Diagnosis - Pediatrics

Also called ascorbic acid, is a water-soluble vitamin which is mostly essential for collagen synthesis and its antioxidant properties. The vitamin catalyzes several enzymes in the synthesis of collagen as well as catecholamine synthesis. When the vitamin is deficient, the most notable effect is the onset of Scurvy, a disease characterized by poor wound healing and perifollicular hemorrhage. Additionally, patients deficient in the vitamin can have anemia due to poor antioxidant ability as well as iron absorption problems.

Vitamin C deficiency

Scurvy = poor wound healing, petechiae, bleeding gums

Vitamin C deficiency

What is the most worrisome complication associated with hip dislocation? A. Acetabular artery injury B. Increased chance of recurrent dislocation C. Fracture D. Labral injury E. Pelvic floor injury

A. Acetabular artery injury Hip dislocation, often caused by 'dashboard injury' or posterior directed force causing posterior dislocation, may result in injury to the acetabular artery which may lead to avascular necrosis and femoral head collapse.

Causes oral herpes, commonly called cold sores. Other manifestations include herpetic gingivostomatitis, keratoconjunctivitis, and temporal lobe encephalitis. After the patient begins to produce antibodies, ____ becomes latent in the trigeminal ganglia and can become reactivated with certain stimuli including stress and UV light exposure. Acyclovir is commonly used as treatment.

Type 1 HSV

Primarily a sexually transmitted infection that can cause clusters of inflamed vesicles on the outer surface of the genitals. __________ becomes latent in the sacral ganglia. These organisms can be visualized on Tzanck smear, which is a scraping of an ulcer base for evidence of multinucleated giant cells. Acyclovir is commonly used as treatment.

Type 2 HSV

Most commonly causes a holosystolic murmur as its most notable ausculatory finding rather than a continuous machinery-like murmur. Characterized by a holosystolic murmur at the LLSB.

Ventricular septal defect = MC form of congenital heart disease

Erythematous macular papular rash that is pruritic often starting in childhood accompanied by other atopy, aka hay fever, asthma.

Atopic dermatitis

Dermatology: Dermatitis

Dermatology: Dermatitis

Most common in children, esp < 5 years old; Asians highest risk and thought to occur after respiratory pathogen or viral syndrome

Kawasaki Disease

Constipation

Constipation

A 5-year-old girl is brought to your clinic by her mother because she has developed a rash on her arms and trunk after playing with a neighborhood cat several days ago. Which of the following physical examination findings would suggest a diagnosis of tinea corporis? A. Annular lesions with erythematous advancing borders and a central clearing B. Velvety, hypopigmented macules C. Erythematous morbilliform rash D. Salmon-colored oval papules E. Copper-colored annular plaques with scaling

A. Annular lesions with erythematous advancing borders and a central clearing This description is commonly associated with tinea corporis. Lesions are often pruritic with fine scales. It can be contracted by direct contact with another infected person, or through contact with infected animals. KOH prep will show hyphae. It is treated with topical antifungal agents.

A 20-month-old infant is brought to the clinic. Her mother states that the child has a red, bumpy rash along the anterior elbow and the posterior knees, which has been present for 3 months. She has noticed the child scratching the areas. The mother confirms a positive family history of asthma and hay fever. What is the most likely diagnosis? A. Atopic dermatitis B. Roseola Infantum C. Tinea Corporis D. Contact Dermatitis E. Dishydrotic Dermatitis

A. Atopic dermatitis Atopic dermatitis is a common skin condition in infants and children, commonly appearing on the flexor surfaces and head/neck. It is often seen in cases where there is a positive personal or family history of asthma and allergic rhinitis.

A 9-year-old boy comes to the office with his mother to discuss treatment for chronic dry skin, and pruritic inflammatory lesions of the flexor surfaces of the neck, hands and wrists. Past medical history is significant for allergic rhinitis in the spring and fall. On physical examination the skin lesions are excoriated, and lichenified with crusted patches. Which of the following prevention strategies can help minimize the symptoms in this patient? A. Avoid rubbing or scratching B. Limit sun exposure C. Take hot baths D. Consume hot liquids

A. Avoid rubbing or scratching Rubbing or scratching plaques can exacerbate the pruritis and lichenification in atopic dermatitis.

In a patient who has testicular torsion, you would expect to find all of the following on physical exam EXCEPT? A. Bilateral loss of cremasteric reflex B. High riding testes C. Scrotal swelling D. Testicular tenderness E. Transverse lie of the testicle

A. Bilateral loss of cremasteric reflex The usual presentation is an ipsilateral loss of cremasteric reflex. All other answers represent physical exam findings of a patient with testicular torsion. This condition is considered a medical emergency.

Which of the following types of hip fracture has the highest risk for avascular necrosis and nonunion? A. Femoral neck B. Intertrochanetric C. Subtrochanteric D. Greater trochanteric

A. Femoral neck Fractures involving the femoral neck typically disrupt the blood supply to the femoral head and may cause avascular necrosis and nonunion.

The presence of solitary/multiple, isolated abscess formation without scarring or sinus tract characterizes what clinical stage of hidradenitis suppurativa? A. First stage B. Second stage C. Third stage D. Fourth stage

A. First stage The first stage is characterized by the presence of solitary/multiple, isolated abscess formation without scarring or sinus tract. The second stage is characterized by recurrent abscesses, single/multiple widely separated lesions, with sinus tract formation and cicatrization. The third stage is characterized by diffuse/broad involvement, with multiple interconnected sinus tracts/abscesses. There is no fourth stage.

A 17-year-old teenage boy comes to the clinic with an inflamed mass in the right axilla for five days. Physical examination shows a 4 cm indurated, deep-seated mass that is tender to palpation. The patient is afebrile. There is no streaking or fluctuance. He reports that he has had similar bumps in the area on and off over the past year, that usually resolve after about one week. Which of the following is the most likely diagnosis? A. Hidradenitis suppurativa B. Cellulitis C. Abscess D. Erysipelas E. Boils

A. Hidradenitis suppurativa HS arises from a chronically clogged apocrine gland. Diagnosis of this condition is based upon clinical characteristics, and does not require a biopsy. The three main factors to consider if this diagnosis is suspected are: 1) lesions must be typical for HS - round, deep nodules that may appear alone or in groups, 2) lesions must appear in typical locations - most often in axilla, groin, or inframammary area, and 3) chronicity or relapses are common.

Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions? A. Hirschsprung's disease B. Meckel's diverticulum C. Chagas disease D. Hashimoto's hypothyroidism

A. Hirschsprung's disease Hirschsprung disease, also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.

Which of the following is accurate regarding the treatment of contact dermatitis? A. Patients should avoid using topical antihistamines, including topical doxepin B. When medication is indicated, topical corticosteroids are no longer considered the mainstay of treatment C. Removing the tops of large vesicles is routinely beneficial D. The application of warm-to-hot water is recommended to reduce serous drainage in mild contact dermatitis

A. Patients should avoid using topical antihistamines, including topical doxepin Patients should avoid using topical antihistamines, including topical doxepin, because of the risk for iatrogenic allergic contact dermatitis to these agents; additionally, sedation can occur if large amounts of doxepin cream are applied.

What is the most effective prophylaxis against respiratory syncytial virus (RSV) infection in the general pediatric population? A. Proper hand-washing techniques B. A monoclonal antibody C. H. Influenzae B vaccine D. Oseltamivir (Tamiflu)

A. Proper hand-washing techniques Proper hand washing and reduction in exposure is most effective in general population to prevent RSV.

Which of the following is the most appropriate study for diagnosing Hirschsprung disease? A. Rectal biopsy B. Stool leukocyte test C. CT of the abdomen and pelvis D. Fecal occult blood test

A. Rectal biopsy A rectal biopsy showing the absence of ganglion cells in both the submucosal and muscular layers of the involved bowel is the most appropriate diagnostic study for Hirschsprung disease.

A patient presents with eye pain and blurred vision. Snellen testing reveals vision of 20/200 in the affected eye and 20/20 in the unaffected eye. Fluorescein staining reveals the presence of a dendritic ulcer. Which of the following is the most likely diagnosis? A. Viral keratitis B. Fungal corneal ulcer C. Acanthamoeba keratitis D. Bacterial corneal ulcer

A. Viral keratitis Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining.

A person with atopic dermatitis should be advised to: A. avoid cutaneous irritants. B. take hot water baths or showers. C. use a high potency glucocorticoid on skin after bathing. D. begin a prophylactic antibiotic.

A. avoid cutaneous irritants. Avoidance of cutaneous irritants, such as wool and other rough clothing, is the cornerstone of therapy for atopic dermatitis.

A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding? A. stridor B. aphonia C. inability to cough D. progressive cyanosis

A. stridor An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea or larynx.

A 63-year-old man comes to the emergency department with constipation for seven days. He admits to chronic back pain for which he takes oxycontin 30 mg twice daily to help relieve his pain. On physical examination hard stool is noted in the rectal vault. An abdominal radiograph shows a large amount of stool in the rectum and distal colon, but no signs of obstruction. All of the following are appropriate interventions at this time EXCEPT: A.Colace B.Digital disimpaction C.Polyethylene glycol 3350 (GoLYTELY) D.Magnesium citrate E.Sodium phosphate enema

A.Colace While stool softeners are an appropriate therapy for patients using narcotic medications, this patient has not had a bowel movement in seven days and is in the emergency department for treatment. All other options may help relieve his constipation at this time. Colace has not been proven to be more effective than placebo in the treatment of acute constipation.

A 36 year old woman presents to the urgent care complaining of increasing fatigue and weight gain over the last two months. She is worried since her mother had issues with her thyroid. On physical exam you note a diffusely enlarged thyroid gland that is non-tender to palpation. Lab testing reveals an increased TSH level, decreased free T4, and positive antithyroglobulin antibodies. Which of the following is the most likely diagnosis? A.Hashimoto's thyroiditis B.Subacute thyroiditis C.Postpartum thyroiditis D.Suppurative thyroiditis E.Reidel's thyroiditis

A.Hashimoto's thyroiditis Hashimoto's thyroiditis is the most common type of thyroiditis and is generally an autoimmune type disease affecting females. They will generally have a non-tender gland, and positive anti-TPO, and anti-TGB antibodies. These patients should be treated with thyroid hormone replacement.

What is the most common type of thyroiditis? A.Hashimoto's thyroiditis B.Subacute thyroiditis C.Postpartum thyroiditis D.Suppurative thyroiditis E.Reidel's thyroiditis

A.Hashimoto's thyroiditis Hashimoto's thyroiditis is the most common type of thyroiditis and is generally an autoimmune type disease affecting females. They will generally have a non-tender gland, and positive anti-TPO, and anti-TGB antibodies. These patients should be treated with thyroid hormone replacement.

Which of the following Vitamin deficiencies is most likely to present with poor wound healing? A.Vitamin C B.Vitamin B 12 C.Vitamin D D.Vitamin A E.Niacin

A.Vitamin C Scurvy is the condition of Vitamin C deficiency. Lack of vitamin C prevents proper synthesis of collagen and connective tissues. It presents with poor wound healing, and may also show petechiae, arthralgias, bleeding gums, and loose teeth. Onset of symptoms is within several months of following a diet deficient in Vitamin C.

Defined as cellular death of bone components due to interruption of the blood supply. The bone structures then collapse, resulting in bone destruction, pain, and loss of joint function. This usually involves the epiphysis of long bones, such as the femoral or humeral heads. Small bones can also be affected. This is most commonly encountered in the hip.

Avascular necrosis (AVN) of the femoral head

What are the signs of an acute herpes simplex infection?

Acute infection = development of multinucleated giant cells.

Nickel, poison ivy etc. Type 4 hypersensitivity

Allergic Contact Dermatitis

_____________ are commonly ordered when Hashimoto thyroiditis is suspected.

Antithyroperoxidase antibodies

A 4-year-old patient presents with episodic wheezing and a non-productive cough for the last 4 weeks. His symptoms are worse at night. Past medical history reveals a history of atopic dermatitis. Physical examination at this time is unremarkable. Which of the following is the most likely diagnosis?

Asthma Asthma is a chronic inflammatory disorder of the airways. It is characterized by episodic or chronic symptoms of airflow obstruction, breathlessness, cough, wheezing, and chest tightness. The strongest identifiable predisposing factor for the development of asthma is atopy.

A 3-year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future?

Asthma Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future.

Diagnosis is clinical: Pruritic papules and plaques

Atopic Dermatitis

Infant- face, and scalp Adolescent- flexural surfaces

Atopic Dermatitis

Pruritic, eczematous lesions, xerosis = dry skin, and lichenification = thickening of the skin and an increase in skin markings. Most common on flexor creases ex. antecubital and popliteal folds

Atopic Dermatitis

IgE, type 1 hypersensitivity

Atopic Dermatitis = Inflammation in atopic dermatitis results in lichenification of the skin from itching, which leaves the skin dry and scaly when it resolves. The inflammation is the result of elevated T-lymphocyte activation, defective cell- mediated immunity, and IgE overproduction.

Topical corticosteroids and emollients, topical calcineurin inhibitor ie, tacrolimus or pimecrolimus. Patients with moderate to severe that is not controlled with optimal topical therapy may require phototherapy or systemic immunosuppressant treatment to achieve adequate disease control.

Atopic dermatitis treatment

Atopic dermatitis, also known as eczema is a chronic inflammatory skin condition. Patients often experience a pruritic, erythematous, vesicular rash that occurs on the cheeks in infants and the flexural areas in adults. Atopic dermatitis is highly associated with other atopic diseases like asthma and allergic rhinitis. The preferred management of atopic dermatitis is a multi-pronged approach to avoid triggers, restore the skin barrier function and treat the inflammation. Treatment depends on severity but may include moisturizers, corticosteroids, tacrolimus, antihistamines, and phototherapy.

Atopic dermatitis, also known as eczema is a chronic inflammatory skin condition. Patients often experience a pruritic, erythematous, vesicular rash that occurs on the cheeks in infants and the flexural areas in adults. Atopic dermatitis is highly associated with other atopic diseases like asthma and allergic rhinitis. The preferred management of atopic dermatitis is a multi-pronged approach to avoid triggers, restore the skin barrier function and treat the inflammation. Treatment depends on severity but may include moisturizers, corticosteroids, tacrolimus, antihistamines, and phototherapy.

Patient will present as a 39 year old HIV positive male with CD4 count less than 50 develops cough, sputum production, fevers, and weight loss

Atypical mycobacterial disease

Long-term presentations: Weight loss, failure to gain weight, and wasting syndrome, leukopenia, hepatosplenomegaly, and persistent generalized lymphadenopathies.

Atypical mycobacterial disease = Pulmonary disease, disseminated disease in AIDS, Skin and soft tissue disease, and Lymphadenitis.

Presents with non-tender unilateral lymphadenopathy in a systemically well child.

Atypical mycobacterial disease = Pulmonary disease, disseminated disease in AIDS, Skin and soft tissue disease, and Lymphadenitis.

What is the treatment for a pulmonary infection that typically occurs in patients with underlying lung disease and it is a disseminated disease noted in patients with advanced HIV.

Atypical mycobacterial disease treatment: Azithromycin or Clarithromycin, rifabutin or rifampin and ethambutol; Prophylactic treatment with Azithromycin or Clarithromycin when CD4 count < 50.

This is a late complication of fracture resulting from disruption of the blood supply to the bone.

Avascular necrosis

A 9-year-old boy comes to the office with his mother to discuss treatment for chronic dry skin, and pruritic inflammatory lesions of the flexor surfaces of the neck, hands and wrists. Past medical history is significant for allergic rhinitis in the spring and fall. On physical examination the skin lesions are excoriated, and lichenified with crusted patches. Which of the following prevention strategies can help minimize the symptoms in this patient?

Avoid rubbing or scratching Rubbing or scratching plaques can exacerbate the pruritis and lichenification in atopic dermatitis

Which of the following statements is accurate about the presentation of contact dermatitis? A. Cumulative irritant contact dermatitis typically occurs with exposure to strong irritants rather than weak ones B. A minimum of 10 days is required for individuals to develop specific sensitivity to a new contactant C. The clinical appearance suggests the etiologic agent in most cases of acute irritant contact dermatitis D. Onset of dermatitis within 2 weeks of exposure and reports of coworkers or family members affected are among the more important criteria for irritant contact dermatitis

B. A minimum of 10 days is required for individuals to develop specific sensitivity to a new contactant A minimum of 10 days is required for individuals to develop specific sensitivity to a new contactant. For example, an individual who never has been sensitized to poison ivy may develop only a mild dermatitis 2 weeks following the initial exposure but typically develops severe dermatitis within 1-2 days of the second and subsequent exposures.

What is the pathologic mechanism of Hirschsprung's disease? A. Pyloric circular muscle hypertrophy causing gastric outlet obstruction B. Absence of ganglion cells in the mucosal and muscular layers of the colon C. A defect in the diaphragm leading to protrusion of the abdominal viscera into the thoracic cavity D. Absence of relaxation of the lower esophageal sphincter and lack of peristalsis in the esophageal body

B. Absence of ganglion cells in the mucosal and muscular layers of the colon Hirschsprung's disease results from an absence of ganglion cells in the mucosal and muscular layers of the colon.

An 8-month-old girl is brought to the emergency department by her parents because she has had fever, runny nose, and cough for the past three days. Over the past day, she has also had progressive difficulty feeding. Temperature is 38.3°C (101°F). Physical examination shows an infant in moderate respiratory distress with nasal flaring and expiratory wheezing. Chest x-ray study shows hyperinflation and peribronchial thickening. Which of the following is the most likely diagnosis? A.Asthma B. Bronchiolitis C. Foreign body aspiration D. Pertussis E. Pneumonia

B. Bronchiolitis Bronchiolitis is an inflammation of the bronchioles that typically occurs in children less than 2 years of age. It presents with coughing, wheezing and shortness of breath which can cause some children difficulty in feeding. This inflammation is usually caused by respiratory syncytial virus (70% of cases), and is much more common in the winter months.

A 3-year-old male presents with his mother, who is reporting that he began coughing and wheezing about an hour ago while eating lunch. His temperature and pulse are within normal limits and his respirations are 26 per minute. No cyanosis is noted. Chest X-ray is normal. You suspect that he has a partial obstruction of the trachea due to a foreign body. What is the most appropriate next step in the care of this patient? A. Start O2 at 2 liters flow by nasal canula B. Bronchoscopy C. Tracheostomy D. Endotracheal intubation E. Observation

B. Bronchoscopy Bronchoscopy is the definitive test to confirm the diagnosis of tracheal foreign body, and removal can be accomplished at the same time.

Where is atopic dermatitis most commonly seen in infants and young children? A. Scalp B. Cheeks C. Palms and soles D. Upper back and thighs E. Groin area

B. Cheeks The most common site for atopic dermatitis in infants and children are the cheeks. Atopic dermatitis is also common on flexor surfaces including the antecubital and popliteal fossae.

A 15-year-old man comes to the office with acute onset of nausea, severe pain and swelling within the right testis. He has no fever or irritative voiding symptoms. Which of the following scrotal physical examination findings would you expect in this patient? A. Nodular mass within the testis B. High-lying testis C. Transilluminated fluid mass D. Palpation of a soft bag of worms

B. High-lying testis Testicular torsion occurs in the 10-20 year age group, and is characterized by acute onset of severe pain and swelling of the testis. Physical examination will reveal a tender high-riding testis. . In testicular torsion, you will have a negative Prehn's sign and no relief of pain.

A 28-year-old soccer player presents to the emergency room complaining of right testicular pain of sudden onset during a game. Physical exam reveals an absent right cremasteric reflex and an extremely tender and indurated right testicle. Which of the following is the next best step in management of this patient? A. Observation B. Surgical consult C. Empiric antibiotics D. MRI scan of the testes E. Ice and elevation

B. Surgical consult Testicular torsion should be assumed based on physical exam and immedate urological/surgical consultation needs to be obtained to get the patient to the OR as soon as possible. A classic exam question, the answer is NOT to wait for confirmatory testing because this can result in a delay that kills the testicle. Also remember that a present cremasteric reflex does not completely rule out testicular torsion.

A 5-year-old presents to your office complaining of scrotal pain and you note swelling of the left testis. What is the appropriate next step? A. Elevation of the scrotum and ice therapy B. Ultrasound evaluation with Doppler color flow C. Continued observation D. Computed tomography (CT) scan of the pelvis E. Doppler stethoscope evaluation

B. Ultrasound evaluation with Doppler color flow Testicular torsion should be suspected in patients who complain of acute scrotal pain and swelling. Testicular viability is in jeopardy with delay in diagnosis, ultimately impacting the patient fertility. Associated conditions that may resemble testicular torsion not warranting surgery are torsion of a testicular appendage, epididymitis/ orchitis, trauma, incarcerated hernia, varicocele, and idiopathic scrotal edema. Testicular torsion is most common in men younger than 25 years old, although it can occur in men of any age. A prepubertal or young male adult with acute scrotal pain should be diagnosed as testicular torsion until proven otherwise. Physical exam finding of higher testicular lie and absent cremasteric reflex are supportive evidence for this condition. Scrotal imaging with Doppler color flow ultrasound is necessary when the diagnosis remains unclear. Once the correct diagnosis is established, prompt surgical evaluation should be performed. It is reasonable to perform manual detorsion for immediate noninvasive treatment followed by elective orchiopexy.

A 16-year-old male presents with increasing pain and swelling of his right scrotum. The right testicle is extremely tender to palpation on examination. A Doppler ultrasound demonstrates decreased blood flow. Which of the following is the most appropriate intervention? A. oral doxycycline B. emergent surgery C. incision and drainage D. scrotal elevation and ice packs

B. emergent surgery Once a diagnosis of testicular torsion is suspected, emergent surgery is indicated to have the best possible chance of salvaging the testicle (85-97% chance if less than 6 hours). Any other treatment measures delay the definitive treatment and increase the risk of testicular ischemia and infarction.

Which of the following fractures is associated with the greatest risk of avascular necrosis of the femoral head? A. intertrochanteric B. femoral neck C. subtrochanteric D. pelvic rim

B. femoral neck Femoral neck fractures lead to the greatest disruption of arterial blood supply to the femoral head.

What demographics are most commonly associated with testicular torsion? A. infants B. young males through late teens C. males age 20 to mid thirties D. middle-aged males E. males > age 70

B. young males through late teens This is a urological emergency that requires surgery. The pain is characteristically unilateral and sudden which can even awaken the patient from sleep.

What demographics are most commonly associated with testicular torsion? A. infants B. young males through twenties C. middle-aged males D. males > age 65

B. young males through twenties

Which of the following gastrointestinal conditions occurs primarily in young children, and is characterized pathologically by the absence of ganglion cells (i.e. absence of Meissner and Auerbach autonomic plexus)? A.Crohn disease B.Hirschsprung disease C.Intussusception D.Irritable bowel syndrome E.Volvulus

B.Hirschsprung disease Hirschsprung disease is a congenital anomaly of innervation of the lower intestine, usually limited to the colon, resulting in partial or total functional obstruction. It is caused by the congenital absence of the Meissner and Auerbach autonomic plexus (aganglionosis) in the intestinal wall.

A 2-year-old child presents to the emergency department with increasing respiratory distress. The mother states that the child had a "cold" 2 weeks ago. Last week the cough progressed and is described as barky in nature, associated with stridor. The child appeared to be getting better, but last night,developed a fever and increased respiratory distress. Physical examination reveals a temperature of 102°F. The child is in moderate respiratory distress. A portable lateral neck x-ray film reveals severe subglottic and tracheal narrowing. Which of the following is the most likely diagnosis?

Bacterial tracheitis Bacterial tracheitis usually presents following a viral upper respiratory infection, especially laryngotracheobronchitis (croup). It should be suspected when a patient develops high fever and respiratory distress after a few days of apparent improvement or if the patient fails to respond to the usual treatment for croup. The findings of subglottic and tracheal narrowing on the lateral neck x-ray film highly support this diagnosis.

Which of the following is the most common organic cause of constipation in children? A. Parkinson's disease B. Colon cancer C. Hirschsprung disease D. Diverticular disease

C. Hirschsprung disease Hirschsprung disease is the most common organic cause of constipation in children. It is a congenital anomaly of innervation of the lower intestine, usually limited to the colon, resulting in partial or total functional obstruction. Symptoms are obstipation and distention. Diagnosis is by barium enema and rectal biopsy. All others occur in adulthood.

Which of the following is accurate regarding the etiology of contact dermatitis? A. Poison ivy (Toxicodendron radicans) is the leading cause of allergic contact dermatitis around the world B. Dry air alone is insufficient to provoke irritant contact dermatitis C. Acrylates and methacrylates have been significantly associated with contact allergy and allergic contact disease D. Irritation associated with trauma is not considered contact dermatitis

C. Acrylates and methacrylates have been significantly associated with contact allergy and allergic contact disease Acrylates and methacrylates have been recognized as emerging, important causes of contact allergy and allergic contact disease. A study that spanned 13 years determined that acrylic nail sources and wound dressings represent emerging sources of sensitization. A separate study found that acrylates and methacrylates were significantly associated with allergic contact dermatitis.

Which of the following is the most appropriate intervention in suspected child abuse? A. Arrange for the arrest of the parents. B. Confront the suspected assailant in front of the child. C. Assure the safety of the child, with hospitalization if necessary. D. Contact social service department after discharge of the child.

C. Assure the safety of the child, with hospitalization if necessary. The primary goal should be the safety and well-being of the child. Hospitalization may be the only way the clinician has to remove the child from the care of a possible abusive home if no other recourse is available due to a lack of social services and investigators.

The mother of a 2-year-old with atopic dermatitis asks how frequently she should bathe her. What is the best answer? A. Bathing is not recommended for children with atopic dermatitis. B. Bathing once per week is optimal for children with atopic dermatitis. C. Bathing once or even twice daily can be helpful in some cases, so long as gentle cleansers are used and moisturizers are applied immediately after bathing. D. Bathing 3-4 times daily is ideal for all patients with atopic dermatitis. E. Bathing in salt water is the only acceptable way for patients with atopic dermatitis.

C. Bathing once or even twice daily can be helpful in some cases, so long as gentle cleansers are used and moisturizers are applied immediately after bathing. Bathing once or even twice daily can be helpful in some cases, so long as gentle cleansers are used and moisturizers are applied immediately after bathing. Also make sure to recommend the use of tepid water.

A 3 month-old female presents with her mom for physical examination. The patient's mom denies any complaints. On examination, you note a well-developed, well-nourished infant in no apparent distress. There is no cyanosis noted. Heart examination reveals a normal S1 with a physiologically split S2. There is a grade III/VI high-pitched, harsh, pansystolic murmur heard best at the 3rd and 4th left intercostal spaces with radiation across the precordium. Which of the following is the initial diagnostic study of choice in this patient? A. CT angiogram B. Electrocardiogram C. Echocardiogram D. Cardiac catheterization

C. Echocardiogram Echocardiogram is the initial diagnostic study of choice in the diagnosis of a VSD.

An 18-year-old man is seen in the urgent care clinic for a rash that developed on his right ring finger one day after he started wearing his new high school graduation ring. He states the finger is itchy, and the affected skin is slightly red with some small blisters. Allergy to which of the following metals is the most likely cause of this patient's condition? A. Cobalt B. Gold C. Nickel D. Platinum E. Silver

C. Nickel Nickel is the most common cause of metal induced contact dermatitis.

Which of the following is the most appropriate plan for a patient with Legg-Calve-Perthes disease? A. Corticosteroid injections B. Adduction splinting C. Orthopedic consultation D. Broad-spectrum antibiotics E. Watchful waiting

C. Orthopedic consultation Legg-Calve-Perthes disease (LCPD) results from avascular necrosis of the femoral head, proximally. This condition tends to occur most often in males, ages 4-10. These patients should be referred to an orthopedist for evaluation and treatment and remain non-weight bearing until evaluated by ortho.

Which of the following is accurate about the workup for contact dermatitis? A. Laboratory studies are key in positively confirming a diagnosis of contact dermatitis B. Patch testing is used to confirm that a cutaneous irritant is responsible for a particular case of irritant contact dermatitis C. Potassium hydroxide preparation or fungal culture is often indicated to exclude tinea in dermatitis of the hands and feet D. Skin biopsy is routinely indicated in patients with suspected contact dermatitis

C. Potassium hydroxide preparation or fungal culture is often indicated to exclude tinea in dermatitis of the hands and feet Potassium hydroxide preparation and/or fungal culture to exclude tinea are often indicated for dermatitis of the hands and feet. This helps identify disorders such as tinea pedis.

What is the definitive diagnostic test for a patient with suspected testicular torsion? A. Scrotal CT with IV contrast B. Scrotal CT without contrast C. Scrotal ultrasound D. Pelvic radiography E. Scrotal MRI

C. Scrotal ultrasound Testicular torsion is a potentially devastating event in which arterial blood supply to the testicle is interrupted. Color doppler ultrasound is the mainstay of diagnosis of testicular torsion. Additionally, scrotal ultrasound allows for the evaluation of other pathology should torsion be on the differential but not proven by imaging. Prior to the use of real-time, high definition color doppler ultrasound, nuclear scintigraphy was test of choice.

A two-month-old infant appeared well until three weeks ago when he became dyspneic and had difficulty feeding. A 4/6 holosystolic murmur is heard at the left lower sternal border in the 3rd ICS. An electrocardiogram (ECG) shows left and right ventricular hypertrophy. Which of the following is the most likely diagnosis? A. Atrial septal defect B. Pulmonary hypertension C. Ventricular septal defect D. Tricuspid insufficiency

C. Ventricular septal defect This is a classic presentation for a ventricular septal defect.

A 2-year-old child is brought to the office because of a cough and a fever of 102 degrees F for 2 days. The physician assistant notes the presence of hoarseness, a barking cough, and stridor. The ears and nose exam are unremarkable. Auscultation of the chest reveals decreased breath sounds without crackles or expiratory wheezes. Which of the following would be the initial diagnostic impression? A. pneumonia B. bronchiolitis C. croup D. asthma

C. croup Hoarseness, inspiratory stridor, and a barking cough are classic signs of croup, all of which are noted in this patient.

Which of the following statements is true concerning atopic dermatitis (AD) in infants and young children? A. approximately 25% of patients with atopic dermatitis develop allergies and/or asthma B. topical calcineurin inhibitors such as pimecrolimus (Elidel) are first-line agents in infants with mild atopic dermatitis C. infants with atopic dermatitis typically present with pink, chapped cheeks and respond to topical low-dose corticosteroids D. approximately 75% of infants continue to have atopic dermatitis in adulthood E. atopic dermatitis is associated with low IgE levels

C. infants with atopic dermatitis typically present with pink, chapped cheeks and respond to topical low-dose corticosteroids Approximately 80% of patient with AD develop allergies and/or asthma, although 50% of infants and young children resolve their AD symptoms by 18 months of age and another 75% by later in childhood. Topical calcineurin inhibitors are no longer first-line medications, but they may be used for moderate AD that does not respond to other treatments in children older than age 2 years. AD is associated with high IgE levels.

A 3-year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is A. renal. B. cardiac. C. pulmonary. D. hepatic.

Cardiac The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.

Common ages 9-12 and often by male known to child Any raises suspicion: evidence of sexually transmitted infection, knowledge about sexual acts inappropriate for age, initiates sexual acts with others, peers, exhibits sexual knowledge through play

Child Sexual Abuse

Injury not adequately explained or inconsistent with history given: Bruises/lacerations/soft-tissue swelling, dislocations/fractures, spiral fractures; Burns = doughnut-shaped, stocking-glove, symmetrically round; Bruises or injuries with regular patterns on face, back, buttocks, thighs; Internal hemorrhages, abdominal injuries, bite marks, injury with shape of instrument used

Child abuse

May also manifest with: Anxiety Aggressive/violent behavior PTSD Depression or suicide Substance abuse Poor self-esteem Dissociative disorders Paranoid ideation Failure to thrive

Child abuse

Patient will present with bloating, abdominal pain, straining and pain with bowel movements. History of less than 3 bowel movements per week.

Constipation

Diagnosis is clinical: Well-demarcated erythema, erosions, vesicles

Contact Dermatitis

Well-demarcated erythema, erosions, vesicles

Contact Dermatitis

Caused by contact with an irritant to the skin and presents with dry, edema, erythematous, and pruritic vesicles in a linear distribution.

Contact dermatitis

Pruritic demarcated areas of erythema at site of contact of irritant.

Contact dermatitis

Avoid offending agent. Burrow's solution = aluminum acetate, topical steroids, zinc oxide = diaper rash

Contact dermatitis treatment

"Steeple sign" on PA neck X-Ray: narrowing of the trachea in the subglottic region

Croup

Usually presents with a prodrome of upper respiratory tract symptoms followed by onset of a barking cough and stridor.

Croup

A 2-year-old child is brought to the office because of a cough and a fever of 102 degrees F for 2 days. The physician assistant notes the presence of hoarseness, a barking cough, and stridor. The ears and nose exam are unremarkable. Auscultation of the chest reveals decreased breath sounds without crackles or expiratory wheezes. Which of the following would be the initial diagnostic impression?

Croup Hoarseness, inspiratory stridor, and a barking cough are classic signs of croup, all of which are noted in this patient.

Treatment is antipyretics, hydration, nebulized racemic epinephrine: only if signs of distress, and corticosteroids. Prognosis is excellent.

Croup treatment

A 4-year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?

Croupy cough and drooling A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.

Which of the following is the appropriate treatment for contact dermatitis? A. Steroid cream B. Antihistamine cream C. Avoid the offending agent D. All of the above

D. All of the above

Which of the following is the treatment of choice for Kawaski's disease? A. Methotrexate B. Prednisone C. Pencillin D. Aspirin

D. Aspirin Patients with Kawasaki's disease present with fever, bilateral conjunctival injection, pharyngeal erythema, edema of the hands and feet, rash, and LAD. Tx of choice is high-dose aspirin and IV immunoglobulin

A 2-year-old presents with sudden onset of cough and stridor. On examination, the child is afebrile and appears non- toxic with a respiratory rate of 42 breaths per minute. What is the next step in the evaluation of this patient? A. Lateral soft tissue x-ray of the neck B. Indirect laryngoscopy C. Finger sweep D. Chest x-ray

D. Chest x-ray Chest x-ray should be done first when foreign body aspiration is suspected.

A 5-year-old boy is brought to your office because his mother has noticed him walking with a limp that didn't resolve after a few days. He has now been limping for the past week, but does not complain of pain. Physical exam is unremarkable, other than mildly restricted internal rotation of the hips bilaterally. Which of the following diagnostic studies is the next best step in the evaluation of this patient? A. Joint fluid aspiration with culture and sensitivity B. MRI of the hips C. Bilateral hip radiographs D. Complete blood count and erythrocyte sedimentation rate E. Serum uric acid levels

D. Complete blood count and erythrocyte sedimentation rate This clinical presentation most likely represents a patient with Legg-Calve-Perthes disease. An idiopathic avascular necrosis of the femoral head commonly affecting males ages 4-8. Bilateral hip radiography including AP, Lateral, and Frog leg views is indicated as the initial diagnostic evaluation in these patients.

A 14-year-old girl with a history of atopic dermatitis on the hands and wrists notes that she is using hydrocortisone 2.5% ointment twice daily every day and is only getting minimal relief. On exam, there is thick lichenification of the hands and wrists with many excoriations. What is the best next step? A. Advise to stop all topical corticosteroids at this time B. Treat with an oral antibiotic for several weeks to exclude infection C. Advise daily dilute bleach baths to prevent infection D. Increase the potency of the topical steroid to fluocinonide given the location and thick lichenification E. Decrease the potency of the topical steroid to hydrocortisone 1% cream to minimize the chance of steroid-related side effects

D. Increase the potency of the topical steroid to fluocinonide given the location and thick lichenification The appropriate next step would be to Increase the potency of the topical steroid to fluocinonide given the location and thick lichenification

Which of the following is a long-term manifestation of atopic dermatitis? A. Seborrheic dermatitis B. Perioral dermatitis C. Psoriasis D. Lichen Simplex Chronicus

D. Lichen Simplex Chronicus Lichen simplex chronicus (LSC), also termed neurodermatitis, is lichenification (thickening) of the skin. LSC is a sequela of several dermatological processes and is caused by chronic rubbing and itching of the skin.

Which of the following valvular heart abnormalities will most likely be seen on echocardiography as a complication of acute myocardial infarction? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral regurgitation

D. Mitral regurgitation In patients with acute myocardial infarction, echocardiogram can show the severity of mitral regurgitation and the presence of VSD if one is present. Acute inferior wall myocardial infarction is associated with acute mitral regurgitation due to necrosis of the posterior papillary muscle which is supplied by the right coronary artery.

A 2-year-old presents to the emergency department in acute respiratory distress. The parents relate a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing. The child is noted to have stridor at rest, but has no evidence of cyanosis. Which of the following is the most appropriate initial intervention? A. Intravenous antibiotics B. Endotracheal intubation C. Inhaled mucolytic agent D. Nebulized racemic epinephrine

D. Nebulized racemic epinephrine This patient most likely has laryngotracheobronchitis (viral croup). Treatment with nebulized racemic epinephrine and glucocorticosteroids is indicated for patients with stridor at rest.

A 9 year-old male is brought in by his mother who reports the patient has exhibited an extremely negative attitude for the past year. He seems angry much of the time and frequently loses his temper. Arguing over even trivial details is common place and he seems to take delight in annoying his family. His grades and conduct at school remain excellent. He has few friends, though he has never been seen bullying or destroying others' property. What is the most likely diagnosis? A. Attention deficit disorder B. Conduct disorder C. Antisocial personality disorder D. Oppositional defiant disorder

D. Oppositional defiant disorder Oppositional defiant disorder (ODD) best fits this scenario and is differentiated from conduct disorder by the lack of bullying and the lack of destruction of property. Many children with ODD do drift into conduct disorders over time. His good grades and conduct at school lessen the probability of untreated ADD. Personality disorders (i.e. antisocial personality disorder) can not be diagnosed at this early an age.

A 22-month-old male infant presents with one day of barking cough preceded by three days of cold symptoms. On physical examination, his axillary temperature is 100.4°F and he has no stridor at rest. Inspiratory stridor is evident when he becomes agitated during the examination. There are no signs of respiratory distress or cyanosis. Which of the following is the most appropriate treatment for this patient? A. Nebulized albuterol B. Nebulized epinephrine C. Oral amoxicillin D. Oral dexamethasone

D. Oral dexamethasone Corticosteroids are beneficial in the treatment of croup. Intramuscular administration has shown no benefit over oral administration.

An 18 month-old male presents with his parents who report symptoms of a barking cough and intermittent stridor that has worsened over the past 12 hours. They note improvement in symptoms when he was taken outdoors to the cool night air. Which of the following is the most likely organism causing this patient's symptoms? A. Rubeola virus B. Adenovirus C. Influenza virus D. Parainfluenza virus

D. Parainfluenza virus Croup is most often caused by parainfluenza virus. Commonly in children 6 months - 3 years of age. Fall and early winter months: same time of year as bronchiolitis; Patient presents with → Barking cough and stridor!

A 2-year-old boy presents to the Emergency Department with fever, cough, and rhinorrhea for 2 days. His vaccinations are up to date. On physical examination you note intercostal retractions and diffuse inspiratory stridor at rest, but the patient is nontoxic. Vital signs: P 155, RR 38, T 101 F (38.3 C). The mother states that the patient's cough sounds like a seal barking. Which of the following is the most appropriate initial treatment for this patient's condition? A. Empiric antibiotic therapy B. Nebulized albuterol C. Nebulized ipratropium D. Racemic epinephrine E. Ribavirin

D. Racemic epinephrine Racemic epinephrine is the initial therapy of choice in a patient with moderate to severe presentation of croup. Other adjunctive treatments to administer to this patient include dexamethasone.

According to the Rome III criteria, functional ______ is defined as any two of the following features: -straining -lumpy hard stools -a sensation of incomplete evacuation -use of digital maneuvers -a sensation of anorectal obstruction or blockage with 25% of bowel movements -a decrease in stool frequency = < three bowel movements per week!

DEFINITION OF CONSTIPATION

An 18-month-old girl is brought to the emergency department by her parents because of fever, runny nose, and cough for the past three days. Temperature is 38.3°C (101°F), pulse rate is 152/min, respirations are 42/min, blood pressure is 110/50 mmHg. Physical examination shows moderate respiratory distress with nasal flaring and expiratory wheezing. Chest x-ray study shows hyperinflation and peribronchial thickening. Which of the following is the most likely causative organism? A. Bordetella pertussis B. Escherichia coli C. Group B streptococcus D. Respiratory syncytial virus E. West Nile virus

D. Respiratory syncytial virus Respiratory syncytial virus is the most common cause of bronchiolitis.

Which of the following is accurate about complications and further treatment of contact dermatitis? A. Long-term topical steroid use is routinely indicated for contact dermatitis near or involving the eye B. Bentoquatam can be used as a replacement for other barrier devices, such as gloves C. Long-term dietary changes have not shown efficacy in contact dermatitis prevention D. Shorter courses of corticosteroids may allow poison ivy dermatitis to relapse

D. Shorter courses of corticosteroids may allow poison ivy dermatitis to relapse Acute severe allergic contact dermatitis, such as from poison ivy, often needs to be treated with a 2- to 3-week course of systemic corticosteroids. Most adults require an initial dose of 40-60 mg. The oral corticosteroid is tapered over a 2- to 3-week period, but a complicated tapering regimen is not necessary given the short duration of systemic corticosteroid use. The systemic corticosteroids must be administered for 2-3 weeks because shorter courses are notorious for allowing poison ivy dermatitis to relapse. Long-acting intramuscular triamcinolone acetonide (Kenalog) 40-60 mg may be used in place of oral prednisone.

The cremasteric reflex is most likely to be absent in which of the following conditions? A. Erectile dysfunction B. Hydrocele C. Polycystic kidney disease D. Testicular torsion E. Varicocele

D. Testicular torsion The most sensitive physical examination finding in testicular torsion is the absence of the cremasteric reflex. This reflex is elicited by stroking or pinching the medial thigh, causing contraction of the ipsilateral cremaster muscle, which elevates the testis.

Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)? A. drooling B. high fever C. "hot potato" voice D. barking cough

D. barking cough Viral croup is characterized by history of an upper respiratory tract symptoms followed by onset of a barking cough and stridor.

Which of the following clinical manifestations is most commonly seen in viral croup? A. drooling B. wheezing C. sputum production D. inspiratory stridor

D. inspiratory stridor = high-pitched sound, often on inspiration and associated with airway obstruction or conditions such as croup. Croup typically presents with a barking cough and stridor.

What is the most common cause of hypothyroidism in the US? A.Postpartum B.Iodine deficiency C.Medication related D.Hashimoto's

D.Hashimoto's

Herpes viruses cause all except which of the following: A.Varicella zoster B.Kaposi's Sarcoma C.Epstein Barr D.Rubella E.Roseola

D.Rubella

A 14-year-old boy is brought to the emergency department by his parents because of abrupt onset of left-sided scrotal pain, nausea and vomiting for the past hour. The boy states that he had a similar episode of pain three weeks ago, but that it had resolved almost immediately. Temperature is 37.2°C (99°F), pulse rate is 104/min, respirations are 20/min, and blood pressure is 132/88 mmHg. Physical examination shows a moderately swollen, tender and firm left scrotal sac with an elevated, and horizontally lying testicle. Which of the following is the most likely diagnosis? A. Epididymitis B. Fournier gangrene C. Hydrocele D. Spermatocele E. Testicular torsion

E. Testicular torsion Testicular torsion refers to the twisting of the spermatic cord structures, and subsequent loss of blood supply to the ipsilateral testicle. It is a urological emergency. Testicular torsion is primarily a disease of adolescents and neonates, and it is the most common cause of testicular loss in these age groups. In adolescents, if the attachment of the tunica vaginalis to the testicle is too high, the spermatic cord can rotate within it, which can cause intravaginal torsion. This defect is referred to as the "bell clapper" deformity. Neonates more often have extravaginal torsion. Twisting of the testicle causes venous occlusion and engorgement, as well as arterial ischemia, and infarction of the testicle. Both the degree and duration of torsion play a role in the viability of the testicle over time. Testicular salvage is more likely if the duration of torsion is <6-8 hours. If >24 hours have elapsed, testicular necrosis develops in most patients. Intravaginal testicular torsion produces a sudden onset of severe, unilateral scrotal pain followed by inguinal or scrotal swelling. Clinical findings often include, pain duration of <6 hours, fever, nausea, vomiting, history of trauma or activities, absence of cremasteric reflex, and a swollen, tender, high-riding testis with an abnormal transverse lie. Patients may describe previous episodes of recurrent acute scrotal pain that resolve spontaneously. Pain may lessen as the necrosis becomes more complete. A negative Prehn sign (relief of pain with elevation of the testicle) is classically thought to be a predictor of torsion, but it is unreliable for diagnosis.

Patients with ________ will have an underactive thyroid gland with a decrease in the radioactive iodine uptake. The thyroid gland is not producing enough thyroid hormones so the free T4 level will be low and the TSH level will be increased as the body tries to stimulate the thyroid gland to produce more thyroid hormone.

Hashimoto thyroiditis

A 17-year-old male presents to the urgent care after sustaining a fall onto his right hand while doing tricks on his skateboard. On examination, you find he is exquisitely tender over the anatomic snuffbox. You suspect a scaphoid fracture and send him promptly to obtain an MRI of the wrist. Why must a suspected scaphoid fracture be detected and treated so aggressively? A. To prevent loss of range of motion of the wrist B. To prevent secondary infection from an external source C. To prevent fracture non-union D. It can be life-threatening if not treated properly E. To prevent avascular necrosis of the bone

E. To prevent avascular necrosis of the bone Because the blood supply to the scaphoid bone occurs mostly by retrograde flow and does not usually have good collateral flow, any compromise in this blood supply, due to fracture to this bone, can result in avascular necrosis.

Each of the following is an appropriate treatment for contact dermatitis EXCEPT: A. Oral antihistamines B. Phototherapy C. Topical corticosteroids D. Topical immunomodulators E. Topical isopropyl alcohol

E. Topical isopropyl alcohol Topical isopropyl alcohol should not be used in the treatment of contact dermatitis because it may act as an irritant that worsens the condition.

A 2-month-old infant is brought to your office by his mother. He developed an erythematous, dry rash on both cheeks approximately 1 week ago. Although the rash is always present, the mother states that it seems to be worse after she feeds him. The mother breast-fed for the first 4 weeks of life, but she returned to work 4 weeks ago and switched the baby from breast-feeding to bottle-feeding. The mother has a history of asthma, and the father has seasonal allergies. On examination, the child appears healthy. He has an erythematous maculopapular eruption that covers his cheeks, and he appears to be developing an erythematous rash on his neck, both wrists, and both hands. The rest of the physical examination is within normal limits. What is (are) the recommended initial treatment(s) of the rash in the infant presented? A. skin hydration with petroleum products B. local corticosteroid therapy C. minimizing bathing and the use of soap D. topical calcineurin inhibitor (Elidel) E. a, b, and c

E. a, b, and c The treatment of atopic dermatitis begins with the avoidance of any environmental factors that precipitate the condition and also maintenance of the skin barrier. Disruption of the acid mantle of the skin by alkaline soaps is a major factor in the development and worsening of the condition. The most important maintenance therapy is to use non-soap alternatives (Aveeno, Cetaphil, and Dove) or pH-neutral cleaners and to bathe only dirty skin areas. In addition, emollients (e.g., petroleum products) to restore skin hydration should be applied within 3 minutes of bathing. Excessive drying of the skin should be avoided. Atopic dermatitis is best managed with local therapy. Flare-ups of the condition are treated with topical corticosteroid creams or lotions. To further prevent scratching, the fingernails should be cut short. Percutaneous absorption of corticosteroid does occur, and atrophy of the skin should be watched for. This can be avoided by use of only low- or moderate-potency topical corticosteroids. Topical calcineurin inhibitors such as pimecrolimus (Elidel) are not approved for infants younger than 2 years, especially since the addition of the Food and Drug Administration black box warning for lymphomas and skin cancer, but they are used for second-line therapy in older children and are still used by some physicians in place of high-potency steroids in younger children with severe atopic dermatitis. Systemic antihistamines and nonsedating antihistamines have to be used to control pruritus, but not in infants. These can improve sleep and prevent more excoriations and secondary infections. Secondarily infected atopic dermatitis may often be managed by topical mupirocin, but it may occasionally require systemic treatment.

Who is the most likely adult to sexually abuse a child?

Family member Adults within the immediate or extended family perpetrate the most child sexual abuse, usually this is a trusted member of the family.

Can present with stridor, wheezing or decreased breath sounds depending on where it has lodged. Most common in children and the elderly. Aspiration of a food bolus is the most common cause in adults which leads to a history of a choking episode followed by dysphagia, wheezing and coughing. Physical examination findings are dependent on the location of the obstruction.

Foreign body aspiration = often presents with a sudden episode of coughing or choking while eating with subsequent wheezing, coughing, or stridor.

Infants that pass through the vaginal canal in a female with an outbreak of _______ can lead to _______, characterized by multiple vesicular lesions on the skin or involvement of internal organs or the central nervous system. Infants with CNS _____ present with temporal encephalitis can commonly present with seizures, tremors, and lethargy.

Genital herpes, neonatal herpes

Grouped vesicles on erythematous base all at the same stage of development. Presence of lesions are heralded by burning or stinging.

HSV

There are 8 types of herpes viruses known to affect humans. They are called the Herpes Human Viruses (HHV). There are 2 types of Herpes Simplex viruses:

HSV 1 - Oral lesions, including tongue, lips etc. HSV 2 - Genital lesions, including vulva, vagina, cervix, glans, prepuce, and penile shaft

Diagnose mucocutaneous infections clinically, but do viral culture, PCR, or antigen detection if patients are neonates, immunocompromised, or pregnant or have a CNS infection or severe disease.

HSV = Mucocutaneous infections cause clusters of small painful vesicles on an erythematous base.

A viral disease from the herpes viridae family. This family of viruses is enveloped and has double stranded linear DNA.

Herpes simplex virus (HSV) = a viral infection caused by the HSV group. Vesicles may be visualized on the soft palate, floor of mouth, and tongue. A Tzanck smear is taken from a vesicular lesion and stained for identification of herpes simplex.

A 33-year-old woman presents with complaints of recurrent rashes under the arm that come and go and the development of painful cysts with scar tissue formation. The most likely diagnosis is:

Hidradenitis suppurativa

A painful, erythematous, and nodular condition that affects the axilla, genitalia, and perianal areas. Hallmarks for the disease include open comedones, enlarged follicular orifices, and scarring. Nodules become inflamed and pus filled, rupture, drain pus and blood, and then cause scarring. Sinus tracts can form. The disease often waxes and wanes. Staphylococcus bacteria are frequently the causative agent. Treatment consists of appropriate antibacterial agents based on culture and sensitivities. Intralesional corticosteroids, such as triamcinolone, can also be used to reduce the inflammatory response. For severe cases, excision and skin grafting may be necessary. The condition may regress as the patient approaches middle age.

Hidradenitis suppurativa

Chronic follicular occlusive disease manifested as recurrent inflammatory nodules, abscesses, sinus tracts, and complex scar formation; Lesions are tender, malodorous, often with exudative drainage. Common in intertriginous skin regions: axillae, groin, perianal, perineal, inframammary skin; Most common in women, ages 20-30 years.

Hidradenitis suppurativa

Diagnosis is by examination. Cultures should be taken from deep abscesses and sinus tracts in patients who have chronic disease, but often no pathogens will be found. The Hurley staging system describes the severity of disease.

Hidradenitis suppurativa

Patient will present with → tender inflammatory nodules and abscesses in her axillae and anogenital area. The lesions have waxed and waned over the past few years but have become more painful and bothersome in the past month. Some of the larger lesions are draining a purulent material.

Hidradenitis suppurativa

A 33-year-old woman presents with complaints of recurrent rashes under the arm that come and go and the development of painful cysts with scar tissue formation. The most likely diagnosis is

Hidradenitis suppurativa It is a painful, erythematous, and nodular condition that affects the axilla, genitalia, and perianal areas. Hallmarks for the disease include open comedones, enlarged follicular orifices, and scarring. Nodules become inflamed and pus filled, rupture, drain pus and blood, and then cause scarring. Sinus tracts can form. The disease often waxes and wanes. Staphylococcus bacteria are frequently the causative agent. Treatment consists of appropriate antibacterial agents based on culture and sensitivities. Intralesional corticosteroids can also be used to reduce the inflammatory response. For severe cases, excision and skin grafting may be necessary. The condition may regress as the patient approaches middle age.

Presents with chronic constipation, vomiting and abdominal distention. It causes inability of bowel complex to relax resulting in obstipation, vomiting and failure to thrive.

Hirschsprung disease = congenital megacolon

Treatment for Kawasaki Disease:

IVIG (IV Immunoglobulin) + Aspirin

A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears well with a respiratory rate of 42 per minute. What is the next best step in the evaluation and treatment of this patient?

Indirect Laryngoscopy Laryngoscopy is indicated not only for diagnosis, but also removal of the foreign body.

Treatment: Hidradenitis suppurativa

Intralesional triamcinolone is the first-line treatment in hidradenitis suppurativa. If lesions do not resolve, surgical excision is recommended. Local care including improved hygiene, warm soaks, and weight loss should be encouraged. topical (+/-) oral antibiotics: Tetracycline 500 mg BID, Doxycycline 100 mg q12h, Augmentin 875 mg q8-12h, Clindamycin 300 mg BID

Cleaners, solvents, detergents, urine, feces

Irritant, aka diaper rash, Dermatitis (subtype of contact dermatitis)

Mucocutaneous lymph node syndrome

Kawasaki Disease

Rash on trunk and extremities, Red palms & soles

Kawasaki Disease

Fever > 5days and 4 of the following: 1. Conjunctivitis 2. Rash 3. Mucosal changes 4. Edema of hands/feet 5. Cervical adenopathy

Kawasaki Disease: warm + CREAM = Fever + Conjunctivitis, Rash (polymorphous), Extremity changes (hand & feet rash, induration), Adenopathy (cervical, erythematous, no pus), Mucous membrane involvement (strawberry tongue, lip swelling)

Polymorphous exanthema is seen in patients with disease.

Kawasaki disease

What are the signs of a latent herpes simplex infection?

Latent infection triggered by fever, trauma and exposure to UV light.

Presents with a painless limp of the hip in children, mostly boys, ages 4-10 due to avascular necrosis of the femoral head.

Legg-Calve-Perthes disease Irregularity and fragmentation of the joint space is associated with avascular necrosis of the femoral head as seen in Legg-Calve-Perthes disease. This typically occurs in a younger male population and is not associated with the classic externally rotated hip with ambulation, (which is seen in SCFE).

Lichen striatus

Lichen striatus

** For your boards just know that ______ is treated with Clarithromycin + Ethambutol for at least 12 months +/- Rifampin and Prophylaxis HIV patients with single drug if CD4 < 50**

MAC = Atypical mycobacterial disease

An afebrile 2 year-old female presents with a three-day history of foul smelling, blood-tinged, mucoid drainage from the left nostril. Which of the following is the most likely diagnosis in this patient?

Nasal foreign body Nasal foreign body typically presents in children under 3 years of age. The symptoms include mucopurulent drainage, epistaxis, foul odor and nasal obstruction.

Screening for hypothyroidism is indicated in which of the following patients?

Newborn The American Academy of Pediatrics recommends screening of hypothyroid disease between 2-4 days of birth.

Non-alcoholic liver disease

Non-alcoholic liver disease

A six-year-old child presents with circular patches of baldness and hair that fluoresces yellow-green under a Woods lamp. Which of the following would be the best treatment?

Oral Griseofulvin; Tinea capitis is best treated with Oral Griseofulvin until the lesions clear, usually 4-8 weeks.

Testicular torsion diagnosis: ________ for diagnosis = best initial test ________ demonstrates decreased uptake in the affected testes = gold standard

Testicular doppler Radionuclide scan

Torsion treatment:

Orchiopexy This is a surgical emergency - 6 hour time frame for repair with the best outcomes Emergent surgical intervention on the affected testis must be followed by elective surgery on the contralateral testes, which is also at risk for torsion.

Avascular necrosis of subchondral bone, most commonly seen during adolescence.

Osteochondritis dissecans

A 26-year-old female presents with several pruritic lesions on her dorsal forearms. The lesions are erythematous with vesicles, with a few beginning to weep. She works in a photography laboratory, but denies any other possible exposures. Which of the following is the most useful diagnostic test? A. VDRL serology B. KOH prep C. Patch testing D. Gram's stain

Patch testing: Patch testing with a suspected agent is usually positive in cases of allergic contact dermatitis.

What is the treatment for avascular necrosis of the femoral head?

Protective weight bearing should be started until definitive treatment. Surgery indicated in most cases, if collapse has occurred, then hip arthroplasty.

Characterized by wheezing on auscultation and the course is typically 3-7 days.

RSV

Which of the following is the most common pathogen implicated as the cause of bronchiolitis in children?

Respiratory syncytial virus RSV is the most common cause of bronchiolitis. Peak incidence occurs in children 2-6 months old during the winter months.

Patient will present as → 17-year-old male who reports he was playing basketball when he started to have left sided testicular pain. Since, it has been becoming worse over the last several hours and he is unable to get comfortable. You notice some edema and the testis is very tender to palpation. The patient has a past medical history significant for cryptorchidism.

Testicular torsion

Remember cough, coryza, conjunctivitis, and Koplik spots.

Rubeola = measles

One or more, asymmetrically distributed, annular, well-demarcated erythematous scaling plaques with central clearing. Inflammatory forms may be frankly pustular or vesicular at the borders.

Tinea corporis = trunk, legs, arms or neck! Characterized by raised rings of erythema that have an advancing scaly border and central clearing. It occurs on skin regions other than scalp, groin, palms, and soles. Diagnosis is confirmed by KOH prep or culture

Fungal infection of body surfaces other than the feet, groin, face, scalp hair, or beard hair; annular rash with raised borders and central clearing

Tinea corporis = trunk, legs, arms, or neck

Usually seen in younger children or in young adolescents with close physical contact to others (i.e., wrestlers). ______ is the most common cause of tinea corporis. Lesions may occur anywhere on the body.

Tinea corporis = trunk, legs, arms, or neck; T. rubrum is the MCC

Treatment of Tinea corporis, which is classically described as pink to red raised rings, or annular patches with scaly borders and a central area of clearing:

Topical azole antifungals: 1% clotrimazole, Lotrimin, 2% ketoconazole or 1% terbinafine cream, Lamisil, applied twice daily for 2-4 weeks

Treatment of HSV:

Treatment is with antivirals - acyclovir (zovirax), valacyclovir (valtrex), famciclovir (famvir)