Adding these numbers up gives a score of 15 points for physical maturity. Adding that to the 15 points for neuromuscular maturity gives a point total of 30, which correlates to a gestational age of 36 weeks. This would be expected with a birth weight of 2,500 grams.

You are going to obtain a social history on an early adolescent boy. How should you proceed to obtain the best information? A) Ask his mother to leave the room. B) Ask if he would prefer his mother to leave the room. C) Ask your questions with his mother in the room. D) Ask his mother how she would like to proceed.

B) Ask if he would prefer his mother to leave the room. It is best to ask the patient what he or she would prefer. Because the examination should include a genitalia examination, some children in early adolescence are more comfortable with their parents in the room. Some examiners will provide "confidential time" to both the adolescent and the parent, so that parental concerns can also be adequately addressed. Leaving the parent in the room without asking the adolescent is usually not a good idea and can limit optimal history gathering and examination.

An infant presents with a heart rate of 180, a respiratory rate of 68, and an enlarged liver. What diagnosis does this suggest? A) Pneumonia B) Heart failure C) Sepsis D) Necrotizing enterocolitis

B) Heart failure Heart failure presents differently in infants than in adults. This triad should suggest this diagnosis. Pneumonia, necrotizing enterocolitis, and sepsis should not necessarily cause hepatomegaly. Observe closely for central cyanosis of the lips and tongue. Peripheral cyanosis alone does not mean much in infants. Perform a careful cardiac examination in as quiet a setting as possible, perhaps while the infant is in the mother's arms, to look for evidence of valvular disease.

A mother brings her 4-year-old daughter to your office because of fever and decreased eating and drinking. When you ask the little girl what is wrong, she says her mouth and throat hurt. On examination her temperature is 101 degrees. Her ears and nose examinations are unremarkable. Her mouth has ulcerations on the buccal mucosa and the tongue. She also has cervical lymphadenopathy. Her cardiac and pulmonary examinations are normal. She is up to date on her childhood vaccinations.What mouth abnormality does she most likely have? A) Strep throat B) Herpetic stomatitis C) Oral candidiasis (thrush) D) Diphtheria

B) Herpetic stomatitis With herpetic stomatitis there is often a low-grade fever with small ulcers covering the mucosa of the mouth. The pain from the ulcers leads to decreased oral intake and even dehydration.

You have been unable to hear normal S2 splitting in children up to this point. What technique will maximize your chances of hearing this phenomenon? A) Listen with the diaphragm over the left lower sternal border. B) Listen with the bell over the 2nd left intercostal space. C) Listen with the bell over the apex. D) Listen with the diaphragm in the axilla.

B) Listen with the bell over the 2nd left intercostal space. S2 is made of aortic and pulmonic components. Of these, the pulmonic component is much softer and heard best over the pulmonic area. Even in the proper location, the pulmonic component may be difficult to hear with the diaphragm because it is a soft, low-pitched sound. For this reason, the bell should be used to listen for S2 splitting over the pulmonic area during inspiration, when splitting should be maximized. Breathing also changes heart rate more rapidly in children. One may think an arrhythmia is present until she notices that this rate change is related to the respiratory cycle.

You are assessing an infant and notice that his nares flare, he has a soft grunt with each breath, and the skin between his ribs is pulled inward with inhalation. What is the significance of these findings? A) These are indicative of a CNS process. B) These are indicative of respiratory distress. C) These are indicative of muscular dystrophy. D) These are frequently accompanied by stridor.

B) These are indicative of respiratory distress. It is critical to notice these findings of respiratory distress. Muscular dystrophy may not allow the appearance of these signs because they are caused by muscular effort. It is hard to find a cause for these signs in the CNS. Stridor is usually inspiratory, so while nasal flaring and retractions may occur, grunting is unusual because exhalation is unimpeded.

A quiet 3-year-old is brought in for a routine check-up when you notice a fresh bruise in the axilla and bilateral bruises over the upper back that appear slightly older. There are brown bruises over his shins as well. His mother said this happened when he fell off of a couch. What diagnosis should be considered? A) Von Willebrand's disease B) Normal childhood bruises from activity C) Abuse D) Seizure disorder

C) Abuse No one wants to think that a child could be abused.shins are very normal for this age group with normal activity.areas which do not correlate with the given history are important to notice and should make you consider this diagnosis. A very thorough examination must be conducted to search for otherIn this case the bruises on the The presence of bruises in other lesions that might be consistent with the use of implements such as an electrical cord, clothes iron, cigarette, etc. A social services consult and/or formal abuse evaluation should be considered. Unfortunately, emotional and sexual abuse do not frequently leave outward signs. It is important to keep an open mind to the presence of these other types of abuse as well.

You are assessing Tanner staging of the breast in a young woman. You notice projectionof the areola and nipple to form a secondary mound above the level of the breast. Tanner stage would this be? A) I B) II C) III D) IV

C) III This would be a Tanner stage III because there is elevation of the nipple and areola above the level of the surrounding breast tissue and because the areola has not receded to the general contour of the breast.

A mother brings her infant to you because of a "rattle" in his chest with breathing. Which of the following would you hear if there were a problem in the upper airway? A) Different sounds from the nose and chest B) Asymmetric sounds C) Inspiratory sounds D) Sounds louder in the lower chest

C) Inspiratory sounds It is important to distinguish upper airway sounds from lower because many benign conditions cause upper airway noise, such as viral upper respiratory infections. It is reassuring to hear the same noises at the nose as at the chest. Lower respiratory conditions also are generally symmetric, and sounds are louder at the upper chest versus the lower chest. They are usually very harsh and loud, which concerns parents.

A young Hispanic mother brings in her 2-month-old son. She is upset because her neighbors have threatened to call the Child Protective Agency because they think his birthmark is a bruise. Her son was the product of an uneventful pregnancy and spontaneous vaginal delivery. On examination you see a large, smooth-bordered bluish mark on his buttock and lower back. Otherwise his examination is unremarkable.What form of birthmark is this likely to be? A) Café-au-lait spot B) Salmon patch C) Mongolian spot

C) Mongolian spot Mongolian spots are large, smooth-bordered birthmarks found on the back and/or buttocks. They are found more often in darker-pigmented infants such as in the Hispanic or Asian population. They are commonly mistaken for bruises.

A 6-month-old infant is brought in for a well check. It is noted his head circumference is off the chart and at a much higher percentile than was previously measured. What should you do next? A) Recommend a neurology consult. B) Order a CT of the head. C) Remeasure the circumference. D) Admit the child to the hospital for further workup.

C) Remeasure the circumference. It is difficult to obtain accurate measurements of a squirming infant. The first step would be to remeasure. Some recommend starting with three measurements and averaging or picking the middle measurement. Height is technically not measured until a child is standing, so infants' measurements are recorded as length.

A mother brings in her 3-year-old son for a well-child check-up. She is concerned that he seems different in size from all of the other preschool boys. He was the product of an uneventful pregnancy and vaginal delivery. He has hit all of his developmental milestones on time. On examination he is 26 lbs (11.8 kg) and is 35 inches (89 cm) tall. Otherwise his examination is unremarkable. You give the correct education for his age and then discuss his size. For his age, what are his growth chart percentiles? A) Tall and heavy for his age (>95%) B) Average height and weight for his age (5 to 95%) C) Small and light for his age (<5%)

C) Small and light for his age (<5%) According to the growth charts, this child is less than the fifth percentile for both height and weight, indicating that he is small and light for his age. This can be from a growth hormone deficiency but is usually due to genetic factors (such as short, light parents). It is most important to follow the trend of growth. It is more significant if this child was previously at the 50th percentile for height and weight than if he has always been about the same percentile and following a line parallel to expected growth lines.

A 24-year-old mother who is a smoker and cocaine addict gave birth at 39 weeks to a 2,000-gram female infant who is in the neonatal intensive care unit. Using the Intrauterine Growth Curve chart, you determine whether the infant's weight is appropriate for her gestational age.In which category does the infant best fit? A) Large for gestational age B) Normal for gestational age C) Small for gestational age

C) Small for gestational age For a 39-week infant, any weight less than 2,500 grams would be considered small. Intrauterine growth retardation and low birth weight would be expected in a smoker who also abuses cocaine.

You are examining a 5-year-old before he begins school. You notice a systolic, gradeII/VI vibratory murmur over the LLSB and apex with normal S2 splitting. He has normal pulses as well. Which of the following is most likely? A) Tricuspid stenosis B) Mitral stenosis C) Still's murmur D) Venous hum

C) Still's murmur This description is consistent with Still's murmur, a very common and benign murmur of childhood. Tricuspid and mitral stenosis would be diastolic murmurs and the venous hum is usually not heard in this area. Further evaluation is usually not necessary.

A mother is upset because she was told by another provider that her child has a worrisome murmur. You listen near the clavicle and notice both a systolic and diastolic sound. You remember that diastolic murmurs are usually indicative of bad pathology. What would you do next? A) Cardiology referral B) Echocardiogram C) Supine examination D) Reassure the mother

C) Supine examination The next step would be to examine the patient in the supine position. If this is a venous hum, this murmur will resolve almost completely in the supine position. This is a very common phenomenon in school-aged children, particularly over the clavicle, but can also occur outside this range. Reassurance cannot be given without further examination, especially with a diastolic murmur. Cardiology referral and echocardiography are unnecessary if examination in the supine position reveals no murmur.

You are examining an infant in the nursery and notice a soft bump over the posterior right side of the skull. It is not evident on the left. What does this represent? A) Caput succedaneum B) Plagiocephaly C) Craniosynostosis D) Cephalohematoma

D) Cephalohematoma Cephalohematoma represents bleeding under the periosteum, which is why this lesion does not cross the midline. The blood can contribute to neonatal jaundice as it breaks down. Caput succedaneum is commonly seen as a spongy mass over the vertex, particularly when vacuum extraction is used. Craniosynostosis describes a premature closure of bony skull sutures, and plagiocephaly is a flattening of the parieto-occipital region on one side of the skull, which is frequently thought to be positional.

A mother brings her 16-month-old son in for an evaluation. She is afraid he is not meeting his developmental milestones and wants to know if he should be sent to therapy. He was the product of an uneventful pregnancy and a spontaneous vaginal delivery. His Apgar scores were 7 and 9. Until reaching a year old the mother believes he was hitting his milestones appropriately. You decide to administer the Denver Developmental Screening Test. You find that he is using a spoon to eat with and can take off his own shoes and shirt. He can build a tower of two cubes and dump raisins. His vocabulary consists of at least 10 words. He can stand alone and stoop and recover, but he is unable to walk without holding onto someone's hand.What type of developmental delay does he have? A) Personal/social B) Fine motor C) Language D) Gross motor

D) Gross motor By 16 months a child should be able to walk unaided and even walk backwards and run. This child was referred to physical therapy and did well.

27. A 15-month-old is brought to you for a fever of 38.6 degrees Celsius and fussiness. The ear examination is as follows: external ear, normal appearance and no tenderness with manipulation; canal, normal diameter without evidence of inflammation; tympanic membrane, bulging, erythematous, and opaque. Insufflation is deferred due to pain. What is your diagnosis? A) Otitis externa B) Cholesteatoma C) Ruptured tympanic membrane D) Otitis media

D) Otitis media There is no inflammation of the outer ear, including the canal, thus excluding otitis externa. Cholesteatoma is a painless white lesion behind the TM. There is no drainage from the TM; thus, rupture is unlikely. This is a classic description of otitis media. Many examiners will forego insufflation if the diagnosis is clear, because this can cause discomfort in an already uncomfortable ear.