Ch 18 from HA Peds

1. During the delivery of a male infant, you are there to assess the Apgar score. He was born through an intact pelvis & had no complications during labor or delivery. At 1 minute he is pink all over & grimaces. He is flexing his arms & legs occasionally. He is breathing well & his HR is 110. At 5 minutes he is still pink all over but now is crying vigorously, with active movement. His respiratory effort is good & his HR 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

Ans: A 8 at 1 minute, 10 at 5 minutes To calculate Apgar look at color, reflex irritability, muscle tone, respiratory effort, & HR at the 1-min & 5-min marks. --at 1 min => 2 pts for being pink all over, 1 pt for grimacing, 1 pt for flexion of the arms & legs, 2 pts for strong respiratory effort, & 2 pts for a HR > 100. 1-min total of 8. --At 5 min he was given 2 pts for being pink all over, 2 pts for vigorous crying, 2 pts for active movement, 2 pts for strong breathing, & 2 pts for a HR >100. 5-min total of 10. --These are normal, healthy Apgar scores.

13. 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 watches close by

Ans: A Doing the examination out of order if necessary to take advantage of quiet periods for auscultation, etc. While order & routine are comforting to the examiner, children should be examined in an order which allows maximum yield. Many prefer to listen to the heart & lungs first while the child is quiet, in a parent's arms. Likewise, you may gain an advantage in 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.

10. 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 PE is unremarkable & you sign his school's 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 & 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)

Ans: 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) & not the distant future, as is seen with late adolescence. He also denies the experimentation often seen in middle adolescence.

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

Ans: A Fetal alcohol syndrome The facial appearance in fetal alcohol syndrome shows short palpebral fissures (width of eye), a wide & flattened philtrum (upper lip groove), & 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.

22. You are having trouble examining the abd 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.

Ans: A Have the child press on your hand. By having the child participate in the examination & 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.

11. A 38-wk gestation, 2500-g 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

Ans: A Term, normal birth weight Preterm is defined as <37 wks; term, 37-42 wks; & post-term, >42 wks. --Birth weights have similar limits: -extremely low birth wt <1000 g -very low birth wt <1500 g -low birth wt <2500 g -normal birth wt =/>2500 grams. --These have prognostic implications & impact on how closely to watch & how aggressively to treat these infants.

9. A mother brings her 15-mo daughter to your office for evaluation of a rash & fever. She says the rash started one day & 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, & ulcers in different stages of development. What illness prevented by proper vaccination does this toddler have? A) Varicella (chickenpox) B) Measles C) Smallpox

Ans: A Varicella (chickenpox) Normally the first varicella vaccine is given at 12-15mo. The characteristic rash in waves of lesions is in a pattern of papules, vesicles, ulcers, & 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.

14. A 6-mo infant is brought in for a well check. It is noted his head circumference is off the chart & 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.

Ans: 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 & averaging or picking the middle measurement.

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

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

6. A 32-yo white female presents to labor & delivery fully effaced & delivers a 5.8-lb (2,500-g) infant female with Apgar scores of 6 & 8. The mother has had no prenatal care & 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 & few veins on the skin. The lanugo hair has bald areas and the plantar surface of the foot has creases on 2/3 of it. The areola is stippled with a 2-mm bud. The pinna is well curved, is firm, & has instant recoil. The labia majora & 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

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

24. 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.

Ans: B Ask if he would prefer his mother to leave the room It is best to ask the pt 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 & 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 & examination.

18. An infant presents with a HR of 180, a RR of 68, & an enlarged liver. What diagnosis does this suggest? A) Pneumonia B) Heart failure C) Sepsis D) Necrotizing enterocolitis

Ans: B Heart failure Heart failure presents differently in infants than in adults. This triad should suggest this diagnosis. --PNA, necrotizing enterocolitis, & sepsis should not necessarily cause hepatomegaly. --Observe closely for central cyanosis of the lips & 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.

8. A mother brings her 4-yo daughter to your office because of fever & decreased eating & drinking. When you ask the little girl what is wrong, she says her mouth & throat hurt. On examination her temperature is 101 degrees. Her ears & nose examinations are unremarkable. Her mouth has ulcerations on the buccal mucosa & the tongue. She also has cervical lymphadenopathy. Her cardiac & 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

Ans: 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.

19. 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.

Ans: B Listen with the bell over the 2nd left intercostal space S2 is made of aortic & pulmonic components. Of these, the pulmonic component is much softer & 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.

16. You are assessing an infant & notice that his nares flare, he has a soft grunt with each breath, & 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.

Ans: 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 & retractions may occur, grunting is unusual because exhalation is unimpeded.

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

Ans: C 8 months Assessing developmental milestones is of major importance during the 1st year & beyond. These accomplishments in the physical, cognitive/language, & social domains are normal for an 8-mo infant.

26. A quiet 3-yo is brought in for a routine check-up when you notice a fresh bruise in the axilla & 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

Ans: C Abuse No one wants to think that a child could be abused. In this case the bruises on the shins are very normal for this age group with normal activity. The presence of bruises in other 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 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.

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

Ans: 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.

17. 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 & chest B) Asymmetric sounds C) Inspiratory sounds D) Sounds louder in the lower chest

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

5. A young Hispanic mother brings in her 2-mo 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 & spontaneous vaginal delivery. On examination you see a large, smooth-bordered bluish mark on his buttock & 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

Ans: 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. document well at birth

7. A mother brings in her 3-yo 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 & vaginal delivery. He has hit all of his developmental milestones on time. On examination he is 26 lbs (11.8 kg) & is 35 inches (89 cm) tall. Otherwise his examination is unremarkable. You give the correct education for his age & then discuss his size. For his age, what are his growth chart percentiles? A) Tall & heavy for his age (>95%) B) Average height & weight for his age (5 to 95%) C) Small & light for his age (<5%)

Ans: C Small & light for his age (<5%) According to the growth charts, this child is <5th percentile for both ht & wt, indicating that he is small & 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 ht & wt than if he has always been about the same percentile & following a line parallel to expected growth lines.

2. A 24yo mother who is a smoker & cocaine addict gave birth at 39 wks to a 2,000-g female infant who is in the NICU. Using the Intrauterine Growth Curve chart, you determine whether the infant's wt 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

Ans: C Small for gestational age For a 39-wk infant, any weight <2,500 g would be considered SGA. --Intrauterine growth retardation & low birth weight would be expected in a smoker who also abuses cocaine.

23. You are examining a 5-yo before he begins school. You notice a systolic, grade II/VI vibratory murmur over the LLSB & 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

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

20. A mother is upset because she was told by another provider that her child has a worrisome murmur. You listen near the clavicle & notice both a systolic & 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

Ans: C Supine examination The next step would be to examine the pt 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.

15. You are examining an infant in the nursery & 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

Ans: D Cephalohematoma Cephalohematoma (bleeding under the periosteum), 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. --Plagiocephaly a flat spot on a baby's head that develops when a baby spends too much time back lying --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.

3. A mother brings her 16-mo son in for an evaluation. She is afraid he is not meeting his developmental milestones & wants to know if he should be sent to therapy. He was the product of an uneventful pregnancy & a spontaneous vaginal delivery. His Apgar scores were 7 & 9. Until reaching 1 yo 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 & can take off his own shoes & shirt. He can build a tower of two cubes & dump raisins. His vocabulary consists of at least 10 words. He can stand alone & stoop & 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

Ans: D Gross motor By 16 mo a child should be able to walk unaided & even walk backward & run. --This child was referred to physical therapy & did well.

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

Ans: 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.