Pediatrics Exam Master
A 3-year-old boy was visiting his grandparents when he found a bottle of phenobarbital belonging to his grandfather; the bottle had just been refilled with 50 tablets. The boy was found with 1 tablet in his mouth and 3 more missing. He was immediately rushed to the emergency department within 30 minutes. He appears frightened, but otherwise well. Which of the following gastrointestinal decontamination modalities would be most appropriate for this patient? Syrup of ipecac Gastric lavage Activated charcoal Cathartics Whole bowel irrigation
Activated charcoal Activated charcoal (AC) in a multiple dose regimen should only be considered if a patient has ingested a life-threatening amount of phenobarbital, carbamazepine, dapsone, quinine, or theophylline.
A 5-year-old Hispanic boy with acute lymphoblastic leukemia presents with fever and rash. He is currently on induction chemotherapy that includes dexamethasone. He was exposed to a friend with varicella 2 weeks ago; he has never had the varicella vaccination and his mother cannot recall that he ever had a varicella infection. Blood tests prior to initiation of chemotherapy showed the absence of antibody to the varicella virus. He now has 10 small vesicles and several red macules on his face and chest. Temperature is 38.5° C. Exam is otherwise normal. What is the most appropriate immediate treatment for this patient? Observation Varicella-zoster immune globulin 125 units/10 kg IM Varicella vaccine 0.5 mL IM Acyclovir 500 mg/m2 IV every 8 hours Acyclovir 200 mg/m2 PO 5 times a day
Acyclovir 500 mg/m2 IV every 8 hours High doses of IV acyclovir (500 mg/m2 IV every 8 hours) should be administered to immunocompromised patients with primary varicella infections due to the high risk of disseminated disease and complications from infection. To prevent primary varicella infection in susceptible patients who have been exposed to the virus, varicella-zoster immune globulin (VZIG) needs to be administered within 96 hours of exposure and sooner, if possible, for maximum effectiveness. Varicella vaccination should not be administered to persons receiving high dose systemic steroids, and it should not be given concurrently with VZIG.
A 30-year-old mother with full term pregnancy developed chickenpox 3 days before delivery. She delivered a term female infant weighing 3.2 kg with a good cry. Systemic examination is normal, and neonatal reflexes are intact. What is the appropriate step for prevention of varicella infection in this infant? Isolate the infant from the mother Observe the infant for development of chickenpox Start intravenous acyclovir Administer varicella vaccine Administer varicella zoster immune globulin (Vari ZIG)
Administer varicella zoster immune globulin (Vari ZIG) Infants born to mothers who have contracted chickenpox 5 days before or 2 days after delivery are at risk of severe varicella infection. Maternal viremia occurs about 48 hours prior to the onset of rash. The rash in the infant usually appears by the end of first week or the early part of second week of life. As the mother has not developed a significant antibody response, the infant receives a large dose of virus without maternal varicella-zoster virus (VZV) specific antibodies. These infants should receive 1 vial of varicella zoster immune globulin (Vari ZIG) as soon as possible after birth, ideally within 3 days and a maximum of up to 10 days. Each vial contains 250 mg solution for intramuscular injection. Although neonatal varicella may occur in 50% of these neonates despite receiving vari ZIG, it is usually mild. Perinatally acquired varicella can be life-threatening, so the infant should be treated with acyclovir 10 mg/kg every 8 hours intravenously, but only when the lesions develop. Treatment is continued for 10 days. Infants with neonatal varicella who receive prompt antiviral therapy have an excellent prognosis.
A 30-year-old primipara mother develops chicken pox near the time of delivery; 4 days later she delivers a healthy infant. What is the best line of action to protect the infant from varicella infection? Isolate the infant Administer varicella zoster immunoglobulin Administer oral acyclovir Administer varicella zoster immunoglobulon and oral acyclovir soon after birth Administer varicella zoster immunoglobulin soon after birth and start IV acyclovir when the infant develops the varicella lesions
Administer varicella zoster immunoglobulin soon after birth and start IV acyclovir when the infant develops the varicella lesions All newborns whose mothers develop varicella 5 days before to 2 days after delivery should receive 1 vial (125 units) of VariZIG intramuscularly. Since perinatally-acquired varicella can be a life-threatening condition, the infant should be treated with acyclovir 10 mg/kg/8 hours intravenously when the lesions develop. Infants who develop severe community-acquired varicella infection, especially those who develop complications like pneumonia, encephalitis, or hepatitis, should also receive intravenous acyclovir.
A preterm infant develops abdominal distention and bilious vomiting. Meconium has not been passed since birth, which occured 2 days ago. Physical examination finds a distended abdomen. Rectal examination indicates increased sphincter tone and watery stool appears after the removal of examining finger. Plain radiograph shows absence of intra-intestinal air in the pelvis and a barium enema is inconclusive. What is the most appropriate next step in evaluating the likely diagnosis? Full-thickness rectal biopsy Trial with stool softeners Follow-up X-ray Anorectal manometry Repeat barium enema
Anorectal manometry The clinical presentation is strongly suggestive of Hirschsprung's disease. It is a congenital condition which is characterized by the absence of ganglion cells in the submucosal (Meissner's) and myenteric plexus of the distal bowel. The failure of the ganglionic cells to fully migrate caudally during embryonic life is believed to be the cause. In Hirschsprung's disease anorectal manometry shows no recto-sphincteric inhibition reflex on rectal distension. Anorectal manometry is non-invasive and has good accuracy of detection; therefore, it is the diagnosis of choice in infants.
A 3-month-old male infant presented for his first well-child visit. He was born at 32 weeks gestation and experienced hyperbilirubinemia in the nursery, requiring phototherapy and exchange transfusion. He has had rhinorrhea without fever for 2 days. Physical examination revealed a normal-appearing infant at the 25th percentile for height and weight. Vital signs were normal. There was mild clear rhinorrhea without respiratory distress. 2 types of immunizations against rotavirus are available: RotaTeq and Rotarix. Should you administer rotavirus vaccine at this point? No, since the child has an upper respiratory infection No, since the child was born prematurely Begin either immunization series now Initiate the RotaTeq series No, since the rotavirus series was not initiated at 2 months of age
Begin either immunization series now Rotavirus is the most common cause of gastroenteritis and diarrhea under 2 years of age, especially between 3 and 15 months of age. 2 types of immunizations are available: Rotarix, which is administered orally at 2 and 4 months, and RotaTeq, which is given orally at 2, 4, and 6 months. Either series can be initiated after 6 weeks and before 15 weeks. Both immunizations are approximately 75% effective in reducing the number of cases of gastroenteritis due to rotavirus, which account for nearly all severe cases and hospitalizations due to rotavirus.
A 9-month-old, former low birthweight premature infant born at 29 weeks gestation is being seen for a well child visit. He stayed in the NICU for 3 months after birth where he spent 2 weeks on ventilator support for mild bronchopulmonary dysplasia and antibiotics. He had normal head ultrasound studies and vision exams. He spent the rest of the time feeding and growing until discharge. Initially, he had some intermittent apnea, which ceased a few weeks prior to discharge. He continues to gain weight and is eating and doing relatively well according to his mother, who is a single 18-year-old. She is going to school part time and relies on some school daycare and a sister who also helps with child care. So far he has had 1 cold and ear infection. His mother wonders about his development, as he is noticeably behind his cousins who are crawling and cruising well, though his development has been progressing. She has many questions and concerns, however. What developmental screening test would be best for this patient? Ages and Stages Questionnaire Bayley Infant Neurodevelopmental Screen Denver II screening Parents Evaluations of Developmental Status Child Behavioral Inventory
Bayley Infant Neurodevelopmental Screen The Bayley Infant Neurodevelopmental Screens (BINS) is a developmental screening tool that identifies general developmental delay in high risk preterm, low birth weight, or low socioeconomic status population that is practitioner-administered. The risk for neurodevelopmental morbidities increases with the rising number of high risk, low birth weight premies that survive. There is an increased awareness between the potential long-term alterations of growth and development and certain perinatal interventions, such as oxygen administration and postnatal steroids. These findings have led to the recognition of the need to improve standardization and comparability of methodology and data collection.
A 3-year-old child presents with a 2-day history of high fever with headache and vomiting. The child is irritable and is not accepting feeds. Temperature is 103oF. Neck stiffness, Kernig's, and Brudzinsky's sign are positive. Cardiac, pulmonary, and abdominal examinations are normal. CSF examination shows cells 2000/mm3 predominantly polymorphs, protein 200mg/dL, and glucose 30mg/dL. Gram stain of CSF smear shows Gram-negative coccobacilli suggestive of Hemophilus influenza type b meningitis. The patient is successfully treated with intravenous ampicillin for 10 days. If required, what chemoprophylaxis would you advise before sending the child home? Chemoprophylaxis with ciprofloxacin Chemoprophylaxis with trimethoprim-sulfamethoxozole Chemoprophylaxis with clindamycin Chemoprophylaxis with rifampin No chemoprophylaxis required
Chemoprophylaxis with rifampin The child should be given chemoprophylaxis with rifampin, as it is effective against nasopharyngeal carriage of H. influenzae b (Hib). For prophylaxis, children should be given rifampin orally (0 - 1 month of age 10mg/Kg/dose, >1month of age 20mg/Kg/dose, not to exceed 600 mg/dose) once a day for consecutive 4 days. Rifampin prophylaxis is not recommended for pregnant women.
The parents of an 8-year-old boy are worried about his height because he is the shortest child in his class. The boy was born at full term and had a normal birth weight. The neonatal period was uneventful, and he achieved his developmental milestones on time; his elder brother, who also achieved his developmental milestones normally, is of normal height. His anthropometric measurements are as follows: Height: 104 cm (41 in) Weight: 20 kg Head circumference: 53 cm Span 100 cm: Upper segment: Lower segment ratio 1.5: 1 His bone age is appropriate for his chronological age. What is the most likely diagnosis? Familial short stature Constitutional delay in growth Chondrodystrophy Growth hormone deficiency Hypothyroidism
Chondrodystrophy The most likely diagnosis is chondrodystrophy, which is also known as 'achondrosplasia' because of the characteristic features of short height, span less than height, upper segment: lower segment (US:LS) ratio of more than 1, and bone age appropriate for chronological age Normally US:LS ratio is 1.7:1 at birth and decreases by .07 to 0.1 every year; it becomes 1:1 at about 10 years. Normally, the span is equal to height from birth to puberty. Achondroplasia is a common cause of short stature with disproportionately short limbs. It is a genetic disorder of bone growth, and there is an autosomal dominant mode of inheritance.
While rounding in the newborn nursery, you are told about a young woman on the labor and delivery floor who developed chickenpox during her first trimester. She had many skin lesions but otherwise recovered well. She apparently had never been vaccinated and has had poor and sporadic prenatal care. You are asked to attend the delivery. Which manifestation of varicella is most likely to occur in her infant? Skin superinfection Encephalitis Pneumonia Mild varicella Cicatricial skin scars
Cicatricial skin scars Varicella infection that occurs in the first or second trimester of pregnancy will cause approximately 2% of infants to develop congenital varicella syndrome. With current childhood vaccination recommendations this is now rare, however the most prominent manifestation seen is zigzag, cicatricial skin scars reported in >60% of cases. Other manifestations include small infant size, hypoplastic limbs, chorioretinitis, microphthalmos, Horner syndrome, cataracts, nystagmus, cortical atrophy or mental retardation, zoster, and early death. If maternal varicella occurs 5 days before or 2 days after delivery, infants are at increased risk of a severe or fatal varicella infection. Other clinical features may include pneumonia and hepatitis.
While doing newborn nursery rounds, you are called about a male infant that was born 48 hours ago. His nurse is concerned that he has not passed any meconium yet. The baby was born at 38 weeks gestation, had a normal spontaneous vaginal delivery with Apgars of 7 and 9 at 1 and 5 minutes. There was a history of polyhydramnios. He had fed well, but is now refusing feedings and has had bilious emesis. On exam, he is somewhat irritable and has abdominal distention that has a doughy character that indents on palpation. Rectal exam is normal. Plain abdominal films reveal multiple loops of dilated small bowel. What is the most likely diagnosis in this infant? Hirschsprung's disease Imperforate anus Necrotizing enterocolitis Meconium plug syndrome Cystic fibrosis
Cystic fibrosis Newborns with cystic fibrosis (CF) frequently present with meconium ileus. This occurs when meconium becomes inspissated or thickened and tenacious and obstructs the distal ileum. Approximately 20% of infants with cystic fibrosis present with meconium ileus at birth. Infants may present with bilious vomiting, abdominal distention, and failure to pass meconium. Abdominal palpation reveals loops of bowel with a doughy character that may indent on palpation. Pulmonary manifestations usually develop soon after. Plain films show nonspecific low small bowel obstruction with numerous air-filled loops of bowel. There may be a history of polyhydramnios. A sweat test for cystic fibrosis should be performed and if meconium ileus is suspected, a contrast barium enema performed for clarification of the intestinal obstruction, and a surgical evaluation obtained. Later associated rectal prolapse can occur in 20% of patients with CF that may need surgical correction if manual reduction fails.
A 3-day-old male neonate is seen in the nursery due to failure to pass meconium and 2 episodes of vomiting. Prenatal and perinatal histories are unremarkable. Family history reveals a brother and sister with severe asthma. Examination revealed a moderately distended abdomen without signs of tenderness. A barium enema revealed meconium ileus with distal narrowing and proximal dilatation of the colon. Meconium passed during the procedure, relieving the distention. Rectal manometry and rectal biopsy were normal. Sweat chloride analysis on 2 occasions revealed 70 mmol/L and 74 mmol/L of chloride in adequate amounts of sweat. How do you advise the parents regarding the infants condition and prognosis? Cystic fibrosis has been confirmed, and the older siblings should also have sweat testing performed. Cystic fibrosis is an autosomal dominant condition; the parents should be sweat tested, as they may have a mild form. Cystic fibrosis is usually fatal by age 10 years. Hirschsprung disease is still likely. Mutation analysis must be done to confirm the diagnosis of cystic fibrosis.
Cystic fibrosis has been confirmed, and the older siblings should also have sweat testing performed. Elevated chloride levels on 2 occasions with adequate amounts of sweat confirms the diagnosis of cystic fibrosis. The "severe asthma" in the 2 siblings may well represent cystic fibrosis as well; therefore, they should also undergo sweat testing. Cystic fibrosis may be diagnosed if any of the following from the first group are present: 1) one or more typical phenotypic features, including chronic sinopulmonary disease, characteristic gastrointestinal and nutritional abnormalities, salt loss syndromes, and obstructive azoospermia; 2) a sibling affected with cystic fibrosis; or 3) positive neonatal screening test PLUS the presence of any of the following from the second group: 1) an elevated sweat chloride concentration of greater than 60 meq/L on at least 2 occasions; 2) identification of mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene, located on the long arm of chromosome 7, that are known to cause cystic fibrosis; or 3) the demonstration in vivo of characteristic abnormalities of ion transport across the nasal epithelium.
A 3-year-old, HIV-positive boy has contracted varicella infection. He has not shown a satisfactory response to treatment with acyclovir. He is suspected of having an acyclovir resistant varicella zoster infection. What is the alternate drug appropriate for treatment of varicella in this child? Zidovudine Ribavirin Oseltamivir Foscarnet Nevirapine
Foscarnet Foscarnet is the appropriate drug for treatment of varicella in the above child. Acyclovir resistant varicella-zoster virus (VZV) infection has been identified in children infected with HIV. These children may be treated with intravenous foscarnet 120 mg/kg/day, divided every 8 hours for up to 3 weeks. The dose needs to be modified in the presence of renal insufficiency. When foscarnet is used to treat VZV infection in acquired immunodeficiency syndrome (AIDS) patients, it also decreases HIV viral load, but it is not used primarily for HIV infection.
A 1-year-old girl presents for a well child visit. She has been well, except for 1 upper respiratory infection in the past 6 months. She is not in daycare. She has begun to eat table foods and is growing well. Her mother has no specific concerns. Past medical history and family history are unremarkable. Physical examination is normal. What developmental milestone should she have now achieved that is met by greater than 95% of infants her age? Walks well Has a very good pincer grasp Hugs her parents Indicates wants by pointing Has several intelligible words
Has a very good pincer grasp
While doing newborn nursery rounds, you are called about a male infant that was born 48 hours ago. His nurse is concerned that he has not passed any meconium yet. The baby was born at 38 weeks gestation and had a normal spontaneous vaginal delivery with Apgars of 9 and 9 at 1 and 5 minutes. He had fed well, but is now refusing feedings and had 1 episode of slightly green-tinged emesis. On exam, he is somewhat irritable and has abdominal distention with a tightly contracted anal sphincter with empty rectal vault. There is some passage of stool after the exam. Plain abdominal films reveal multiple loops of dilated small bowel with decreased gas in the rectum. His mother also tells you that her other toddler son has been having problems with constipation. What is the most likely diagnosis in this infant? Hirschsprung's disease Imperforate anus Necrotizing enterocolitis Meconium plug syndrome Cystic fibrosis
Hirschsprung's disease Hirschsprung's disease (HSD) is characterized by the congenital absence of ganglion cells in the myenteric and submucosal plexuses of the intestine resulting in abnormal intestinal motility and obstruction. This usually begins at the internal anal sphincter and extends a variable distance proximally. HSD has a male predominance, and it can be sporadic or familial, and is usually an isolated defect. There is an inherited predisposition for HSD with the incidence of affected siblings being about 3.5%. Most infants will fail to pass meconium by 48 hours of age, may have bilious vomiting or infrequent stools, abdominal distention, and refusal to feed. A contracted anal sphincter, empty rectal vault, and release of explosive foul-smelling stool may be present on digital exam.
A 4-year-old HIV-infected (but asymptomatic) child presents for a polio vaccination. Her parents received a postcard reminding them of the routinely recommended immunization. What is the most appropriate next step? Immunize and record it in the patient's chart Immunize but do not record in the chart Postpone immunization till the age of 5 years Cancel immunization with this vaccine Administer human serum immunoglobulin
Immunize and record it in the patient's chart The inactivated polio vaccine (IPV) is the routinely recommended polio vaccine is the US now. The oral polio vaccine (OPV) is no longer recommended. HIV positive children can receive the IPV; it is inactivated and does not pose a risk of neurovirulence.
You evaluated a 5-year-old girl at a well-child visit. There were no complaints. Past medical and family histories were unremarkable. Growth and development were normal and immunizations were current. Vital signs, growth parameters, and physical examination were normal. In reviewing safety guidelines as part of anticipatory guidance, the parents noted that they had recently installed an in-ground pool and that their daughter was quite interested in swimming. What is the most effective water safety measure regarding the pool? Instructing the child to stay away from the pool unless accompanied by an adult Insuring the child learns to swim from a certified instructor Providing approved flotation devices Installing appropriate pool fencing with self-latching gates Hiring a full time lifeguard during the summer
Installing appropriate pool fencing with self-latching gates Drowning is still a major cause of death and disability in children, with significant neurologic sequelae in survivors. Prevention of drowning is more effective than treatment. While constant parental supervision is the ideal, given the inevitable lapses of such supervision, other measures are necessary. As to in-ground pools, the most effective preventive measure is to equip the pool with appropriate fencing with self-latching gates to protect children who live at the residence, as well as guests and children who may wander onto the property. This will help to insure that no child is in the water without appropriate supervision. It would not be prudent to expect a 5-year-old child to always follow her parents' instructions and, in any event, this would not prevent accidents to guests and those who wander onto the property.
A 3-year-old boy presents with an 8-day fever as high as 104° F; it is accompanied by a rash and oral sores. His parents have had little success in reducing the fever with antipyretics. He has been alert, but irritable, and has managed to take fluids well. There is no history of recent exposure to illness. Past history is unremarkable except for upper respiratory symptoms a few days before the fever began. Family history is unremarkable. Growth and development have been normal and immunizations are current. Examination reveals a mildly ill-appearing child. A pale, red maculopapular rash is present on the trunk and extremities. The dorsae of the hands and feet are red and swollen. The bulbar conjunctivae are red, bilaterally, without exudates. The tongue appears red with white spots and the oral mucosa is generally reddened. Enlarged, nonfluctuant, right anterior cervical lymph nodes are present. What is the most likely diagnosis? Kawasaki disease Lyme disease Mononucleosis Rocky Mountain spotted fever Scarlet fever
Kawasaki disease The presentation in this child is typical of Kawasaki disease (mucocutaneous lymph node syndrome), a generalized vasculitis involving small to medium-sized arteries affecting mainly children under 10 years of age (most of whom are younger than 5 years of age). While bacterial, viral, rickettsial, environmental, and other etiologies have been proposed, the cause remains unknown; it is presumed to be infectious. Fever typically lasts 7 - 10 days, often reaching 104° F. Fever for 5 days or longer is a necessary diagnostic criterion, in addition to 4 out of 5 of the following symptoms: 1) erythema and edema of the hands and feet, with desquamation approximately 10 days later; 2) nonexudative bulbar conjunctivitis; 3) oral mucosal manifestations, including strawberry tongue, mucosal erythema, and fissuring of the lips; 4) nonpurulent cervical lymphadenopathy, usually unilateral; and 5) a polymorphous skin eruption that may be macular, papular, maculopapular, morbilliform, or target-like (but not vesicular) and may be generalized or confined to the extremities. Cutaneous findings are the most variable and most commonly absent. Incomplete forms occur.
A 4-year-old girl presents with a 5-day history of fever, sore throat, skin rash, and right sided neck swelling. She has no significant past medical history. The neck swelling has increased in size over the last 24 hours to about 2.5 cm. There is no history of any injury, recent travel, or sick contacts. On examination, the neck mass is located near the angle of the jaw; it is rounded, firm, tender, and mobile, but the overlying skin shows no erythema or breakdown. Her conjunctiva appear red, but no eye discharge is noted. The skin rash is diffuse and maculopapular, and her hands and feet also show mild swelling. Oral examination reveals red, fissured lips, a strawberry tongue, and erythematous pharyngeal walls; there is no tonsillar enlargement. A rapid Streptococcal test done in the clinic is negative. Given this patient's history, symptoms, and exam findings, what is the most likely cause of her symptoms? Staphylococcus aureus lymphadenitis Streptococcal lymphadenitis Tubercular lymphadenitis Kawasaki disease Histoplasmosis
Kawasaki disease This child has the classic findings of Kawasaki Disease, and this diagnosis has to be made on the basis of this combination of clinical findings. Along with presence of fever of 5 days' duration, presence of any 4 of the following is considered diagnostic for Kawasaki Disease: Edema and redness of hands and feet Polymorphic rash Bilateral painless conjunctival injection without exudates Lips and oral cavity showing fissured and cracked lips, strawberry tongue or erythema of oral and pharyngeal mucosa Unilateral cervical lymphadenopathy (>1.5cm diameter)
A 9-year-old boy presents with sudden onset of anterior chest pain, vomiting, and general malaise. 12 months prior to presentation, the patient had a febrile illness associated with conjunctivitis and peeling of the skin on the hands and feet. Physical exam is as follows: Temperature 99°F; pulse 120 beat per minute: respirations 23 per minute; blood pressure 110/60. Skin: normal with no petechiae or splinter hemorrhages. Lungs: Clear. Heart: Normal. Lab: WBC 8,900/mm3, hematocrit 35%. EKG: ST elevation in the right precordial leads with an anterior myocardial infarction. Based on the history and physical exam, what is the most likely diagnosis? Bicuspid aortic valve Kawasaki's disease Rheumatic heart disease Coarctation of the aorta Bernard-Soulier syndrome
Kawasaki's disease The patient's presentation is most consistent with the diagnosis of Kawasaki's disease. Kawasaki's disease is a febrile condition of early childhood whose exact etiology is uncertain. The clinical syndrome includes erythema and desquamation of the skin on the palms of the hands and feet. Conjunctivitis and reddening of the tongue (so-called "strawberry tongue") as well as cervical lymphadenopathy may also be present. Long-term, the illness causes vasculitis that may eventually lead to coronary aneurysmal dilatation. These aneurysms can subsequently thrombose, producing acute coronary insufficiency and myocardial ischemia/infarction.
A 9-month-old female infant presents with an acute onset of a rash on her trunk. She has a 4-day history of fever up to 104oF, but the mother states her daughter has no fever today. She has had some diarrheal stools, but no vomiting. No coughing or nasal congestion has been noted. The child has previously been well. Her past medical history is unremarkable, and she is up-to-date on her immunizations. She attends day care, and her mother notes that some children have been ill with non-specific febrile illnesses over the past 2 weeks. Her only medication has been ibuprofen for the fever. Physical exam shows a temperature of 98.8 F, pulse of 124 BPM, and respiratory rate of 28/min. She is alert and shows no other abnormalities. Her exam shows normal tympanic membranes in the ear and normal conjunctivae in the eye. The neck shows some shotty anterior cervical adenopathy; the throat shows slight erythema of the posterior pharynx, and the skin appears with an erythematous maculopapular rash most pronounced on the trunk. Her chest is clear to auscultation, heart rhythm is regular without murmurs, abdomen is soft and non-tender, and her neurological exam is normal. What is the most appropriate intervention for this patient? Draw measles titers of acute and convalescent sera Oral acyclovir Observe the child and reassure the parent Draw a complete blood count and blood cultures Treat presumptively with oral antibiotics
Observe the child and reassure the parent The clinical syndrome in this vignette is typical for roseola infantum, also known as exanthem subitum. Typically, the patient will have a moderate-to-high fever for 3 to 4 days, followed by defervescence and the outbreak of an erythematous macular or maculopapular rash that usually begins on the trunk, spreads to the arms and neck, and occasionally affects the face and legs. The rash is usually gone within 3 days. Occasional cervical lymphadenopathy is seen, as well as a slight pharyngeal inflammation and coryza. The patient can present with a bulging fontanelle and suffer from febrile convulsions during the high fever stage of the illness. Human Herpes virus 6 is the etiologic agent of the vast majority of cases. Once the rash has appeared and the child appears well, the only treatment is reassurance for the parents in regard to the benign nature of the condition.
You are evaluating a 3-year-old African-American boy at a well-child visit. Prenatal and past medical histories are unremarkable. Growth and developmental are normal. Immunizations are up to date. Examination is normal. When inquiring about living arrangements, the child's mother tells you that they live in a 3rd story apartment of an older building that has exterior fire escapes accessible by the windows. What should you advise regarding the windows? She should have window bars spaced 8 inches part installed Operable window guards should be installed on all windows All windows should be screened. She should have all windows bricked over Fixed window guards should be installed on all windows
Operable window guards should be installed on all windows The leading cause of childhood injuries is a fall; they are rarely fatal. Childhood falls that are fatal usually occur from a height greater than 2 stories (approximately 22 feet). Falls from windows from the 2nd story or higher are still a serious problem in older buildings. Operable window guards should be placed on all windows so that exit by a child is prevented, but exit under adult supervision in case of emergency, such as fire, can be readily accomplished.
A 3-year-old boy presents with a loud cough. 2 days ago, the boy developed a runny nose and irritability; the next day, he began to cough loudly and felt warm. His mother tells you that the cough sounded like a wounded animal or a dog barking. The child is diagnosed with croup, and humidification is prescribed. What organism is most likely responsible for the patient's croup? Group A streptococci Haemophilus influenzae type b Influenza virus Parainfluenza virus Respiratory syncytial virus (RSV)
Parainfluenza virus The correct answer is parainfluenza virus,the most common cause of croup. Croup is more formally known as acute laryngotracheobronchitis. It occurs most often in children 2 to 3 years of age, and it has a distinctive 'seal barking' sound. This is caused by the marked edema in the respiratory tract. The same edema may show up on an A-P neck film as subglottic edema, or the "hourglass sign." This sign is also referred to as the "steeple sign."
You evaluate a 13-year-old boy for sexual infantilism. He has a history of developmental delay, and he has been classified as moderately intellectually disabled. The parents note that he has always appeared quite "floppy"; walking was delayed. Although he had feeding difficulties as an infant, his appetite now seems insatiable. Family history is unremarkable. Immunizations are current. Vital signs are normal. Height is 4 feet 9 ½ inches (10th percentile for age); weight is 176 pounds (> 98th percentile), and BMI is 37.4 (> 99th percentile). The bifrontal diameter is narrow, with almond shaped, up-slanting palpebral fissures. Genitalia are Tanner stage I, with a small penis, hypoplastic scrotum, and testes measuring 1.5 cc. bilaterally. Hands and feet are small. In light of the above findings, to what do you attribute this boy's obesity? Klinefelter syndrome Exogenous obesity Cushing syndrome Prader-Willi syndrome Down syndrome
Prader-Willi syndrome It occurs equally in male and female patients; it features hypotonia and feeding problems in infancy, hypogonadism, onset of satiety disorder with hyperphagia and obesity in childhood, cognitive impairment, and a variety of dysmorphic features. It is caused by a variety of abnormalities in the chromosome 15q11-q13 region, including microdeletion of the paternally derived chromosome number fifteen (70%), uniparental disomy for chromosome number 15 (with both chromosomes number 15 being maternally derived) (25%), imprinting errors for the 15q11-q13 region (5%) and balanced translocations involving the 15q11-q13 region (rare). The 15q11-q13 region contains genes that are normally imprinted, meaning that they are differentially expressed, depending upon whether they are paternally or maternally derived. Absence of the paternally expressed genes in this region leads to the findings of Prader-Willi syndrome.
An 8-year-old boy sustained a puncture wound to his right foot 4 days ago. He was playing and stepped on a nail that went through his sneaker. His mother said the wound bled profusely but the nail did not go completely through his foot. They washed the wound at home with soap and water, wrapped it in a bandage, and did not seek further care. This morning, he complained that it was very painful and his mother noted that his foot looked red and swollen. On exam, his temperature is 99°F; pulse is 114 BPM, and his BP is 104/68 mm Hg. The plantar surface of his right foot has a small 2 mm scabbed entry wound that is surrounded by a 5 - 6 cm area that is erythematous, swollen, and quite tender. There is a scant amount of thin, seropurulent material from the entry wound on examination. You are worried about possible osteochondritis. What bacteria would most likely cause this complication? Streptococci Eikenella Pasturella Clostridium Pseudomonas
Pseudomonas Pseudomonas aeruginosa causes more than 90% of foot osteochondritis in plantar puncture wounds. It should be considered as a likely pathogen when there is a penetrating injury through footwear, especially sneakers or from soil and manure contamination. It is believed that the penetrating object may push particles of foam contaminated with bacteria into the wound. In addition, anaerobes, Klebsiella, Bacteroides, Serratia, and Salmonella sp. are less common organisms in this setting that may also cause secondary infections.
A 3-day-old male neonate is seen in the nursery due to failure to pass meconium and 2 episodes of vomiting. Prenatal and perinatal histories are unremarkable. Family history reveals a brother and sister with severe asthma. Examination reveals a moderately distended abdomen without signs of tenderness. A barium enema reveals meconium ileus with distal narrowing and proximal dilatation of the colon. Meconium is passed during the procedure, relieving the distention. What study/studies should be ordered? Chest radiograph Chromosome analysis of peripheral blood lymphocytes Qualitative stool fat Rectal manometry, rectal biopsy, sweat chloride Urine electrolytes
Rectal manometry, rectal biopsy, sweat chloride Meconium ileus is associated with both Hirschsprung's disease (colonic aganglionosis) and cystic fibrosis. Rectal manometry and biopsy will provide the most information regarding the former, and sweat chloride analysis is the standard for the initial diagnosis of cystic fibrosis.
An 18-month-old infant is brought to your clinic office with a 5-day history of fever of 104°F. On physical examination, you note a mildly lethargic and irritable infant. There are no other clinically significant findings. You prescribe Children's Tylenol (acetaminophen) and tell the mother to monitor the infant's fever for the next few days; if the fever goes down, everything should be fine. The mother calls the next day and says that the fever has stopped, but a rash has developed, and she is concerned. The infant examination reveals a diffuse, fine, maculopapular rash. Presently, the child does not appear ill. What is the most likely diagnosis? Rubella Rubeola Erythema infectiosum Roseola Chicken pox
Roseola The clinical picture is suggestive of roseola. Roseola is a benign illness in humans caused by the human herpes virus 6 or 7. It is the major cause of acute febrile illness in young children. The most prominent feature is a fever lasting up to 8 days; the fever can be as high as 104° F. After the fever subsides, a rose-pink maculopapular rash appears.
A 13-month-old boy presents with a rash. The mother tells you that the child has had high fevers over the past 4 days, although he has not had a fever for the past 24 hours. The rash began 6 hours ago; it started on his chest and back, and it spread to his neck, face, and arms. The child doesn't appear to be itchy, and he has been acting normally since the fever subsided. The mother denies cough, runny nose, vomiting, and diarrhea. The only medication that the child has taken is acetaminophen. On examination, the child is happy and playful. The only physical finding is the rash that is shown in the image. What is the most likely diagnosis? Rubella Roseola Measles Drug hypersensitivity Varicella
Roseola This child exhibits the typical rash of roseola. Roseola infantum (also called exanthem subitum) is caused by Human Herpesvirus-6 and occurs almost exclusively during infancy. There is usually no prodromal period. The illness begins with high temperatures (averaging 103 F) for 3 to 5 days; the fever typically resolves rather abruptly. The rash appears within 12 to 24 hours of the fever resolution. The rash of roseola is rose-colored and begins as discrete, small, slightly raised pink lesions on the trunk and spreads to the neck, face and proximal extremities. The rash is not pruritic and no vesicles or pustules develop. The lesions may become confluent. Roseola is self-limited and the treatment is supportive only (e.g., antipyretics during the febrile phase).
In the winter, an 11-month-old infant presents with a 2-day history of vomiting, diarrhea, and fever. His temperature is 104° Fahrenheit. Clinically, he is significantly dehydrated; his white blood cell count is 5400 cells/mm3 with a normal differential. His stool and urine are negative for white blood cells. What is the most likely cause of gastroenteritis in this child? Escherichia coli Clostridium difficile Norwalk virus Rotavirus Shigella
Rotavirus A viral etiology is suspected in a patient with a normal white blood cell count. In the 1st 2 years of life, especially in the winter months, rotavirus is a common cause of gastroenteritis. Epidemics are not uncommon; therefore, rotavirus vaccinations are now considered standard at 2, 4, and 6 months of age.
You are evaluating a 7-year-old boy for a pruritic rash. It began on the hands 10 days ago; it has spread to the arms, trunk, and genitalia. Pruritus has been intense, especially at night. A younger sibling has a similar rash. Past medical history is unremarkable. Growth and development are normal, and immunizations are current. Vital signs are normal. There are papules, vesicles, and pustules; some in linear array (especially at the interdigital web spaces), with multiple excoriations of the interdigital spaces of the fingers, palms, soles, flexion creases of the elbows, trunk, and genitalia. What is the most likely causative agent of this rash? Borrelia burgdorferi Sarcoptes scabiei Pox virus Parvovirus B19 Malassezia furfur
Sarcoptes scabiei The presentation is that of scabies, which is caused by the human itch mite, Sarcoptes scabiei, an ectoparasiteacquired by humans from close physical contact.The pregnant female mite burrows under the skin, depositing eggs and excrement. 3 to 10 days later, the human host develops a hypersensitivity reaction to the mite, ova and excrement, at which time intense pruritus (especially nocturnal) begins. Burrows (linear tracks of the progression of the mite) are typical, but papules, vesicles and pustules are also present. Lesions are present at the scalp, face, extremities (including the palms and soles and characteristically featuring burrows at the web spaces of the fingers), chest, back, abdomen and genitalia; however, lesions are usually not present above the neck in patients older than 5 years.
An 8-month-old male infant presents with rashes over the scalp and eyebrows. Physical examination shows a dry, scaly, and crusting lesion over the scalp, eyebrows, and nape area. He is comfortable, so his mother presumed that it was not itchy at all. He has been breastfed up to the present, and he started solid food at about 5 months old. There are no other signs and symptoms noted. Bowel movement and urination are normal. Developmental milestones are consistent with age. What is the most likely diagnosis? Atopic dermatitis Seborrheic dermatitis Psoriasis Candidiosis Lichen simplex chronicus
Seborrheic dermatitis The clinical picture is suggestive of seborrheic dermatitis, which is a chronic inflammatory disease common in the pediatric age group especially during infancy and adolescent. The etiology is unknown, but it has been attributed to stressful situations, poor hygiene, and excessive perspiration.
A 2-year old infant was admitted for failure to thrive. The infant suffered from 4 episodes of respiratory tract infection since birth. During neonatal period, the child had intestinal obstruction due to inspissated meconium. The child is asthenic with little subcutaneous tissue and has a protuberant abdomen. Both the parents of the child are normal. Which of the following laboratory tests will be enable you to establish a diagnosis in this case? Serum immunoglobulin level CT scan of the abdomen Bronchoscopic examination Sodium chloride content of sweat Endoscopic biopsy of intestinal mucosa
Sodium chloride content of sweat Cystic fibrosis should be suspected in young adults suffering from a history of: Chronic lung disease (esp. bronchiectasis) Pancreatitis Or infertility Characteristically sodium chloride levels in the sweat of such individuals is unusually high. A pilocarpine iontophoeresis sweat test reveals elevated sodium and chloride levels In the sweat of patients with cystic fibrosis.
A 5-year-old boy presents with 6-day history of fever, fatigue, and rash. He has no significant past medical history. He is current with his vaccinations, except for varicella, which his parents have refused in the past. On exam, his temperature is 101.3º F; heart rate is 110, and blood pressure is 94. He has bilateral conjunctival injection, an erythematous pharynx without exudate, cracked red lips, and an erythematous right tympanic membrane. He has shotty enlarged anterior cervical lymph nodes bilaterally, the largest nodes measuring 1.6 cm on the right side and 1.5 cm on the left side. His lungs are clear, and his heart has a regular rhythm. His abdomen is soft. He is in no acute distress, and he has a generalized maculopapular rash. What are some other possible findings associated with his probable diagnosis? Sterile pyuria, meningismus Peripheral neuropathy, thrombocytopenia Epistaxes, hematuria Colonic polyps, gastritis Splenomegaly, pleuritis
Sterile pyuria, meningismus This patient meets the diagnostic criteria for Kawasaki disease, which includes fever for at least 5 days, and at least 4 of the 5 following signs: bilateral conjunctival injection, generally nonpurulent changes in the mucosa of the oropharynx changes of the peripheral extremities rash cervical adenopathy >1.5 cm, usually unilateral The most serious complication of Kawasaki disease is a coronary aneurysm with the potential for thrombosis, myocardial infarction, and rupture. Other possible findings include aseptic meningitis, diarrhea, hepatitis, hydrops of the gallbladder, urethritis and meatitis with sterile pyuria, otitis media, arthritis, myocarditis, and pericarditis.
A 6-week-old male infant presents with a 4-day history of cough and nasal congestion. According to his mother, he occasionally has a bluish tint around his lips while sleeping. There is no history of fever. His older siblings have an upper respiratory infection. The patient's appetite has been decreased somewhat, mostly due to the copious nasal secretions; however, he has been maintaining a normal urine output. He was delivered pre-term at approximately 34 weeks gestation. He had mild respiratory distress syndrome, spending 2 days on a ventilator in the neonatal intensive care unit (NICU). He went home in 10 days and has done well since. He has had no immunizations. A physical exam reveals an infant in mild respiratory distress, respirations of 52/min, with slight intercostal retractions. Temperature is 100.2 F with a HR of 130/min. Perioral duskiness is seen. Oxygen saturation at room air is 83%, and HEENT exam is otherwise normal. His chest exam shows coarse rhonchi and expiratory wheezes. Heart rate and rhythm are regular. No murmurs appreciated. Abdomen is soft and non-tender. Neurological is intact. Chest X-ray shows mild hyper expansion, but no consolidation. Nasal swab for respiratory syncytial virus (RSV) is positive. What is the most appropriate treatment? Aerosolized albuterol Intravenous steroids Empiric ampicillin and cefotaxime Aerosolized ribavirin Supplemental oxygen and supportive therapy
Supplemental oxygen and supportive therapy The severity of bronchiolitis is diagnosed and assessed based on history and physical examination. Infants with mild bronchiolitis can be treated symptomatically at home. The following are the criteria for hospitalization in RSV bronchiolitis: Age less than 12 weeks Gestational age at birth of less than 34 weeks Cardiopulmonary disease or immunodeficiencies Wheezing and respiratory distress associated with oxygen saturation below 92 percent on room air (hypoxemia) History of significant apnea before assessment. The management in moderate-to-severe bronchiolitis involves supplemental oxygen therapy and supportive measures such as prevention of dehydration and respiratory support. Supplemental oxygen is the single most useful therapy, usually delivered via nasal prongs when oxygen saturation (SpO2) falls persistently below 90% in previously healthy infants. Mechanical ventilation may be needed for respiratory failure or severe apnea.
A 7-year-old boy presents with a 6-day history of a rash on his right flank. It is painful and appears blistered in some areas. His mother states that his right flank became painful a few days prior to the onset of the rash. He is up to date on his immunizations. He had chicken pox at the age of 18 months. He has been well recently, his past medical history is unremarkable, and he has no known drug allergies. On exam, the boy has a vesiculobullous rash on his right flank in a continuous band from the middle of his back spreading around to his mid-axillary line. No other lesions are present. He does have some right axillary lymphadenopathy as well. What is the most appropriate treatment option? Symptomatic treatment and prevention of secondary infection Oral acyclovir Intravenous varicella-zoster immune globulin Oral cephalexin Aspirin
Symptomatic treatment and prevention of secondary infection In a normal child, symptomatic treatment and prevention of secondary infection are the mainstays of treatment.
A 12-month-old Caucasian boy presents for a well-baby visit. Prenatal and past medical histories are unremarkable. Growth and development are normal. Immunizations are up to date. There are no acute complaints. Examination is normal. As part of your routine anticipatory guidance, you discuss poisoning prevention. What instruction should you give for poisoning prevention at home? Toxic liquid cleansers should be placed at the far rear of the cabinet under the bathroom sink Ipecac should be kept at home to induce vomiting in the case of ingestion of a toxic substance Child resistant containers insure against ingestion of toxic substances Toxic substances should be kept out of sight and out of reach Loose prescription medication should be stored in relabeled containers
Toxic substances should be kept out of sight and out of reach Accidental poisonings occurred an estimated 1.2 million times among children younger than 6 years of age in the United States in 2001. Fortunately, fatalities were rare. Child resistant packaging and safer medications have reduced the number of fatalities, as has rapid and more specific therapy. Toxic substances should be kept out of sight and out of reach; if possible, they should be locked away.
A full-term male infant was delivered by emergency cesarean section due to obstructed labor. Birth weight of the baby was 3.5 kg. He developed respiratory distress at 2 hours of age. Physical examination reveals that the infant is dyspneic, and respiratory rate is 68/min with subcostal and intercostal retractions. There is no cyanosis. Septic screening is negative. He is managed with IV fluids, and oxygen saturation is maintained with 40% oxygen. Respiratory distress settles after 24 hours. The 1st image shows 4 hours of age, and the 2nd shows 24 hours of age. What is the most likely clinical diagnosis? Meconium aspiration syndrome Hyaline membrane disease Congenital pneumonia Transient tachypnea of the new born (TTNB) Persistent fetal circulation
Transient tachypnea of the new born (TTNB) The most likely diagnosis is transient tachypnea of the newborn (TTNB), as evidenced by the fact that the respiratory distress could be successfully managed by 40% oxygen and IV fluids as well as it disappearing within 24 hours. The diagnosis is further supported by the chest X-ray (4 hours) findings of pleural effusion on the left side in the 1st film done at 4 hours of age and complete clearance of the effusion after 24 hours, which is seen in the 2nd X-ray. TTNB is a relatively mild, self-limited disorder manifesting as respiratory distress. It commonly occurs in term and near term babies. It occurs due to slow absorption of fetal lung fluid, and it manifests with tachypnea, chest retractions, and respiratory grunting, which may respond to 40% oxygen, and respiratory distress should disappear within 2 - 3 days.
A 5-year-old boy presents with sudden onset of a stumbling gait following a 3-day history of a spreading rash. His mother notes that the rash began as red "bumps" but has progressively changed to fluid-filled blisters. The boy says the rash is itchy. A few days prior to onset he had a low-grade fever, abdominal pain, lethargy and a headache. Aside from his unsteady gait, his anxious mother has also noted that his speech seems slightly slurred. He has had no known exposure to sick children. The boy's older brother is present during the exam and is flapping his hands spastically, chewing on a rubber "P"-shaped toy, and jumping up and down facing the wall. The mother seems to keep checking on his whereabouts and what he's doing. It seems as the boy may be autistic. He has not exhibited any similar symptoms or been ill recently. On physical exam, the patient appears to have a clumsy, wide based gait as well as difficulty articulating certain words. He also has numerous vesicles with a cloudy fluid over his entire body. Intermixed with these are a few lesions that are already scabbed over, as well as numerous erythematous papular lesions. His temperature is 99.4°F. What is the most likely etiology of these findings? Parvovirus B19 Rubella Rubeola Varicella Coxsackie virus
Varicella Explanation The most likely etiology is varicella. Varicella, or chicken pox, presents initially as erythematous macules that develop quickly into papules and thin-walled vesicles surrounded by an erythematous base. Patients will have successive crops of lesions, which scab over in 5 to 7 days with occasional residual scarring. Mucosal involvement of areas such as the oropharynx and vagina is common. Marked pruritus may be seen. The incubation period is 14 to 21 days, and the prodrome consists of malaise, fever, and headache. The causative agent is the varicella-zoster virus.
A 3-year-old boy presents for a well-child visit. He is recovering from laryngotracheitis which was managed with over-the-counter cold medications. He has started daycare and seems to be adapting well. He enjoys a varied diet and his parents have no specific concerns. Past medical history and family history are unremarkable. Physical examination is normal. What developmental milestone is appropriate for his age? Tells a story Throws a ball overhand Washes his hands Engages in interactive play with other children Goes to the toilet alone
Washes his hands A child of 3 years of age would be expected to speak in short sentences, but he would not be able to tell a story. Although gross motor skills are developing, the strength and coordination to throw a ball overhand would not usually be expected until age 4. Children at this age generally engage in parallel play more so than group play. Some children at this age will be potty-trained, but rarely will they be able to go to the bathroom alone.
A 6-month-old girl presents for a well-baby visit. Prenatal and past medical histories are unremarkable. Growth and development are normal. Immunizations are up to date. There are no acute complaints. Examination is normal. As part of your routine anticipatory guidance, you discuss bath time safety. What instruction should you give regarding bath time safety? The girl's 7-year-old sister should attend to the girl in the bath if her mother is otherwise occupied Water heater maximum temperature should be set no higher than approximately 120°F to prevent scalding If the child must be left unattended in the bath, an inflatable tube or bath seat should be provided Water heater maximum temperature should be set no higher than approximately 140° to prevent scalding The tub may be refilled by an older sibling provided that the water heater maximum temperature is set no higher than approximately 120°F
Water heater maximum temperature should be set no higher than approximately 120°F to prevent scalding Scald injuries and drowning are 2 of the major risks at bath time for the young infant. The higher the water temperature, the shorter the duration of skin contact required to cause a serious burn. Very high temperatures cause burns on contact (scalding). Water heater maximum temperature should be set at approximately 120°F to prevent scalding. Because the water heater thermostat setting may not accurately regulate the temperature of the outflowing water, the supervising adult should test water temperature as well before placing the child in the bath.
