GENERAL PRACTITIONER EXAM
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A married couple brings their newly adopted 5 month old for his first well child visit. They ask when the child can sit in a safety seat in the car facing forward. Your advice will be that the child should face rearward until he is
If a child faces forward in a crash, the force is distributed via the harness system across the shoulders, torso, and hips, but the head and neck have no support. Without support, the infant´s head moves rapidly forward in flexion while the body stays restrained, causing potential injury to the neck, spinal cord, and brain. In a rear-facing position, the force of the crash is distributed evenly across the baby´s torso, and the back of the child seat supports and protects the head and neck. For these reasons the rear-facing position should be used until the child is 12 months old and weighs 20 lb (9 kg). For example, a 13- month-old child who weighs 19 lb should face rearward, and a 6-month-old child who weighs 21 lb should also face rearward.
A 1 year old child is brought to the office by his mother for his routine health checkup. She states she has just been diagnosed with hypercholesterolemia. Her fasting serum total cholesterol concentration was 260 mg/dL and her LDL cholesterol concentration was 130 mg/dL (rec <129 mg/dL). A special diet has been recommended for her; however, she is very concerned about the risk of hypercholesterolemia for her son. What is the most appropriate management at this time?
The mother, whose age is unspecified, but is likely less than 60 years old, has no major risk factors for cardiac disease and her cholesterol levels are not elevated enough to trigger concern for a familial hypercholesterolemia. For these reasons, her child does not require any immediate attention but should wait until roughly two years old when his diet is free of breast milk and other sources of high fat content that infants often require.
The false statements about stuttering in a 4 year old is
The etiology of stuttering is controversial. The prevailing theories point to measurable neurophysical dysfunctions that disrupt the precise-timing required to produce speech. Stuttering is a common disorder that usually resolves by adulthood. Almost 80 percent of children who stutter recover fluency by the age of 16 years. As with many behavioral disorders of childhood, stuttering occurs three to four times more often in boys than in girls. Mild stuttering is self-limited, but more severe stuttering requires speech therapy, which is the mainstay of treatment. Delayed auditory feedback and computer-assisted training are currently used to help slow down speech and control other speech mechanisms. Pharmacologic therapy is seldom used, although haloperidol has been somewhat effective.
When assessing the nutritional status of an infant it is useful to know that birth weight is expected to be regained within
A helpful guideline for assessing normal growth in the very young infant is that birth weight should be regained by the 14th day.
A 2 year old child comes for his well care visit. His mother is concerned because he is not yet able to walk. The routine physical examination, including an orthopedic evaluation, is unremarkable. Speech and other developmental landmarks seem normal for his age. The most appropriate at this time would be?
A child died from sudden infant death syndrome (SIDS). The parents want to know what they can do to prevent it for their next child. The most appropriate advice is
Sudden infant death syndrome (SIDS) is the sudden and unexpected death of an infant or young child between 2 weeks and 1 year of age in which a thorough postmortem examination fails to show cause.
The prevention involves infants be placed supine (on back) for sleep. The incidence of SIDS increases with overheating (clothing, blankets, hot room) and in cold weather. Thus, every effort should be made to avoid an overheated or an overly cold environment, to avoid overwrapping the infant, and to remove soft bedding, such as sheepskin, pillows, stuffed toys/animals, and comforters, from the crib. Mothers should avoid smoking during pregnancy, and infants should not be exposed to smoke.
Note: “Prone” (face down) is often confused with “supine´ (face up).
A 6 year old boy is found to have unusual cravings for dirt and ice. He has also been seen eating paint chips of the walls. The likely cause is
Pica is the term used to describe craving for and eating nonnutritious things such as dirt and ice. This is a sign of lead poisoning. Most commonly, young children get lead poisoning from lead-based paint, which was used in many old homes. That´s why kids who live in older homes are at a greater risk for lead poisoning.
These children are found to have unsafe levels of lead in their blood, which can lead to a wide range of symptoms, from headaches and stomach pain to behavioral problems and anemia. Lead can also affect a child´s developing brain.
A 1 year old girl presents to the ER. Her mother has been treating her with Tylenol, and although the child appears flushed and ill when the fever is high, she is her usual self when the fever is down. The child has otherwise been a healthy child and has received all her immunizations including MMR vaccine one week ago. On examination, her temperature is 40 degrees Celsius rectally. Her tympanic membranes are normal. Her throat is mildly erythematous, with no exudates. Her lungs are clear, respiratory rate is 30/min, and there are no extra heart sounds. Abdomen is soft. She has a diaper rash. In this case what investigations you should not perform?
A lumbar puncture is not necessary in this child as she does not have a presentation that is suspicious for meningitis.
When prophylactic antibiotic therapy is used for tooth extraction in a patient with a ventricular septal defect
Antimicrobial prophylaxis is recommended for patients at high to moderate risk of infective endocarditis before procedures associated with bacteremias and subsequent infective endocarditis. For most patients and procedures, a single dose shortly before the procedure is effective. Procedures requiring antimicrobial endocarditis prophylaxis include oral-dental procedures, dental extraction, dental implant placement and reimplantation of avulsed teeth and periodontal procedures, including surgery, scaling, root planning, and probing.
Drug treatment in patients allergic to penicillin is with a macrolide such as erythromycin, clarithromycin or azithromycin.
Which one of the following drugs is associated with congenital heart disease?
Phenytoin has been associated with several forms of congenital heart disease, including pulmonary valve stenosis, aortic valve stenosis, coarctation, and patent ductusarteriosus. The other agents have not been described as causative factors for congenital heart disease.
Low birth weight in newborns is associated with all of the following EXCEPT
Maternal diabetes often results in large-for-date babies. Prematurity, active tobacco smoking, maternal alcohol ingestion, and passive tobacco smoking all are associated with low birth weight.
A child should have first developed the ability to copy a rectangular shape by which one of the following well baby office visits?
At the age of five years, approximately the time most children enter kindergarten, children develop the ability to copy rectangles. Prior to this age, they generally cannot perform such an act.
A 6 year old girl is brought by her parents to the emergency room because she is complaining of stomach pain. Physical examination reveals multiple bruises on the child´s boy in different stages of healing. X-ray examination of the chest demonstrates two cracked ribs and the child says. “Mommy hit me.” The parents deny any abuse of their children. What would be the physician´s most appropriate response?
The correct answer is C. All signs, including the child´s report, suggest child abuse; however, there can be mitigating circumstances that are present. All states have laws requiring everyone to protect children by reporting the suspicion of child abuse to Child Protective Services. It is the responsibility of this agency to prove or disprove the suspicion, and to establish supervision of the child if abuse is verified.
“I am going to call the police right now” (choice A), is only appropriate if the Child Protective Services is not available immediately. Choices B, D, and E do nothing to address the issue of the mandatory report of the suspicion of child abuse to the appropriate authorities.
Object permanence typically develops at what age?
An infant will be able to understand the concept of object permanence by nine to ten months. This is evident by the fact that infants of this age group will be able to uncover a hidden object, realizing that because an object is out of sight does not mean that it no longer exists.
An infant be able to transfer an object between different hands at which of the following age?
An infant at six months is able to transfer an object, such as a toy from one hand to another. Prior to that, he cannot.
An 8 month old infant is found to be hypercalcemic and oliguric secondary to nephrocalcinosis. Which one of the following vitamin toxicity may be possible in this infant?
Vitamin D toxicity is associated with hypercalcemia, as well as constipation, and sometimes nephrocalcinosis. Vitamin E toxicity may cause a necrotizing enterocolitis and hepatitis in children. Vitamin K toxicity although uncommon, may cause vomiting and hemolysis, as well as albuminuria and hemoglobinuria. Pantothenic acid toxicity is associated with diarrhea. Pyridoxine toxicity, while very rare, is associated with peripheral sensory neuropathy.
During which age a normal, healthy child will begin the routine use of sentences?
A child will begin the routine use of sentences at three years of age. Prior to this time, the child can only use a few phrases up until the age of one, and only a few phrases up until the age of two. The child cannot participate in an active conversation until about four years, when he also becomes capable of eliciting a series of sentences. At the age of five years, a child becomes capable of using complex sentences that include the use of pronouns, adjectives, prepositions, and other complex language.
A child should have developed the ability to dress without supervision by which of the following well child office visits?
Children at the age of five have developed the ability to dress by themselves; however, many mothers still dress the child at this age even though the child can do it alone.
Preoperational intelligence typically develops at which of the following age?
Preoperational intelligence develops at approximately two years.
At what age in adolescent boys does the testicular volume reaches its maximum?
The onset of maximum testicular volume approximately coincides with the end of the height spurt in adolescent boys, approximately 15.5 years of age.
Fear of injuring one´s own body is an anxiety that is most severely felt by which following age groups?
Children who are elementary school age are more afraid of injuring themselves physically or losing a loved one, such as a parent. Children less than one year of age are most often scared of loud noises, heights, and lack of physical support. Children one year of age typically begin to experience stranger anxiety and separation anxiety. Children between the ages of two and six years are afraid of figments of their imagination (e.g., the bogeyman), as well as animals and the dark. Adolescents and teens are scared of failing or not being accepted socially.
A child should have developed the ability to recite the alphabet by which of the following well child visits?
By the age of five years, a child should have developed the ability to recite the alphabet without help. If this has not occurred; intelligence testing is indicated to determine whether there are any mental handicaps that are preventing the child from doing so.
The greatest numbers of children are classified within which one of the following categories according to Thomas and Chess?
According to the studies of Thomas and Chess, the “easy” child, or one that exhibits normal schedules of sleeping, eating, playing, etc., represents approximately 40% of all children. “Difficult” children, or those with irregular schedules of activities, represent 10% of children. “Slow to warm up” children, who are withdrawing as well as low in activity, represent 15% of children. Thomas and Chess did not designate categories for “indifferent” or “dependent” children.
In children, differences in personality can be recognized at which one of the following ages?
By the age of two years, differences can be recognized in personality. Some parameters that can be measured in two-year-old children include passivity, timidity, and boldness. Other names for these characteristics include “harm avoidance” and “novelty seeking” behavior.
A child visits you for a routine well child visit. He should have first developed the ability to draw a man with six separable parts by which one of the following visit?
A child first develops the ability to draw a man with six separable parts-a stick figure-at approximately the age of five. None of the other ages correspond to the first development of this ability.
FALSE statement regarding interpretation of physical growth measurements is which one of the following?
In older children, recumbent length is more accurate than standing height due to postural factors. Option A is correct, since single measurements that are taken at the beginning or end of a period of defective growth may reveal unusual features of a baby´s growth, but show nothing of the baby´s rate of growth. Since it is impossible to say what measurements represent normal growth, it is impossible to use average weight and height as a reference in determining whether a child´s growth is normal or abnormal. Malnutrition has more of an effect on weight than on height. Figures obtained from one country should not be used as a basis of comparison for children in another country, because the growth and development of children varies from one country to the other.
In children of which one of the following age groups is darkness a significant cause of anxiety?
Children between the ages of two and six years are afraid of figments of their imagination (e.g., the bogeyman), as well as animals and the dark. Children less than one year of age are most often scared of loud noises, heights, and lack of physical support. Children one year of age typically begin to experience stranger anxiety and separation anxiety Children who are elementary school age are more afraid of injuring themselves physically or losing a loved one, such as a parent. Adolescents and teens are scared of failing or not being accepted socially.
An 8-month-old previously preterm infant with bronchopulmonary dysplasia is lethargic. His regular medications include furosemide and spironolactone. Temperature is 31.4°C (99.3°F), blood pressure is 68/32 mm Hg, pulse is 110/mm, and respirations are 10/min. He has poor skin turgor and dry mucous membranes. Laboratory chemistry evaluation reveals: sodium, 131mEq/L; potassium, 3.0mEq/L; chloride, 94mEq/L; bicarbonate, 39mEq/L; blood urea nitrogen, 36mg/dL; and creatinine, 0.4 mg/dL. An arterial blood gas shows pH, 7.52; CO2 49mm Hg; and PaO2, 92mm Hg. Which of the following is the most likely explanation for these findings?
The findings of dry mucous membranes, poor skin turgor, and tachycardia suggest that the infant is volume depleted. He has been taking the loop diuretic furosemide, which is used to treat bronchopulmonary dysplasia. Furosemide causes increased excretion of sodium (therefore water), potassium, and chloride in the urine. The body is therefore hypovolemic. Excessive loss of potassium causes the hydrogen-potassium pump across the cell membranes to transport hydrogen into the cells in exchange for potassium out of the cells. Transportation of hydrogen into the cells causes the number of hydrogen ions in the plasma to decrease and results in alkalosis. The chemoreceptors in the medullary respiratory center of the brain sense the metabolic alkalosis and respond by lowering the respiratory rate.
Therefore, more carbon dioxide is retained in the bloodstream and partially corrects the metabolic alkalosis.
Bartter syndrome is a rare autosomal-recessive disorder that manifests as hypokalemia, hypochloremia, and high renin and aldosterone levels. Primary aldosteronism is characterized by hypertension, hypernatremia, hypokalemia, and a suppressed renin-angiotensin system.
Primary respiratory acidosis with metabolic compensation represents a primary process of respiratory failure and increased retention of carbon dioxide. The kidneys compensate by retention of bicarbonate in an attempt to correct the acidosis. However compensatory mechanisms will never overcompensate for the primary process. Therefore, the pH should never be more than 7.40.
Pseudo hyperaldosteronism, also known as the Liddle syndrome, is a rare disorder of renal transport of sodium and potassium that resembles primary hypcraldosteronism. Affected people present in infancy or early childhood with hypertension, polyuria, polydipsia, and hypokalemic metabolic alkalosis. The serum concentration of aldosterone is low.
A 12 year old girl develops weight loss despite eating large amounts of food over a period of 3 months. Careful history reveals that the child now drinks “all the time.” Which serum chemistry study will likely be diagnostic of her condition?
While it is commonly known that diabetes mellitus is associated with polyuria and polydipsia, many do not realize it also associated with weight loss despite increased eating. In our extremely weight and food conscious society, this phenomenon may be much more striking to the patient and his family than a change in the amount of fluid intake. The lesson learned is that a child who develops weight loss despite increased food intake requires a blood glucose test.
A young mother wishes to teach her 3 year old daughter to pick up his toys when he is finished playing. A friend advises her to reward her child for completing this task. The approach is effective for about 1 week but she returns to his previous untidy behavior. Which pattern of reinforcement did she likely use?
In a patient who develops streptococcal pharyngitis, what is the way to prevent the development of rheumatic fever?
In the differential diagnosis of recurrent abdominal pain the organic causes are all of the following, except
Recurrent abdominal pain (RAP) is common in children especially in pre- school children and adolescents. Recurrent abdominal pain is an expression of physiological maladjustments in response to family or school problems in predisposed children. Contrary to this belief, many studies have found organic causes of RAP to be more common. The occurrence of nocturnal pain is considered an important indicator of an organic (disease-lased). Night pain or pain on awakening suggests a peptic origin, while pain that occurs in the evening or during dinner is-a feature of constipation.
Organic causes include (but are not limited to) gastrointestinal disease, urinary tract infections, parasite infestation and esophagitis/gastritis.
A 15 year old girl experiences the sudden onset of tender, bleeding gums, malodorous breath, and a bad taste in her mouth. On examination she is febrile and has cervical lymphadenopathy and tachycardia. Her mouth has marginal punched-out, crater-like depression of the interdental gingival papillae and gingival margins that are covered with a gray pseudomembranous slough. Which of the following is the drug of choice for this condition?
In a child with an egg allergy how would you approach the administration of the MMR vaccine?
The current measles-mumps-rubella vaccine (M R) does not contain a significant amount of egg proteins) In the past skin testing of all children with severe egg allergies before they received the M R was recommended; This is no longer necessary; Even those with dramatic egg allergies are extremely unlikely to have an anaphylactic reaction to the MMR. The benefits of the vaccine far outweigh the risks.
Although egg protein in the MMR is no longer a big problem, if your child has severe allergies with systemic sym toms, whatever the cause, it pays to become familiar with the hidden ingredients found in products of all kinds.
A boy of age 8 years with family history of urticaria presents for consultation. His investigation reveals C1 esterase inhibitor deficiency. The most likely diagnosis is
Hereditary angioedema is caused by deficiency (type 1; in 85%) or dysfunction (type 2; in 15%) of C1 inhibitor, a protein that regulates the classical complement activation pathway.
Inheritance is autosomal dominant. C1 inhibitor deficiency may also develop when complement is consumed in neoplastic disorders or when C1 inhibitor autoantibody is produced in monoclonal gammopathy (acquired deficiency). Attacks are precipitated by trauma or viral illness and aggravated by emotional stress. Symptoms and signs are similar to those of angioedema except that edema progresses until complement components have been consumed; the GI tract is often involved, causing nausea, vomiting, colic, and signs of intestinal obstruction.
Diagnosis is by detection of low levels C1 inhibitor. Treatment is attenuated androgens to stimulate hepatic C1 inhibitor synthesis.
A 1 year old child with a rapid pulse, slightly low blood pressure, cool extremities, oliguria and dry mucosa should be considered
In infants signs of 5% dehydration are slightly dry buccal mucous membranes, increased thirst and slightly decreased urine output.
In infants signs of 10% dehydration are dry buccal mucous membranes, tachycardia, little or no urine output, lethargy, sunken eyes and fontanelles, loss of skin turgor.
In infants signs of 15% dehydration are same as moderate plus a rapid. thready pulse, no tears, cyanosis, rapid breathing, delayed capillary refill, hypotension, mottled skin and coma.
A 3 month old infant is brought to you with small pustules on the soles of the feet and a few similar lesions on the palms of her hands. Scabies is identified in scrapings of the lesions. You should
Scabies is usually not seen on the head, neck, palms, and soles in adults, but these areas are often affected in infants. Lindane may be hazardous to young infants because of its percutaneous absorption and potential neurotoxicity. Permethrin is at least equally effective, and because it is poorly absorbed and rapidly metabolized, its toxicity is low. Crotamiton cream and sulphur in petrolatum are safe options, but must be applied continuously over 3.5 days. Laundering of clothing and bedclothes is sufficient to prevent reinfestation. In fact, clothes may simply be hung outside for 3-4 days, because the isolated mite dies within 2-3 days.
A 5 year old girl presents with headache, dizziness, tinnitus, sweating, and hyperventilation for 3 days. She was recently diagnosed with juvenile rheumatoid arthritis. The drug is most likely to be associated with these adverse effects is
Rheumatoid arthritis (RA) is s chronic autoimmune disease, producing damage mediated by cytokines, chemokines, and metalloproteases. Peripheral joints (eg, wrists, metacarpophalangeal joints) are symmetrically inflamed, often resulting in progressive destruction of articular structures, usually accompanied by systemic symptoms. Diagnosis requires specific clinical, I laboratory, and radiologic criteria. If a patient takes aspirin daily (for RA, for example), it can cause or worsen tinnitus. For this reason, aspirin is no longer used for RA, as effective doses are often toxic.
A father calls your office because his three week old son has a fever of 39.5 degrees Celsius (103.1 F) measured axially. He was full term and had no complications after a spontaneous vaginal delivery. He was breast-feeding well until yesterday. Since then he has been sleeping more. He has a two-year-old brother who has a cold. What is the best advice for the parent?
A 12 year old obese boy with diabetes mellitus is admitted to the hospital because of severe ketoacidosis and cardiovascular collapse. Initial management consists of cardiac monitoring and intravenous administration of fluids, electrolytes and insulin. Because of the difficulty in obtaining satisfactory peripheral venous access, the left femoral vein is catheterized percutaneously. Six hours later, his mental status is improved, blood pressure is 120/70 mmHg and serum glucose concentration is 250 mg/dL. At that time examination shows a cold left foot with diminished pulses compared with those of the right foot. What is the most likely explanation for the diminished pulses?
During percutaneous placement of central venous lines, many complications are possible. Depending on the site f placement, the most serious complications vary. For all line placements however, injury to the accompanying artery poses a serious risk. In this case, the presence of a cola foot without pulses on the side ipsilateral to the line placement strongly suggests damage to the femoral artery.
A 3 year old child is brought to the emergency department with a barking cough, a hoarse voice, and mild stridor. You diagnose acute laryngotracheitis. The treatment in the emergency department that will reduce this child´s chance of subsequent hospitalization during this acute illness is
In laryngotracheitis (croup) , intramuscular or oral dexamethasone (0.6 mg/kg) has been shown to; reduce the rate of subsequent admission after acute treatment. This disease is usually viral, and antibiotics are not helpful. Humidified air is of unproven benefit, and mist tents separate children from caregivers and hinder observation and evaluation.
A 7 year old child presents with dehydration. Her mucous membranes are dry and she is having tachycardia and decreased urine output. Her initial labs show potassium of 5.0 mEq/L and glucose of 97 mg/dL. The most appropriate IV fluid to administer for maintenance hydration is
The recommended fluid to be infused as maintenance for well children with normal hydration is:
0.45% NaCl with 5% Glucose + 20mmol KCl / Liter.
This is often written as D5 1/2 NS + 20KCl
The D5 refers to the glucose (dextrose); NS refers to Normal saline which is 0.9% NaCl. 1/2 NS would refer to 0.45% NaCl.
In this child the potassium is in the upper limit of normal, since normal/ range is 3.5-5.0. So do not add potassium at this time. The maintenance treatment would be with 0.45% NaCl. If giving a bolus, you would use 0.9% NaCl normal saline.
The most suggestive sign of selective mutism in a child is
Selective Mutism (SM) is a complex childhood anxiety disorder characterized by a child´s inability to speak in select social settings, such as school. These children understand language and are able to talk normally in settings where they are comfortable, secure and relaxed. Over 90% of children with SM also have social phobia or social anxiety, and some experts view SM as a symptom of social anxiety. What is clear is that children and adolescents with SM have an actual fear of speaking and of social interactions where there is an expectation to talk.
A child meets the criteria for selective mutism if the following are true:
1. The child does not speak in ´select´ places such as school or other social events.
2. But, he or she can speak normally in at least one environment; usually this is in the home environment but a small percentage of children with SM are mute at home.
3. The child´s inability to speak interferes with his or her ability to function in educational and/or social settings.
4. The mutism has persisted for at least one month.
5. The mutism is not caused by a communication disorder (such as stuttering) and does not occur as part of other mental disorders (such as autism).
A 13 year old boy is seen because he is constantly blinking. The boy is otherwise well. He was suspected to have ADHD. You note that he frequently clears his throat, yet he denies sore throat or other upper respiratory tract symptoms. He blinks frequently, yet is able to hold his eyes open during examination with an ophthalmoscope. His fundi, visual acuity, extraocular movements, visual fields, eyelids and eyelashes are normal. He also exhibits intermittent facial grimacing without apparent pain. Condition that is frequently associated with this boy´s diagnosis is which one of the following?
People with Tourette´s syndrome often have difficulty functioning and experience considerable anxiety in social situations. In the past, they were shunned, isolated, or even thought to be possessed by the devil. Impulsive, aggressive, and self-destructive behaviors develop-in many people, and obsessive-compulsive behavior develops in about half. Children with Tourette´s syndrome often have difficulty learning. Many also have attention-deficit/hyperactivity disorder. Whether Tourette´s syndrome itself or the extraordinary stresses of living with the disorder cause these problems is unclear.
A child born at 32 weeks gestation is brought to your office at 2 months of age for a routine checkup. The child has an upper respiratory tract infection but is afebrile. Regarding the child´s first vaccination what is your decision?
Acute illness is not a contraindication to immunization. At 2 months of age this child should receive the following shots:
DTaP: Diphtheria, tetanus, and acellular pertussis vaccine
Hib: Haemophilus influenzae type b vaccine
IPV: Inactivated poliovirus vaccine
PCV: Pneumococcal conjugate vaccine
RV: Rotavirus vaccine, recommended for infants at 2, 4, and 6 months of age
A 10 year old boy develops an itchy, red rash on his legs after walking in the forest. He has had similar complains during the summer months. The rash is composed of blisters arranged in lines. Which statement is true for this condition?
Bleeding gums is commonly seen in
Bleeding gums, petechiae, and other form of abnormal bleeding are associated with vitamin C deficiency as a result of abnormal collagen synthesis. The other conditions are not associated with such bleeding.
Maternal cigarette consumption is associated with
The other conditions have not been shown to be related to maternal smoking.
Which one of the following represents the cause of the largest number of deaths in children between the ages of 6 months and 19 years?
Motor vehicles cause approximately 8,000 deaths of children between the ages of 6 months and 19 years, rendering it the cause of the largest number of deaths in children of this age group.
The parents of a 5 year old girl ask their family physician for advice regarding their child. The mother had walked into the girl´s bedroom without knocking and discovered the child stimulating her genitals. The parents are concerned, but seem to be receptive. What would be the best response by the physician?
Snakebite venoms are more likely to be fatal in which of the following?
Snakebites are more likely to be fatal in children because of the small size of the individual and the fact that essentially the same amount of poison is injected with each bite.
A child typically begins to enjoy hobbies and other types of related activities at which one of the following developmental ages?
While school aged children typically develop fine motor skills, it is not until they are in their preteenage years (ten to fourteen years) that true enjoyment of hobbies and scientific activities becomes evident.
A child should have developed a sense of self-esteem by which of the following well child office visit?
Adolescents should have developed a sense of self esteem by the age of fourteen. Prior to this time, a lack of a sense of self-esteem is generally normal.
At what age a child reaches 50% of his or her expected adult height?
Children are expected to reach fifty percent of their expected adult height by the time they are two years of age.
Teething typically occurs at which of the following age?
An infant typically begins teething between six and eight months of age, not earlier.
All of the following are normal findings for a three year old child, EXCEPT
By three years of age, the child is expected to have a vocabulary of more than 50 words. Visual acuity test results equivalent to 20/40 at this age are not uncommon and do not correlate with visual acuity at five years of age and above. A, B, and E are all normal findings at this age.
A boy aged 8 years shows lip smacking with prolonged episodes of staring. On examination, he repetitively picks at his shirt and does not exhibit any jerking or spasticity. His mother reveals that prior to the seizure, the boy claimed that he smelled a “very funny odor.” The most likely diagnosis is
Partial simple seizure is seen in association with focal muscle twitching, usually involving either the arm or the leg. It is often preceded by a lesion in the cranium, such as an infarct or tumor. Partial simple seizures are seen most often in adults. Partial complex seizures are seen in children, and often are associated with lip smacking and staring. Patients with partial complex seizures demonstrate semi purposeful actions, and their seizures are often preceded by sensory delusions, such as a deja vu experience or smelling abnormal odors. Generalized absence seizures are also known as petit mal seizures. They are also seen in children, and often are only recordable by a brief episode of staring. Generalized tonic clonic seizures are also known as grand mal seizures. They are characterized by jerking of the extremities and muscle contraction. Sometimes there can be loss of consciousness and biting of the tongue. Finally alcohol withdrawal seizures are manifested between one and four days after cessation of alcohol consumption. These are typically isolated seizures and are characterized as grand mal seizures.
A 5-month-old infant has diarrhea and decreased activities for the past 3 days. He has been urinating less for few hours. Pulse is 100/min. His anterior fontanelle is flat, buccal mucosa is slightly dry, and he has normal skin turgor. Laboratory investigation reveals:
| Sodium: | 164 mEq/L |
| Potassium: | 5.8 mEq/L |
| Chloride: | 128 mEq/L |
| Bicarbonate: | 14 mEq/L |
| Creatinine: | 0.9 mg/dL |
| Blood urea nitrogen: | 49 mg/dL |
| Glucose: | 154 mg/dL |
Which of the following should be administered to rehydrate the patient?
This infant has developed hypernatremic dehydration from the diarrhea. Diarrhea in children results in a relatively greater loss of water than of sodium. In children, one of the most common fluid-electrolyte abnormalities is hypovolemia or dehydration, often related to vomiting and diarrhea from gastroenteritis. This infant has mild dehydration, as indicated by normal skin turgor, flat (not sunken) fontanelles, and slightly dry buccal mucosa. Infants with mild dehydration may have a normal or slightly decreased urine output. Labs show hypernatremia (serum sodium of 164mEq/L). The treatment for non-emergent (mild) dehydration with hypernatremia requires the administration of 5% dextrose in water (D5), which is a hypotonic solution. Amount of (D5W) to be administered is calculated as follows:
For every 3 mEq of sodium above 140 mEq, add 1 L of D5W In this patient, there is an additional 24 mEq of sodium above 140 mEq (164-140 = 24). Thus, 8 L of D5W (24 divided by3 = 8) has to be added. Correct this hypernatremic state with hypotonic solution (DSW) over 48 hours to avoid dropping the serum sodium too rapidly (15 mEq per 24 hours) to minimize the risk of cerebral edema leading to seizures or other neurologic sequelae.
Administering 4 L of DSW is incorrect because although the choice of fluid (D5) is correct, the amount is inadequate. It does not follow the recommended calculation given above.
Giving 4 L or 8 L of normal saline is incorrect because normal saline is an isotonic solution. We need to use hypotonic solution to correct hypernatremic dehydration. Rapid infusion of 20 mL/kg of normal saline or Ringer´s lactate is incorrect because the present patient is only mildly dehydrated.
This is the emergent management for rapid volume repletion in children with moderate to severe dehydration, regardless of the type of dehydration (hypernatremic/isonatremic / hyponatremic). Severe hypovolemia presents with hypotension, decreased peripheral perfusion with a capillary refill of greater than 3 seconds, cool and mottled extremities, lethargy, or frank shock. Initial therapy requires rapid bolus administration of normal saline or Ringer´s lactate (isotonic fluid) to restore an effective circulating plasma volume. Albumin, blood, or plasma can also be considered if there is no response after 2 coli of isotonic fluid.
ReSoMal is given in malnutrition.
A couple brings their first child to their physician for a well-child examination. The child is 3-month-old healthy-appearing infant whose weight is at 45th percentile of the normal growth curve. There is a blue-black pigmentation over the buttocks. The parents say that it was present from the time of birth. Which of the following is the most appropriate next step in management?
A Mongolian spot is an area of hyperpigmentation found in 66% of all infants of Hispanic, Asian, and Native American ethnic background. It is sometimes mistaken for a bruise caused by trauma and-erroneously reported to the authorities as evidence of suspected child abuse. All physicians, and especially primary care providers, should be aware of this common normal feature in order to avoid such mistakes. An autopsy finding that may be mistakenly attributed to child abuse is postmortem livedo, which is due to blood settling to the dependent parts of the body once circulation stops.
CT/MRI studies would be useful to rule out the possibility of an underlying neural tube defect (dysraphism) in the presence of a hemangioma in a sacral location.
20 year old girl sees her baby cousin for the first time. As she attempts to play with the infant, he begins to cry incessantly. The most likely age of this infant is which one of the following?
The baby is exhibiting stranger anxiety, which normally occurs between the ages of 5 and 9 months. Let´s review some other social milestones that are good to be aware of during clinical work in pediatrics:
Spontaneous smiling begins within several days after birth and disappears by 3 months. Smiling at any face occurs by 2 months, followed quickly by smiling only at familiar faces and when pleased. By 3 months, infants can imitate facial expressions. They laugh at 4 months. Crying occurs from birth. It peaks at 6 weeks and is most frequent from 4-6 PM. Colic is defined as crying more than 3 hours a day for more than 3 days a week. It often spontaneously resolves by 4 months. Treatment includes holding, avoiding overstimulation, and antispasmodics.
Separation anxiety occurs between the ages of 10 and 18 months, when the infant is separated from the mother. Between the ages of 2 months and 2 years, children might show preference for a comforting “transitional object” (e.g., a teddy bear), which is usually discarded by age 4, when the transition from dependence on the mother to independence is more complete.
A 14 year old boy visits you. He is concerned about his height. Physical examination reveals Tanner sage II pubic hair and genital development. Height and weight are at the 10th percentile for age. The most accurate statement about his growth is
The peak height velocity occurs at a mean of 13.5 years in boys and 11.5 years in girls. Since this boy is only in tanner stage II, he still has not reached the peak height yet.
Neighbor´s dog bit a 6 year old child. The dog has received all the necessary vaccine. The most appropriate management is
The patient´s risk of infection with rabies virus must be addressed immediately. Because of the serious risk to the public of a rabid animal on the loose, it is important to document the conditions surrounding the attack. As a result of widespread vaccination of dogs against rabies, the most common source of the rabies virus is now wild animals, specifically raccoons, skunks and bats.
Nonetheless, there are still reported cases of rabies virus associated with a dog bite. Patients with a bite from a nonprovoked dog should be considered at higher risk for rabies infection than patients with a bite from a provoked dog. If the dog owner is reliable and can confirm that the animal´s vaccination against rabies virus is current, the dog may be observed at the owner´s home.
Observation by a veterinarian is appropriate when the vaccination status of the animal is unknown. If the animal cannot be quarantined for 10 days, the dog bite victim should receive rabies immunization.
Which statement is true regarding urinary tract infections in febrile infants and young children (age 2-24 months)?
There are published clinical guidelines for treating infants and young children (2-24 months) with a febrile urinary tract infection (UTI). They recommend ultrasonography in all these children following the first episode of febrile UTI, as well as either voiding cystourethrography or radionuclide cystography to rule out vesicourethral reflux (VUR). More than 50% of these children will have some VUR on these studies, and the degree of VUR correlates with renal parenchymal damage.
All children should have urine for culture collected by suprapubic aspiration or urethral, catheterization. The perineal bag has unacceptable rates of contamination, especially in girls and uncircumcised boys. A 7- to 14-day course of parenteral or oral antibiotics is recommended, with prophylactic oral antibiotics recommended until imaging studies are completed.
A 7 year old boy with moderately severe atopic dermatitis has been treated with a variety of moisturizers and topical corticosteroids preparations over the past year. No satisfactory results have been achieved. The appropriate topical medications at this time is
Tacrolimus is an immunomodulator indicated for the treatment of atopic dermatitis when corticosteroids and other conventional remedies are inadvisable, ineffective, or not tolerated. It is approved for use in patients over 2 years of age.
A 9 year old boy presents to the physician for a routine health visit. His mother states that he has had difficulty reading and concentrating in his class. In examination, seven café-au-lait spots on his body, as well as two small, soft masses above his orbit, are seen. He also has axillary freckling. His mother also has café-au-lait spots on her arms. The most likely diagnosis is
A 10 year old boy visits you for evaluation of bedwetting. He is dry during the day but wets every night. His physical examination and urinalysis are normal. The most appropriate method for managing this child is
Nocturnal enuresis is urinary incontinence during sleep. The child is counseled about the etiology and prognosis of enuresis, the aim of which is to remove blame and guilt. The child assumes an active role, including talking to the physician, urinating before going to bed, recording wet and dry nights, and changing wet clothing and bedding himself. The child should not consume fluids during the 2 to 3 hours before bedtime, and caffeinated beverages should be strictly limited. Positive reinforcement is given for dry nights (eg, a star calendar, other age- appropriate rewards). In addition to counseling, enuresis alarms are effective and often recommended simultaneously. Drug therapy can be effective in patients unresponsive to counseling and alarms. Short-term treatment (4 to 6 weeks) with desmopressin acetate nasal spray (a synthetic analog of ADH) is typically used in patients > 6 years with persistent, frequent nocturnal enuresis.
A 5 year old boy is brought by her mother for short stature. Both parents have a history of short stature in childhood, but they are now of normal height. All are features that qualify as main criteria for the diagnosis of constitutional growth delay, except
A 4 year old boy is admitted for the investigation of headaches and is found to have intermittent hypertension. You suspect a neuroblastoma. The most specific investigation for this diagnosis is which of the following?
Neuroblastoma is a cancer arising in the adrenal gland or less often from the extra-adrenal sympathetic chain, including the retroperitoneum, chest, and neck. Diagnosis is based on biopsy.
Routine prenatal ultrasound occasionally detects neuroblastoma. Patients presenting with abdominal symptoms or a mass should have ultrasound or CT. Diagnosis is then confirmed by biopsy of any identified mass.
Alternatively, diagnosis can be confirmed by the presence of characteristic cancer cells in a bone marrow aspirate or core biopsy, along with elevated urinary catecholamine intermediates. Urinary vanillylmandelic acid VMA), homovanillic acid (HVA), or both are elevated in ≥ 90 to 95% A 24-hour urine collection can be used, although a spot urine test is usually sufficient.
An 18 month old infant presents with pallor and irritability. Her mother says the infant´s diet consists almost exclusively of whole milk, approximately 40 oz per day. On physical examination, the infant has a pulse of 160 per min, respirations of 50/min, and normal heart sounds with a grade 2/6 systolic ejection murmur. Liver is palpable 3 cm below the right costal margin. Laboratory studies show: Hematocrit 13%
Hemoglobin 3 g/dL
Mean corpuscular volume 48 µm3
Platelet count 400,000/mm3
After appropriate evaluation, the most appropriate treatment is
Starting transfusion with packed erythrocytes is the most appropriate management because this patient has severe iron deficiency anemia. Pallor is the most important clue to iron deficiency anemia. However, patients may also have other symptoms such as tachycardia, tachypnea, heart murmurs, and hepatomegaly. In patients with hemoglobin under 4 g/dL, a blood transfusion with packed erythrocytes should be given slowly. The quantity of packed erythrocytes administered should be sufficient to raise the level of hemoglobin to a safe level while awaiting the response to iron therapy.
A 15 1/2 year old girl is brought to your office by her mother. They are concerned because she has not started her periods. She has been healthy, and has grown several inches in the last year. Her height is now 152 cm (60 in) and she weight 44 kg (98 lb). Her breast buds started to develop about a year ago and has scant pubic hair. She denies sexual activity. The mother´s menarche occurred at age 15. What will you tell the mother?
A mother is worried about her child, because of a family history of Myopathy. The most appropriate investigation to do first in the child is
Myopathies refer to a class of degenerative skeletal muscle disease that is not caused by nerve dysfunction. Myopathies cause progressive weakness and wasting away of skeletal muscles. The causes for Myopathies vary. They could be hereditary, an inflammatory response, or the result of an endocrine disorder. Creatinine phosphokinase (CPK) is an enzyme found in skeletal muscle, cardiac muscle, and the brain. An initial step is to measure the level of this CPK enzyme with a simple blood test.
Average weight gain per week in the first three months of life is best represented by?
The average weight gain in the first three months of life is 196 g per week. In the second three months of life, the average weight gain is 148 g per week.
The mother of a 6 year old boy brings him to see the pediatrician complaining that the boy is enuretic from 4 to 5 times a week. She reports that the problem began in the past few months after she gave birth to a baby girl. Breast feeding for the new baby has been difficult and has consumed a great deal of her time each day. According to her the boy is very embarrassed about his enuresis and is afraid that the other children where he goes to school will find out and make fun of him. She asks the physician help and advice. What would be the physician´s best course of action?
The correct answer is E. This type of enuresis, the result of the defense mechanism of regression, is very common when new siblings enter the household. The boy feels neglected and returns to response patterns more typical of a younger child either out of anxiety, or as a direct attempt to gain more parental attention. Spending more, separate time with the boy will help to reassure him of the mother´s continued love and affection. With the motive removed, the symptom is likely to dissipate as well.
Having to discuss a problem about which he is already embarrassed with the authority figure of the physician (choice A) is likely to heighten, not reduce, the boy´s discomfort and embarrassment. The issue here is one between mother and child. The physician should encourage that direct relationship and not seek to form an indirect substitute.
The capacity of a 6 year old to articulate the abstract relationship issues which may be bothering him (choice B) will be limited. More likely the child will feel uncertain as to what to say, and may walk away with heightened embarrassment about his enuresis.
This is the correct pharmacology, but the treatment is premature. Imipramine (choice C) will reduce the bed-wetting, but this merely addresses the symptom, not the root cause. Remember that one of the key mechanisms by which imipramine reduces bed-wetting is through the reduction of delta sleep, which is not a long-term solution for the child.
Referring the mother to a breast-feeding seminar (choice D) misses the issue. The core problem presented is that of enuresis, not the mother´s difficulties with breast-feeding. Even if the mother is expert at this skill, the child is still likely to feel slighted by the attention given to the new sibling. The mother must be directed to affirm her relationship to her son on a daily basis, not advised how to bond better with the new baby.
Don´t “pass off” (choice F) the child. You can, and should, deal with this yourself. Enuresis after age 5 is diagnosable and, therefore, beyond the normal range (choice G). It is distressing to the mother and a cause of embarrassment to the child. The physician can, and should, provide guidance and help.
A 5 year old girl with dwarfism, mental deficiencies, and photosensitivity is diagnosed with a DNA repair disorder. The most likely diagnosis in this patient is
Cockayne´s syndrome is a DNA repair deficiency in nucleotide excision repair. The defect causes poor repair of genes that are being transcribed. It is manifested by photosensitivity, mental deficiencies, and dwarfism. While all of the other answer choices are also DNA repair disorders, none causes the same triad as seen in Cockayne´s syndrome.
A child should have developed the ability to feel depression in the adult sense by which one of the following well child office visit?
At the age of 14, a child is able to feel as “depressed” as an adult feels. This should be differentiated from sulking, which many children do, which is not the same as true adult depression.
The LEAST likely related to a child´s height is
The factors that have been found to be most associated to a child´s height are sibling size (A), parents´ socioeconomic status (B), parents´ height (C), and the child´s birth weight (D). The mother´s diet during pregnancy most likely has an effect on a child´s height, but not to the extent of the other answer choices.
A baby begins to cry when his mother starts to walk away. The child most likely belong to which age group?
Children one year of age typically begin to experience stranger anxiety and separation anxiety. Children less than one year of age are most often scared of loud noises, heights, and lack of physical support. Children between the ages of two and six years (C) are afraid of figments of their imagination (e.g., the bogeyman), as well as animals and the dark. Children who are elementary-school age (D) are more afraid of injuring themselves physically or losing a loved one, such as a parent. Adolescents and teens (E) are scared of failing or not being accepted socially.
For which of the following reason monitoring the amount of television that a preschooler watches is important?
Studies have demonstrated that the increasing amount of violence that is visible on TV may be detrimental to a child´s development; it may predispose a child to becoming more aggressive and have fewer qualms about harming others.
At which of the following ages will a sudden clamorous noise most frighten a child?
Children less than one year of age are most often scared of loud noises, heights, and lack of physical support. Children one year of age typically begin to experience stranger anxiety and separation anxiety. Children between the ages of two and six years are afraid of figments of their imagination (e.g., the bogeyman), as well as animals and the dark. Children who are elementary school age are more afraid of injuring themselves physically or losing a loved one, such as a parent. Adolescents and teens are scared of failing or not being accepted socially.
What percentage of his expected adult head circumference does a 2 year old boy is expected to have reached?
By the age of two, a child is expected to reach 85% of his or her expected adult head circumference.
An infant of 3 months age is found to have abnormally low levels of serum copper. Which vitamin toxicity should be included among differential diagnoses?
Vitamin C overdose may cause a decrease in copper absorption or a rise in the excretion of oxalic acid. Although thiamin toxicity is very rare, the potential adverse effects include an anaphylactic response and/or respiratory depression. There are no significant toxicities associated with biotin overdose. Vitamin A toxicity may cause pseudotumor cerebri, or retching associated with a rise in intracranial pressure. Niacin overdose may cause anaphylaxis due to histamine release; also, cholestatic jaundice, cutaneous vasodilation, and cardiac arrhythmias may arise.
Which of the following is NOT a risk factor for low birth weight infants?
Maternal diabetes is associated with unusually large babies. The other conditions are all factors responsible for low birth weight infants.
A child who tells his mother that he does not need training wheels on his bicycle, yet fears riding without them, is in which one of the following stages, according to Erik Erikson´s psychosocial development theory?
During the “autonomy versus shame and doubt” stage, a child becomes aware that he is capable of doing things by himself. However; he simultaneously doubts himself and is uncertain of whether or not he is actually capable. While it could be argued that the child in the question is undergoing a battle between the “initiative versus guilt” stage (C), it is during this stage that the child actively seeks out productive means to expend energy i.e., taking initiative. None of the other choices are applicable to doubting and achieving independence from one´s mother or external sources, such as training wheels.
A child should have memorized his/her own name, address, and phone number by which one of the following well child visit?
By the age of five, or approximately at the kindergarten-age level, a child should have garnered the ability to memorize his/her own name, address, and phone number.
The group of individuals can safely be immunized with live attenuated vaccine include
It is important to give these children live attenuated vaccine that they have not yet received before chemotherapy is begun. Patients in the other groups are at increased risk for chronic viral shedding or severe infection with the immunizing agent if they receive live attenuated vaccines.
A girl aged 12 years is brought to the ER after she was found jerking spasmodically. According to her father the spastic episode consisted of jerking of both arms and both legs. The girl is bleeding from the mouth after biting her tongue. The most likely diagnosis is
Partial simple seizure is seen in association with focal muscle twitching, usually involving either the arm or the leg. It is often preceded by a lesion in the cranium, such as an infarct or tumor. Partial simple seizures are seen most often in adults. Partial complex seizures are seen in children, and often are associated with lip smacking and staring. Patients with partial complex seizures demonstrate semi purposeful actions, and their seizures are often preceded by sensory delusions, such as a deja vu experience or smelling abnormal odors. Generalized absence seizures are also known as petit mal seizures. They are also seen in children, and often are only recordable by a brief episode of staring. Generalized tonic clonic seizures are also known as grand mal seizures. They are characterized by jerking of the extremities and muscle contraction. Sometimes there can be loss of consciousness and biting of the tongue. Finally, alcohol withdrawal seizures are manifested between one and four days after cessation of alcohol consumption. These are typically isolated seizures and are characterized as grand mal seizures.
A 15 month old boy has a persistent itchy rash that has been refractory to topical hydrocortisone 0.5% cream. He is often ill with colds and ear infections, and bruises easily. The scratches then become infected and a new cycle of distress develops. No family history of atopic disease is present. He is currently on oral amoxicillin for a recent ear infection. Examination shows multiple ill defined, confluent, scaly, crusted erythematous patches on the cheeks and scalp, retroauricularly and on the extensor aspects of the extremities. The dorsal hands show areas of moderate lichenification. His skin is overall very dry and lightly scaly, with many excoriations. The arms and shins have bruises in various stages and petechiae. What finding would most likely be revealed on investigation?
This patient has the typical clinical presentation of Wiskott-Aldrich syndrome, an X-linked recessive disease of young boys characterized by recurrent infections, thrombocytopenia with hepatosplenomegaly, and eczema. Death usually occurs before the age of 6 due to infection or, less commonly, bleeding or malignancy. Only a few patients will survive to adulthood. They are highly inclined toward developing lymphoid malignancies. Clinically, a chronic eczematous dermatitis resembling atopic dermatitis is typical. Recurrent infections are the rule, such as suppurative otitis media, pneumonia, or purulent skin infections. Thrombocytopenic purpura presents with petechiae and easy bruising. Bleeding outside of the skin may also occur. Hepatosplenomegaly and cervical adienopathy are present. Serum levels of IgA and IgE are elevated, where as IgG is normal or low, and IgM levels are low. Female carriers are detected with genetic testing. Splenectomy may correct the bleeding diathesis and increase platelet counts but it makes the patient susceptible to infection and requires continuous antibiotic prophylaxis thereafter. Bone marrow transplant from an HLA identical sibling as early as possible provides complete reversal of the platelet and immune defect. It´s the treatment and cure for Wiskott-Aldrich syndrome. Elevated IgM levels are not present in Wiskott-Aldrich syndrome. On the contrary, they are usually decreased. Low IgA level and low IgE level are not characteristic of Wiskott -Aldrich syndrome. Synthesis of IgA, IgE, and IgM is accelerated but accelerated catabolism usually results in decreased IgM levels while IgA and IgE levels remain elevated. Lymphopenia is nova characteristic of Wiskott-Aldrich syndrome. The number lymphocytes are normal but they are dysfunctional. The defective gene codes for a protein called WASP that participates in the reorganization of the hematopoietic cell cytoskeleton in response to external stimuli. As a result, the hematopoietic cells of patients with Wiskott-Aldrich syndrome cannot polarize or migrate in response to normal stimuli, resulting in the clinical picture of the syndrome.
A full-term infant on her 6th day of life looks “yellow”. She is strictly breast-fed and has been eating every 2-3 hours. On examination, she is noted to be jaundiced over her trunk and face. There is no scleral icterus. She is otherwise healthy. Both the mother and baby are Rh positive. Which of the following is the most likely cause of this infants jaundice?
Breast-feeding jaundice is common. Breasted infants have a higher incidence of increased bilirubin than formula-fed infants. It is related to decreased intake and increased enterohepatic circulation. The decreased intake is usually related to failure to establish an adequate milk supply.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a red cell enzyme defects resulting in hemolysis and the overproduction of bilirubin. It is X-linked and usually occurs in those of Mediterranean, African, or Asian descent. G6PD should be suspected in male infants with late onset of jaundice.
Hypothyroidism is a cause of prolonged jaundice in infants. However, the infant would be showing other signs of hypothyroidism (such as decreased muscle tone, macroglossia, and hypothermia) and would not look healthy.
Physiologic jaundice usually appears after 24 hours of age, slowly increasing to a peak between 3-5 days of age. In this case, the infant is 6 days old and just starting to get jaundiced; thus she is beyond the typical range for physiologic jaundice.
Rh incompatibility is not indicated in this case, since both the mother and infant are Rh positive.
A 12 year old boy with severe bronchial asthma has white patches on the inside of the cheeks that can be easily wiped off, leaving a red, bleeding, sore surface. He is currently using two inhaled medications for his asthma. Which would be most appropriate the treatment of his oral condition?
A 3 week old child has difficulty feeding, somnolence, failure to thrive, and constipation. There were no apparent signs of hormonal deficiency at birth, but symptoms have developed progressively. Lab studies show low T4 and high TSH. What is responsible for the apparently normal thyroid function at birth?
A child has a history of bilateral shin pain. The statement which suggests that this is not growing pains is
Growing pains are a common complaint of adolescents. Usually found in young men and women around the ages of 9 to 14, growing pains are the result of the rapid growth of these adolescents.
Several conditions such as Osgood-Schlatter Disease, and Sever´s Disease. are types of growing pains. These conditions are caused by inflammation around sites where large tendons insert. These tendons pull on the growing bone (at the growth plate) and cause inflammation.
Growing pains are almost always seen in active youths, often while participating in sports. Growing pains are best treated with rest, stretching, and ice packs. If activities are causing significant growing pains, they should be avoided until the symptoms resolve.
Growing pains are not usually associated with a limp.
A 9 year old kindergarten child is unable to read, write or even to color a picture. He becomes happy when he answers simple questions. The most likely diagnosis is
Kindergarden is usually for children aged 4-6. So a 9 year old in kindergarden would not be considered normal. Also the fact that this child is unable to advance into a higher grade more appropriate for his age suggests that he has a global learning disability rather than a specific one for say math, reading or drawing/coloring. We now turn our attention to a) autism vs b) mental retardation.
a) Autism is a disorder in which a young child cannot develop normal social relationships, uses language abnormally or not at all, behaves in compulsive and ritualistic ways, and may fail to develop normal intelligence. Autistic children develop symptoms in at least 3 of the following areas: social relationships, language, behavior, and sometimes intelligence.
About 50% of autistic children never learn to speak. Those who learn do so much later than normal and use words in an unusual way. These children rarely have an interactive dialogue with others. Autistic children often speak with an unusual rhythm and pitch. About 70% of children with autism have some degree of mental retardation (an IQ less than 70). Their performance is uneven, they usually do better on tests of motor and spatial skills than on verbal tests.
b) Mental retardation is characterized by significantly subaverage intellectual functioning (often expressed as an intelligence quotient < 70 to 75) combined with limitations of > 2 of the following: communication, self-direction, social skills, self-care, use of community resources, and maintenance of personal safety.
Delayed development is usually apparent by preschool age. Among older children, hallmark features are a low IQ combined with limitations in adaptive behavior skills. Although developmental patterns may vary, it is much more common for children with MR to experience slow progress than developmental arrest.
Behavioral disorders include lack of socially responsible behavior, impaired ability to communicate, and discomfort from coexisting physical problems and mental health disorders such as depression or anxiety.
In comparing autism and mental retardation, the question best fits the latter.
False statement comparing the effects of aspirin and acetaminophen in children is
Aspirin has anti-platelet, anti-pyretic, anti-inflammatory and analgesic properties. Acetaminophen only has anti-pyretic and analgesic properties.
Aspirin use in children can cause Reye´s syndrome, which is a rare form of acute encephalopathy and fatty infiltration of the liver that tends to follow some acute viral infections.
A girl aged 7 year presents with recurrent generalized tonic-clonic seizures. Examination reveals multiple hypopigmented skin lesions, freckling in the axilla and scoliosis of the spine. The most likely diagnosis is
In a child who is fed a strict vegetarian diet which excludes meat, eggs, and dairy products, which vitamin deficiency is most likely to occur?
There is no known vegetable source for vitamin B12. If the diet contains milk and eggs, however, the requirement will be satisfied. Vitamin C is present in high concentrations in fruits and vegetables. Vitamin A is found in green, leafy vegetables. Thiamine is present in grains, especially the outer coatings.
What is the most likely complication of an undescended testis?
Cryptorchidism is defined as failure of the testis to descend from its intra-abdominal location into the scrotum. Incidence in premature male infants is 9.2-30%. In full-term infants, the incidence is 3.3-5.8%, and in infants aged l year, it is 0.8%.
The lifetime risk of death from testicular malignancy in men of any age with undescended testis is approximately 9.7 times the risk in men with normally descended testis.
Malignant degeneration: Testicular malignancies occur in 10% of men with cryptorchid testis. The incidence of malignant degeneration in an undescended testis is reportedly as high as 48 times greater than in a normal testis. Seminoma is the most commonly reported malignancy. Torsion is a rare condition, if present, usually is secondary to the presence of a mass.
A 10 year old child is diagnosed with attention-deficit-hyperactivity disorder. The parents ask about drug treatment. Which one of the following would you tell the parents with regard to potential side effects of drug treatments?
Stimulant medications do not precipitate seizures and can be given safely to patients with a history of seizures. Substantial weight loss may occur in up to 15% of patients, but eventual adult height and weight are not affected. The number of side effects is similar for methylphenidate and dextroamphetamine. No significant changes in pulse or blood pressure occur either at rest or with exercise.
A 13 year old, previously healthy boy experiences a sudden onset of pain in the right testicle with accompanying nausea and vomiting. Examination after 8 hours onset of pain shows the testicle is located high in the scrotum and is swollen and exquisitely tender. The overlying epididymis cannot be separately palpated. The most likely diagnosis is which of the following?
Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting. Diagnosis is based on physical examination and confirmed by color Doppler. Treatment is immediate manual detorsion followed by surgical intervention.
A 5 year old girl has history of high fever, unresponsive cervical adenopathy, and a macular exanthema which involves the palms and soles for about 6 days. The most likely diagnosis is which of the following?
A 10 year old girl is referred by the school nurse for evaluation of scoliosis. The girl´s scoliosis was detected during a routine screening examination at the school, and it appears to be mild (curve less than 10 degrees). She is an athlete and is otherwise healthy. During the physical examination, particular attention should be given to which of the following?
The treatment of scoliosis is dependent on the age of the patient and curve progression. Premenarchal females have a greater chance of curve progression then females one to two years after menarche with similar curves. Curves of less than 25 degrees are observed and reevaluated every four to six months. The stage of pubertal development is important to note because a patient who has attained menarche will only have a small amount of additional growth; therefore, scoliosis will not progress.
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