Peds: Case Questions

A 9-year-old boy has 24 hours of persistent abdominal pain and vomiting. His physical examination reveals abdominal guarding and right lower quadrant rebound tenderness. Which of the following is the most likely diagnosis? A. Appendicitis B. Gastroenteritis C. Gastroesophageal reflux D. Intussusception E. Pyloric stenosis

A. This child most likely has appendicitis based on the clinical presentation

"A 6-week-old male infant has projectile emesis after feeding. He has an olive-shaped abdominal mass on abdominal examination. Which of the following statements is accurate? A. He likely has hypochloremic metabolic alkalosis. B. He likely has metabolic acidosis. C. This condition is more common in female infants. D. He should be restarted on feeds when the vomiting resolves. E. He likely will develop diarrhea

A. This infant has the features of pyloric stenosis, a condition four times more common in males and more common in first-born children. Affected infants usually present between the third and eighth week of life with increasing projectile emesis. Abdominal examination may reveal an olive-shaped mass and visible peristaltic waves. Serum electrolyte levels usually reveal hypochloremic metabolic alkalosis. Ultrasonography is useful in confirming the diagnosis.

Appropriate clinical management of the patient in the previous question includes which of the following? A. Change from enteral to intravenous feeds; obtain genetics consultation for the next morning. B. Change from enteral to intravenous feeds, obtain a blood culture, and initiate antibiotics. C. Change from enteral to intravenous feeds, place a nasogastric tube, and obtain a emergency pediatric surgery consultation. D. Change from cow's milk to soy-based infant formula and continue to observe the infant. E. Do not change your current management

C. Meconium ileus is a surgical emergency, as volvulus and perforation with peritonitis are not uncommon complications

A term infant delivered vaginally develops vomiting and abdominal distention after 10 hrs of birth. No stool passage has been noted. An abdominal radiograph shows distended small bowel loops and a "bubbly" pattern in a portion of intestine; the colon is narrow. Which of the following should you tell the parents? A. You would like to consult a pediatric surgeon because you suspect that their child has Hirschsprung disease. B. The child most likely has necrotizing enterocolitis, a condition more commonly seen in premature infants. Therefore, you question the child's supposed gestational age. C. You are concerned about the possibility of meconium ileus and would like to obtain some family history. D. You believe that the child simply is constipated and would like to change to a soy-based formula to see whether the baby tolerates this better

C. Meconium ileus, obstruction begins in utero, resulting in underdevelopment of distal lumina. It is almost always associated with CF. Intestinal atresia and Hirschsprung disease (congenital aganglionic megacolon) cause similar clinical pictures, but the radiographic findings for this child are most consistent with meconium ileus. Necrotizing enterocolitis also causes emesis and abdominal distension but occurs primarily in extremely low-birth-weight infants

A 3-day-old boy presents with 12 hours of bilious vomiting, abdominal pain, and abdominal distension. Which of the following is the most appropriate next step in management? A. Order an abdominal ultrasonography. B. Order a computed tomography scan of the abdomen. C. Order an upper GI contrast series. D. Order a barium enema. E. Order a chest radiograph

C. Order an upper GI contrast series. Fluid and electrolyte status should also be evaluated.

Malrotation with volvulus is most likely to be present in which of the following patients? A. A healthy 15-month-old with severe paroxysmal abdominal pain and vomiting B. A 15-year-old sexually active girl with lower abdominal pain C. A 3-day-old term infant with bilious emesis, lethargy, and abdominal distension D. A 4-day-old premature baby (33-week gestation) who has recently started nasogastric feeds; he now has abdominal distention, bloody stools, and thrombocytopenia E. A 7-year-old non-toxic-appearing girl with abdominal pain, vomiting, fever, and diarrhea"

C. The 3-day-old term infant with bilious emesis and abdominal distension has classic presenting features of malrotation with volvulus.

A previously healthy 18-month-old child has vomiting and severe, paroxysmal, writhing abdominal pain (he prefers to have his knees flexed to the chest) alternating with periods of relative comfort with a soft, only mildly tender abdomen. On abdominal examination you find a sausage-like mass. He has not stooled, but you find blood upon digital rectal examination. Which of the following is the best next step in management? A. Administer morphine for pain control. B. Order a computed tomography of the abdomen. C. Obtain an air contrast enema. D. Obtain serum acetaminophen levels. E. Begin antibiotics for Escherichia coli 0157:H7

C. The case describes the typical presentation of intussusception. Although a clinical diagnosis can be made, the diagnostic "gold" standard and often treatment is contrast enema. Air contrast usually is preferred because the complication risk is lower than with other forms of contrast material.

A 37 wk gestation male is born after an uncomplicated pregnancy to a 33 yr old mother. At birth he was lethargic and had an HR of 40. Oxygen was administered via bag and mask, and he was intubated; his HR remained at 40 bpm. Which of the following is the most appropriate next step? a) admin IV bicarb b) admin IV atropine c) admin epinephrine d) initiate chest compression e) cardioversion

D) if HR is below 60 - begin chest compressions if hr stays below 60 after chest compression, admin epi

"A 10-year-old boy has a history of recurrent sinusitis and multiple episodes of pneumonia. A sweat electrolyte test result is within the normal range. Which of the following can be removed from your differential diagnosis now? A. Atopy B. Primary ciliary dyskinesia (Kartagener syndrome) C. Gastroesophageal reflux disease (GERD) D. Cystic fibrosis E. Severe combined immunodeficiency"

D. Cystic fibrosis

A 4 mo child has poor weight gain. Her current weight is less than the 3rd percentile, ht about the 10th percentile, and head circ at the 50th percentile. The planned pregnancy resulted in a normal, spontaneous, vaginal delivery; mother and child were discharged after a 48 hr. Feeding is via breast and bottle; the quantity seems sufficient. The child has had no illness. The examination is unremarkable except for the child's small size. Screening laboratory shows the hemoglobin and hematocrit are 11 mg/dL and 33%, respectively, with a platelet count of 198,000/mm3. Serum electrolyte levels are sodium 140, chloride 105, potassium 3.5, bicarbonate 17, blood urea nitrogen 15, and creatinine 0.3. Liver function tests are normal. Urinalysis reveals a pH of 8 with occasional epithelial cells but no white blood cells, bacteria, protein, ketones, or reducing substances. Which of the following is the most appropriate therapy for this child a) transfusion of packed RBCs b) IV infusion of sodium chloride c) sweat chloride analysis d) GH determination e) oral supplementation with bicarb

E) bicarb child is FTT, worry is metabolic acidosis

A female infant is born through emergency cesarean section to a 34-year-old mother whose pregnancy was complicated by hypertension and abnormal fetal heart monitoring. At delivery she is covered in thick, green meconium and is limp, apneic, and bradycardic. Which of the following is the best first step in her resuscitation? a) admin IV bicarb b) admin IV naloxone c) initiate bag & mask ventilation d) initiate chest compression e) intubate with endotrach tube and suction meconium from trachea

E) check for meconium in oropharnyx first prior to initiation of respirations - initiate ventilation after meconium is removed

A term male is delivered vaginally to a 22 yr old mother. Immediately after birth he is noted to have a scaphoid abdomen cyanosis, and respiratory distress. Heart sounds are heard on the right side of the chest, and the breath sounds seem to be diminished on the left side. Which of the following is the most appropriate next step in his resuscitation a) admin IV bicarb b) admin IV naloxone c) initiate bag & mask ventilation d) initiate chest compression e) intubate with endotrach tube

E) endotrach tube BVM would cause more air into bowel due to his diaphragmatic hernia

Parents bring their 6 mo son to see you. He is symmetrically less than the 3rd percentile for ht, wt, and head circ on routine growth curves. He was born at 30 wks gestation and weighed 1000 g. He was a planned pregnancy, and his mother's pregnancy was uneventful until an automobile accident initiated the labor. He was ventilated for 3 days in the intensive care unit (ICU) but otherwise did well without ongoing problems. He was discharged at 8 weeks of life. Which of the following is the mostly likely explanation for his small size? a) chromosomal abnormality b) protein-calorie malnutrition c) malabsorption secondary to short gut syndrome d) congenital hypothyroidism e) normal ex-premie growth

E) growth chart must be calculated due to his pre-term delivery/ growth parameters

A 2-hour-old term newborn male has coughing, choking, and cyanosis prior to feeding. A nasogastric tube is placed and meets resistance at 10 cm. Prenatal history is significant for polyhydramnios. Which of the following is most likely to be found in this infant? A. Congenital cataracts B. Gingival hyperplasia C. Hepatosplenomegaly D. Microcephaly E. Fusion of two lower thoracic vertebral bodies

E. The infant probably has esophageal atresia. VATER association, as described in the case, can have vertebral anomalies such as fused or bifid vertebral bodies. None of the other findings listed is commonly associated with VATER

A term 3700-g male infant is born vaginally to a 27-year-old gravida 2 mother following an uncomplicated pregnancy. Shortly after birth, he begins to cough, followed by a choking episode, difficulty handling secretions, and cyanosis. During the resuscitation, placement of an orogastric tube meets resistance at 10 cm. He is transferred to the level II nursery for evaluation and management of respiratory distress. What is the most likely diagnosis?

esophageal atresia