Questions
Each of the following questions or incomplete statements is followed by suggested answers or completions. Select the ONE BEST ANSWER in each case.
1. A 14-year-old boy presents to your office with a mildly pruritic rash that involves his chest and back. He reports it began with a single lesion on his back, but now has spread to involve his entire back and chest. You note on your examination the presence of multiple secondary lesions that appear to follow cleavage lines. The most likely diagnosis is
A) Herpes zoster
B) Pityriasis rosea
C) Tinea versicolor
D) Varicella
E) Rhus dermatitis
View Answer
Answer and Discussion
The answer is B. Pityriasis rosea is a common, acute exanthem of uncertain etiology. Viral and bacterial causes have been sought, but exact causes have not yet been identified. Pityriasis rosea typically affects children and young adults. It is characterized by an initial herald patch, followed by the development of a diffuse papulosquamous rash. The herald patch often is misdiagnosed as eczema. Pityriasis rosea is difficult to identify until the appearance of characteristic smaller secondary lesions that follow Langer's lines (cleavage lines) in a “Christmas tree–like pattern.� Several medications can cause a rash similar to pityriasis rosea, and several diseases, including secondary syphilis, should be included in the differential diagnosis. One small controlled trial reported faster clearing of the exanthem with the use of erythromycin, but the mechanism of effect is unknown. Resolution of the rash may be hastened by ultraviolet light therapy, but not without the risk of hyperpigmentation. Topical or systemic steroids and antihistamines often are used to relieve itching.
Stulberg DL, Wolfrey J. Pityriasis rosea. Am Fam Physician. 2004;69:87–92, 94.
Pityriasis rosea is characterized by an initial herald patch, followed by the development of a diffuse papulosquamous rash.
2. What is the most common cause of nephritic syndrome in a 4 year old?
A) Trauma
B) Recent strep infection
C) Dehydration
D) Nonsteroidal anti-inflammatories (NSAIDs)
E) Varicella infection
View Answer
Answer and Discussion
The answer is B. Poststreptococcal glomerulonephritis is the leading cause of acute nephritic syndrome. The condition is most frequently encountered in children between 2 and 6 years of age with a recent history of pharyngitis. It is rare in children younger than 2 and adults older than 40. The incidence of poststreptococcal glomerulonephritis appears to be decreasing. The condition typically develops approximately 10 days after pharyngitis or 2 weeks after a skin infection with a nephritogenic strain of group A hemolytic Streptococcus. It has not been determined whether antibiotic treatment of the primary skin infection affords protection from the development of poststreptococcal glomerulonephritis. The classic presentation of poststreptococcal glomerulonephritis is a nephritic syndrome with oliguric acute renal failure. Most patients have milder disease, and subclinical cases are common. Patients with severe disease experience gross hematuria characterized by red or smoky urine, headache, and generalized symptoms such as anorexia, nausea, vomiting, and malaise. Inflammation of the renal capsule can lead to flank or back pain. Physical examination may show hypervolemia, edema, or hypertension. Acute poststreptococcal glomerulonephritis usually is diagnosed on clinical and serologic grounds without the need for biopsy, especially in children with a typical history. The overall prognosis in classic poststreptococcal acute proliferative glomerulonephritis is good. Most patients recover spontaneously and return to baseline renal function within 3 to 4 weeks with no long-term complications.
Hahn RG, Knox LM, Forman TA. Evaluation of poststreptococcal illness. Am Fam Physician. 2005;71:1949–1954.
3. At what age do children normally articulate most words and know basic colors?
A) 3 years
B) 4 years
C) 5 years
D) 6 years
E) 7 years
View Answer
Answer and Discussion
The answer is B. Motor development during the preschool years results in children running, jumping, and climbing. Children learn to balance on one foot and hop. Vocabulary continues to develop rapidly with the mastery of hundreds of words. Language development proceeds with multiword sentences, the use of pronouns, and the gradual improvement in articulation skills. Children normally master the concept of numbers 1, 2, and 3 by 3 1/2 years. Four-year-old children should know basic colors and clearly articulate most words.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:74–79.
4. At what age is it necessary to perform orchiopexy in a child affected with cryptorchism?
A) 12–24 months
B) 36–48 months
C) 5 years
D) 7 years
E) orchioplexy is not necessary
View Answer
Answer and Discussion
The answer is A. Either one or both testes may be absent from the scrotum at birth in about one in five premature or low-birth-weight male infants and in 3% to 6% at full term infants. Cryptorchism is found in 1% to 2% of males after 1 year of age but can be confused with retractile testes that is associated with a strong cremasteric reflex, which requires no treatment. Cryptorchism should be corrected before age 12 to 24 months in an attempt to reduce the risk of infertility, which occurs in up to 75% of males with bilateral cryptorchism and in 50% of men with unilateral cryptorchism. It is not clear, however, whether such early orchiopexy improves ultimate fertility. Some patients have underlying hypogonadism. Cryptorchism is also associated with testicular carcinoma mainly in the undescended testicle and particularly with intra-abdominal malposition; however, up to 10% of cancers can occur on the unaffected side.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:967.
5. A 5 year old presents to your office complaining of scrotal pain and you note swelling of the left testis. Appropriate management at this time includes
A) continued observation
B) elevation of the scrotum and ice therapy
C) ultrasound evaluation
D) doppler stethoscope evaluation
E) CT scan of the pelvis
View Answer
Answer and Discussion
The answer is C. Testicular torsion should be suspected in patients who complain of acute scrotal pain and swelling. Torsion of the testis is a surgical emergency because the likelihood of testicular damage increases as the duration of torsion increases. Associated conditions that may resemble testicular torsion, such as torsion of a testicular appendage, epididymitis, trauma, hernia, hydrocele, varicocele, and Henoch-Schönlein purpura, in general do not require immediate surgical intervention. Testicular torsion is most common in neonates and postpubertal boys, although it can occur in males of any age. Henoch-Schönlein purpura and torsion of a testicular appendage typically occur in prepubertal boys, whereas epididymitis most often develops in postpubertal boys. The cause of an acute scrotum can usually be made based on a careful history, a thorough physical examination and appropriate diagnostic tests. The onset, character, and severity of symptoms must be determined. The physical examination should include inspection and palpation of the abdomen, testis, epididymis, scrotum, and inguinal region. Urinalysis should always be performed. Scrotal imaging with Doppler color flow ultrasound is necessary when the diagnosis remains unclear. Once the correct diagnosis is established, prompt surgical evaluation should be performed.
Galejs LE, Kass EJ. Diagnosis and treatment of the acute scrotum. Am Fam Physician. 1999;59(4):817.
6. Which of the following statements is true regarding head lice infestations?
A) Females are more likely affected.
B) Retreatment with pyrethrin is rarely needed.
C) Head lice can live off the body up to 1 week.
D) Low socioeconomic children are more likely affected.
E) Dogs are a common vector for head lice.
View Answer
Answer and Discussion
The answer is A. Head lice are thought to be the most common type and are developing resistance to commonly used pediculicides. Every year, between 6 million and 12 million people in the United States, primarily children 3 to 10 years of age, are infested with head lice. Girls are at greater risk because they have more frequent head-to-head contact. Head lice affect people of all socioeconomic status. Head lice are obligate parasites that live on human skin and survive on human blood. No other animal is affected. Head lice die if they are away from the host head for more than 2 days. Lice are wingless and cannot jump, but they climb quickly from hair to hair when the hair is dry. Lice move slowly on wet hair and can be removed more easily with a gloved hand or a fine-toothed comb. The adult female louse lays 7 to 10 eggs daily that attach to human hair with a gluelike, water-soluble substance. By 7 to 10 days, a nymph emerges from the egg and is close enough to the scalp to obtain its first meal of blood. Adult lice, after the 7- to 10-day period of molting stages, live about 30 days. Infested people usually have no more than 10 to 12 live head lice at a time, but can harbor hundreds of eggs and nits. Those affected describe itching and a sensation of “something crawling on my head.� Scratching may cause excoriations and secondary infection. Most infestations are asymptomatic. Prior to treatment, live lice can be identified under a magnifying glass, which is best done when the hair is wet. After infestation is confirmed, treatment consists of application of a pediculicidal agent to the hair, followed by mechanical removal. The hair should not be washed for 2 to 3 days after the pediculicide is applied. Thorough physical removal of lice and nits with a sturdy, fine-tooth comb is recommended for several days after application because no pediculicide guarantees total eradication of lice. First-line topical agents containing pyrethrins or permethrin are available over the counter and are relatively nontoxic. Retreatment is advised 7 to 10 days after the first application of pyrethrins. Because permethrin remains active for a longer period, retreatment generally is not necessary. Permethrin 5% cream is available by prescription for use in resistant cases. Alternative agents include lindane or malathion. Lindane has been shown to have limited success and is systemically absorbed, so its use is now considered second-line. Malathion was recently labeled by the U.S. Food and Drug Administration (FDA) for the treatment of head lice and is available in a lotion that is left on the head for 8 to 12 hours. Oral agents include ivermectin and trimethoprim–sulfamethoxizole. Resistance is possible with any treatment because of reduced susceptibility or incorrect use of the medication.
All household members with active infestation should be treated simultaneously. For children younger than 2 years, there is no recommended pediculicide; therefore, treatment consists of manual removal only. Lice that remain active 8 to 12 hours after treatment may require an alternative agent. Itching may persist for up to 10 days after successful treatment and should not be mistaken for treatment failure. The Centers for Disease Control and Prevention recommend that all clothing and bedding in contact with the infested person during the 2 days before application of the pediculicide be laundered in hot water and machine dried using a hot dry cycle. All nonwashable items should be quarantined in a plastic bag for 2 weeks. Combs and brushes should be disinfected with hot water or alcohol.
Mazurek CM, Lee NP. How to manage head lice. West J Med. 2000;172:342–345.
7. A 4 year old presents with short stature. Further evaluation confirms a delayed bone age. The most likely diagnosis is
A) hypothyroidism
B) cartilage defects
C) growth plate disorder
D) genetic influence of the parents
View Answer
Answer and Discussion
The answer is A. Short stature may affect children as a result of intrinsic growth defects or because of acquired extrinsic factors that impair growth. In general, delayed bone age in a child with short stature is suggestive of a hormonal or systemic disorder, whereas normal bone age in a short child is more likely to be caused by a genetic cartilage disorder or growth plate disorder.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:2088, 2216.
8. An 8 year old is seen in the emergency room secondary to abdominal pain. Further evaluation confirms the presence of intussusception. The most likely precipitating cause is
A) colon polyp
B) Meckel's diverticulum
C) lymphoma
D) parasite infection
E) foreign body
View Answer
Answer and Discussion
The answer is C. Intussusception is the most common cause of intestinal obstruction in the first 2 years of life. It is more common in males than in females. In most cases (85%) the cause is not apparent. Associated conditions that can result in intussusception include polyps, Meckel's diverticulum, Henoch–Schönlein purpura, lymphoma, lipoma, parasites, foreign bodies, and viral enteritis with hypertrophy of Peyer patches. Intussusception of the small intestine occurs in patients with celiac disease and cystic fibrosis—related to the bulk of stool in the terminal ileum. Henoch–Schönlein purpura may also cause isolated small-bowel intussusception. In children older than 6 years, lymphoma is the most common cause. Intermittent small-bowel intussusception is a rare cause of recurrent abdominal pain.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:616–617.
9. The initial treatment of choice for symptomatic labial adhesions is
A) testosterone cream
B) estrogen cream
C) GnRH antagonist
D) hydrocortisone cream
E) surgical separation
View Answer
Answer and Discussion
The answer is B. Labial adhesions are common in prepubertal females. The cause is thought related to low levels of circulating estrogen. Most women with small areas of labial adhesions are asymptomatic. However, interference with urination or accumulation of urine behind the adhesion can lead to discomfort and symptoms. Dysuria and recurrent vulvar and vaginal infections are associated symptoms. In rare situations urinary retention may occur. Asymptomatic labial fusion usually does not require treatment. Symptomatic adhesions may be treated with a short course of estrogen cream applied twice daily for 7 to 10 days; this may separate the labia. A new alternative treatment is to use estrogen transdermal patches in close proximity to the labia. When medical treatment fails or if severe urinary symptoms exist, surgical separation of the labia is indicated. This can be done as an office procedure using 1% to 2% topical xylocaine gel. Because of inadequate levels of estrogen, recurrences of labial adhesion are common until puberty. Following puberty, the condition usually resolves spontaneously. Improved hygiene and removal of vulvar irritants may help prevent recurrences.
DeCherney AH, Nathan L. Current Obstetric & Gynecologic Diagnosis and Treatment, 9th ed. New York: McGraw-Hill; 2003:67.
10. Which of the following statements is true regarding iron deficiency in childhood?
A) Iron deficiency commonly occurs in term infants <6 months.
B) Ingestion of cow's milk can result in iron overload.
C) Iron deficiency rarely leads to complications.
D) Pica is associated with iron deficiency.
E) Mild iron deficiency typically leads to symptoms of pallor, fatigue, and delayed motor development.
View Answer
Answer and Discussion
The answer is D. The incidence of iron deficiency in children has decreased substantially due to improved nutrition and the increased availability of iron-fortified infant formulas and cereals. Normal-term infants are born with sufficient iron stores to prevent iron deficiency for the first 4 to 5 months of life. Thereafter, sufficient iron needs to be absorbed to maintain the needs of rapid growth. For this reason, nutritional iron deficiency is most common between 6 and 24 months of life. A deficiency earlier than age 6 months may occur if iron stores at birth are reduced by prematurity, small birth weight, neonatal anemia, or perinatal blood loss or if there is subsequent iron loss due to hemorrhage. Iron-deficient children older than age 24 months should be evaluated for blood loss. Iron deficiency, in addition to causing anemia, has adverse effects on multiple organ systems. Symptoms and signs vary with the severity of the deficiency. Mild iron deficiency is usually asymptomatic. In infants with more severe iron deficiency, pallor, fatigue, irritability, and delayed motor development are common. Children whose iron deficiency is due in part to ingestion of unfortified cow's milk may be fat and flabby, with poor muscle tone. A history of pica is common.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:837–838.
A history of pica is common in iron deficiency anemia.
11. In treating acute sinusitis in children, which of the following sinuses is unlikely to be infected in a 6 year old?
A) Frontal
B) Maxillary
C) Ethmoidal
D) Sphenoidal
E) Sinusitis does not occur in children younger than 8.
View Answer
Answer and Discussion
The answer is A. Acute bacterial infection of the sinuses that lasts <30 days and completely resolves is called acute bacterial sinusitis. The maxillary and ethmoidal sinuse most commonly involved when mucociliary function and drainage are impaired by a URI or allergic rhinitis. Both the ethmoid and maxillary sinuses are present at birth, forming in the third to fourth gestational month. The sphenoid sinuses pneumatize as an extension of a posterior ethmoid cell by age 5 years, and the frontal sinuses form from an anterior ethmoid cell appearing about age 7 to 8 years. Frontal sinusitis is unusual before age 10 years.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:476–478.
12. Which of the following statements regarding attention-deficit/hyperactivity disorder is true?
A) Specific biologic markers are used in the diagnosis.
B) The Conner's ADHD Index is a checklist that helps identify children affected with ADHD.
C) Stimulant medications rarely benefit children with ADHD.
D) Symptoms of ADHD typically progress over time.
E) Drug therapy combined with psychosocial therapy is universally better than medication alone.
View Answer
Answer and Discussion
The answer is B. Attention-deficit/hyperactivity disorder (ADHD) is manifest by inappropriate-for-age hyperactivity, impulsivity, and lack of attention. ADHD cannot be easily diagnosed by a specific test or biologic marker, and some are unclear if the disorder is a truly pathologic condition or just one end of the behavioral spectrum. ADHD is more frequently diagnosed in children with behavioral difficulties and academic underachievement. The prevalence of ADHD is between 6.8% and 10.3%, with boys affected threefold more often than girls. Associated psychiatric conditions, including oppositional–defiant disorder, conduct disorder, depressive disorder, and anxiety disorders, are common. The Conners' ADHD Index and symptom scales from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), are ADHD-specific checklists and have a high sensitivity for identification of children with the disorder. Reviews of the pharmacologic management of ADHD with methylphenidate hydrochloride (Ritalin, Concerta), dextroamphetamine sulfate (Adderall, Dexedrine), and pemoline (Cylert) show these drugs to be generally effective for most children affected. Nonpharmacologic treatments that may have some beneficial effect on behavior and academic performance are behavioral modification and intensive contingency management therapy. Combining drug therapy with psychosocial therapy shows no clear advantage when compared to drug therapy alone. However, the addition of behavioral therapies to medication may have some benefit, including reduction of anxiety and improvement in social skills. The symptoms of ADHD tend to decrease over the long-term, but may continue into adolescence and adulthood. The most common treatment is stimulant medication.
Guevara JP. Attention deficit hyperactivity disorder. West J Med. 2001;175:189–192.
Hunt RD, Paquin A, Payton K. An update on assessment and treatment of complex attention-deficit hyperactivity disorder. Pediatr Ann. 2001;30(3):162–172.
13. A 12-year-old obese boy presents to your office complaining of bilateral leg pain that occurs only at night. His mother denies any pain during the day and reports he has not had a limp. The most likely diagnosis is
A) slipped capital femoral epiphysis
B) Legg-Calve-Perthes disease
C) Osgood Schlatter's disease
D) patellofemoral syndrome
E) “growing pains�
View Answer
Answer and Discussion
The answer is E. A diagnosis of “growing pains� must meet three criteria: (1) the leg pain is bilateral; (2) the pain occurs only at night; and (3) the patient has no limp, pain, or symptoms during the day. To inaccurately diagnose a limping child with growing pains can be dangerous, as the physician risks missing the underlying pathology. However, if a child does fit the criteria for growing pains, the parents should be reassured that this is a benign, self-limited process that occurs for unknown reasons.
Leet AI, Skaggs DL. Evaluation of the acutely limping child. Am Fam Physician. 2000;61:1011–1018.
14. The gold standard for diagnosing peritonsillar abscess is
A) lateral plain films
B) ultrasound
C) CT scan
D) MRI evaluation
E) needle aspiration
View Answer
Answer and Discussion
The answer is E. Peritonsillar abscess is most common in persons 20 to 40 years of age. Young children are seldom affected unless they are immunocompromised, but the infection can cause significant airway obstruction in children. The infection affects males and females equally. Chronic tonsillitis or multiple trials of oral antibiotics for acute tonsillitis may predispose persons to the development of a peritonsillar abscess. The presenting symptoms include fever, throat pain, and trismus. Ultrasonography and computed tomographic scanning are useful in confirming a diagnosis. Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess. After performing aspiration, appropriate antibiotic therapy (including penicillin, clindamycin, cephalosporins, or metronidazole) must be initiated. In advanced cases, incision and drainage or immediate tonsillectomy may be required. Streptococcus pyogenes (group A β-hemolytic Streptococcus) is the most common aerobic organism associated with peritonsillar abscess. The most common anaerobic organism is Fusobacterium. For most abscesses, a mixed group of both aerobic and anaerobic organisms cause the infection.
Steyer TE. Peritonsillar abscess: diagnosis and treatment. Am Fam Physician. 2002;65:93–96.
15. A 12-year-old boy is brought in to your office by his mother and father. The child has been experiencing swelling of his joints, fevers, and a rash. An examination reveals hepatosplenomegaly and lymphadenopathy. Laboratory evaluation shows anemia, leukocytosis, and thrombocytosis. You suspect juvenile rheumatoid arthritis. Which of the following medications would be first-line treatment?
A) Acetaminophen
B) Ibuprofen
C) Codeine
D) Methotrexate
E) Prednisone
View Answer
Answer and Discussion
The answer is B. Juvenile rheumatoid arthritis (JRA), formerly known as Still's disease, is a diverse group of diseases that is clinically distinct from adult rheumatoid arthritis. Most children with JRA have long remissions without loss of function or significant residual deformity. There are no specific laboratory tests to diagnose JRA. One must exclude other causes for arthritis, including reactive arthritis from extra-articular infection, septic arthritis, neoplastic disorders, endocrine disorders (e.g., thyroid disease, type 1 diabetes mellitus), degenerative or mechanical disorders, or idiopathic pediatric joint pain. Diagnosis of JRA requires signs of inflammation rather than simply arthralgias persisting for more than 6 weeks, with onset before age 16 years. JRA has three major subtypes: pauciarticular (40% to 50%), polyarticular (25% to 40%), and systemic (10% to 20%). Each type has different clinical presentations and courses, and treatment is determined by differentiating among the various types. Pauciarticular JRA involves four or fewer joints, usually large joints asymmetrically. Early-onset pauciarticular JRA affects mostly girls younger than 4 years and has a 30% risk of chronic iridocyclitis and a 10% risk of ocular damage. Late-onset pauciarticular JRA affects mostly boys older than 8 years; many of whom later develop spondyloarthropathies; 10% develop iridocyclitis. Slit-lamp ophthalmic examinations are recommended. Polyarticular JRA is defined as arthritis in five or more joints; patients are either RF positive or RF negative. RF-positive patients usually are girls age 8 years or older, have symmetric small-joint arthritis, and have a worse prognosis than do RF-negative patients. Systemic-onset JRA is characterized by high intermittent fevers (>102°F), rash, hepatosplenomegaly, lymphadenopathy, arthralgias, pericarditis, pleuritis, and growth delay. Anemia, leukocytosis, and thrombocytosis are common laboratory findings. Extra-articular symptoms are usually mild and self-limited. Boys and girls are equally affected. NSAIDs are the first-line treatment for JRA. Clinical improvement may not be seen for up to 1 month. Methotrexate is often used with NSAIDs, particularly for systemic and polyarticular JRA. Corticosteroids are used orally for severe, life-threatening, systemic JRA and intra-articularly for pauciarticular JRA. Most children with JRA require a great deal of physical as well as psychologic support. Physical and occupational therapy is important because children often stop using painful joints, adding to disability.
Rakel R. Textbook of Family Practice, 6th ed. Philadelphia: WB Saunders; 2002:990.
16. An asthmatic 8 year old is complaining of wheezing and shortness of breath in your office. An albuterol nebulizer treatment is given, and the child's PEFR is measured at 75%. The appropriate next step would be
A) add an oral steroid
B) add theophylline
C) add ipratropium
D) administer epinephrine
E) intubate the child
View Answer
Answer and Discussion
The answer is A. Early treatment of asthma exacerbations is important to prevent progression to severe disease. First-line treatment should be with a short-acting inhaled β2-agonist such as albuterol; 2 to 4 puffs from a metered-dose inhaler can be given every 20 minutes up to three times, or a single treatment can be given by nebulizer. If the response is acceptable as assessed by sustained symptom relief or improvement in PEFR to over 80% of the child's best, the short-acting β2-agonist can be continued every 3 to 4 hours for 24 to 48 hours. For patients taking inhaled corticosteroids, the dose may be doubled for 7 to 10 days. If the child does not completely improve from the initial therapy, with PEFR between 50% and 80%, the β2-agonist should be continued, and an oral corticosteroid should be added. If the child experiences marked distress or if PEFR persists under 50%, the patient should repeat the β2-agonist immediately. Further emergent treatment may be necessary.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:1058–1059.
17. An 18-month-old female presents to your office with her mother. A urinary tract infection is discovered. Appropriate treatment at this time including antibiotic coverage includes
A) intravenous pyelogram
B) cystoscopy
C) renal ultrasound and voiding cysturethrography (VCUG)
D) observation with no further testing
View Answer
Answer and Discussion
The answer is C. Practice guidelines from the American Academy of Pediatrics recommend renal ultrasonography and voiding cystourethrography (VCUG) in all children two months to two years of age with a documented first urinary tract infection (UTI). After age two some controversy exists. Some authorities recommend postponing workup for the first UTI in females.
Hoberman A, Charron M, Hickey RW. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 2003;348:195–202.
Practice guidelines from the American Academy of Pediatrics recommend renal ultrasonography and voiding cystourethrography (VCUG) in all children two months to two years of age with a documented first urinary tract infection (UTI).
18. Which of the following statements is true regarding child safety seats?
A) Newborn infants should face forward in the back seat of cars.
B) A child outgrows a forward facing seat when their shoulders extend beyond the back of the seat.
C) Once a child is >40 lbs it is important to make sure the harness of the child seat is used.
D) Low-back booster seats are safe to use in children >40 lbs.
E) To sit with a standard seat belt the child's weight should be at least 81 lbs.
View Answer
Answer and Discussion
The answer is E. Motor vehicle crashes continue to be the leading cause of death in children 1 to 14 years of age. Properly used child safety seats significantly reduce child morbidity and mortality. Although many parents know child safety seats are important, >80% of seats are misused. Children should sit in the back seat. The rear-facing position should be used until the child is 1 year of age and weighs 20 lbs (9 kg). Forward-facing child seats face forward and are for children heavier than 20 lbs and older than 1 year. A child outgrows this seat when the ears are above the back of the seat or when the child passes the height or weight limit of the seat (usually 40 lbs). High-back booster seats face forward and have removable harnesses. They are meant for use with children heavier than 20 to 30 lbs (9 to 13.5 kg), depending on the manufacturer, and older than 1 year. The high back protects the head and neck in a rear-end collision. The harness should be used until the child exceeds the weight limit of the harness system (usually 40 lbs). Once the child is heavier than 40 lbs, the harness is removed, and the seat is used to position the vehicle seat belt correctly (over the midclavicle and midchest, and tight over the upper thighs. High-back belt-positioning booster seats boost the child up so that the vehicle seat belt fits correctly. They can only be used with a shoulder-lap belt system. High-back booster seats are for use with children heavier than 40 lbs and can be used until the child fits properly in the vehicle seat belt system. Because safer restraint systems are available for children weighing more than 40 lbs, the use of low-back booster seats is not recommended. To properly fit a child in a standard car seat belt, three elements must be present: (1) the child's legs should bend over the edge of the auto seat with the buttocks against the seat back; (2) the shoulder portion of the belt should be over the midclavicle and center of the chest; and (3) the lap belt should be tight over the upper thighs or the pelvis. A child should have a sitting height of 29 in. (74 cm) to have a proper seat belt fit. This sitting height roughly correlates to a standing height of 58 in. (147 cm) and a weight of 81 lbs (36.5 kg). Increased education of parents regarding proper use of child safety seats can protect children from potentially fatal crash forces. Parents may also be educated about community resources and the several types of child safety seats.
Biagioli F. Proper use of child safety seats. Am Fam Physician. 2002;65:2085–2090.
19. Which of the following findings is not associated with rotavirus infections?
A) Metabolic acidosis
B) Hypernatremia
C) WBCs noted in the stool
D) Normal WBC count
E) Lactic acidosis
View Answer
Answer and Discussion
The answer is C. Vomiting is the first manifestation of rotavirus in the majority of patients, followed within 24 hours by low-grade fever and repeated bouts of watery diarrhea. Diarrhea usually lasts 4 to 8 days but can last longer in young infants or immunocompromised patients. The white blood cell count is rarely elevated. As patients become dehydrated from unreplaced fecal water loss, they may become hypernatremic. The stool does not contain blood or white cells. Metabolic acidosis results from bicarbonate loss in the stool, ketosis from poor intake, and lactic acidemia from hypotension and hypoperfusion. Replacement of fluid and electrolyte deficits and ongoing losses is critical, especially in small infants. The use of oral rehydration fluid is appropriate in most cases. The use of clear liquids or hypocaloric (dilute formula) diets for more than 48 hours is not advisable in uncomplicated viral gastroenteritis because starvation depresses digestive function and prolongs diarrhea. Intestinal lactase levels are reduced during rotavirus infection. Brief use of a lactose-free diet is associated with a shorter period of diarrhea but is not critical to successful recovery in most healthy infants. Reduced fat intake during recovery may reduce nausea and vomiting. Antidiarrheal medications are not effective and can be dangerous (loperamide, tincture of opium, diphenoxylate with atropine). Bismuth subsalicylate preparations may reduce stool volume but are not necessary for recovery. Specific identification of rotavirus is not required in every case, especially in outbreaks. Rotavirus antigens can be identified in stool. False positives (which may actually be nonpathogenic rotavirus) are seen in neonates. Some immunity is imparted by the first episode of rotavirus infection. Repeat infections occur but are usually less severe. Prevention of rotavirus is mainly by good hygiene and prevention of fecal–oral contamination. In July 1999, the American Academy of Pediatrics recommended suspending the use of oral rotavirus vaccine in the United States because of its association with intussusception in the first 3 weeks following vaccine administration. Recently, newer vaccines have been developed with an improved safety record.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:619–621.
20. Which of the following is not associated with early sexual activity?
A) Academic deficiencies
B) Repeat pregnancies
C) Sex education classes
D) Increased STDs
E) Low socioeconomic status
View Answer
Answer and Discussion
The answer is C. Early sexual activity can have a substantial negative impact on adolescents. Currently in the United States, more than 900,000 teenagers become pregnant each year. Those who give birth tend to have more academic deficiencies, poorer socioeconomic outcomes, and repeat pregnancies, and they are more likely to be single parents. In addition, adolescents who engage in early sexual activity expose themselves to sexually transmitted diseases (STDs). Of all STD cases reported in the United States, more than two thirds occur in adolescents and young adults. Prevention strategies should be established to reduce early sexual activity in adolescents.
Lonczak HS, Abbott RD, Hawkins JD. Effects of the Seattle Social Development Project on sexual behavior, pregnancy, birth, and sexually transmitted disease outcomes by age 21 years. Arch Pediatr Adolesc Med. 2002;156:438–447.
21. When evaluating febrile seizures, when is a lumbar puncture indicated?
A) If the seizure is generalized
B) If the seizure lasts 15 minutes
C) If there is a second seizure within 24 hours
D) If the seizure is associated with a recent vaccination
E) All children affected with a febrile seizure should have a lumbar puncture.
View Answer
Answer and Discussion
The answer is C. The majority of seizures in children <5 years are febrile type seizures, and children with a positive family history have a higher incidence. A febrile seizure is defined as any seizure occurring in a child who is 6 months to 5 years of age accompanied by a current or recent fever [at least 38°C (100.4°F)] and without previous seizure or neurologic events. Febrile seizures are typically categorized as simple or complex. Simple febrile seizures are characteristically generalized, usually last <15 minutes, and occur only once in a 24-hour period. Complex febrile seizures may have focal features, last >15 minutes, and recur within a 24-hour period. Viral infections are often present with febrile seizures, with human herpes virus 6 and 7 and influenza A and B being important causes. There also is a significant increased risk of febrile seizures within 24 hours of receiving vaccination for diphtheria and tetanus toxoids and whole-cell pertussis, and within 8 to 14 days of receiving a measles, mumps, and rubella (MMR) vaccination. The risk of recurrent febrile seizures is increased in patients whose initial febrile seizure occurred at <12 months of age, patients with a lower rectal temperature at first seizure [<40°C (104°F)], patients with shorter duration of fever before their first seizure (<24 hours), patients with a family history of febrile seizures, and patients with complex features with the first febrile seizure. The risk of development of epilepsy is slightly higher among persons having simple febrile seizures but is significantly increased among those who have one or more complex febrile seizures. Initial evaluation of children with febrile seizure includes airway and circulatory support, ideally with noninvasive measures until the postictal state resolves. A thorough medical history that includes past seizures and other neurologic conditions, exposure to medications or toxins, allergies, or trauma may point to a specific seizure cause. Treatment with antipyretics is rarely necessary in the typical seizure case. Patients with seizures that last longer than 5 minutes should receive benzodiazepines to control the seizure. After the seizure ends, the physician should conduct a mental status examination and a physical evaluation. Routine laboratory studies include only a blood glucose test; an electrolyte test may be appropriate if a metabolic abnormality is being considered. In most cases no further work-up is necessary, but lumbar puncture is indicated in patients with suspected meningitis. A lumbar puncture should be considered in children younger than 18 months who have a febrile seizure with the following: (1) a history of irritability, decreased feeding, or lethargy; (2) an abnormal appearance or mental state on initial observation after the postictal period; (3) any physical examination evidence of meningitis; (4) any complex features; (5) any slow postictal clearing of mentation; or (6) pretreatment with antibiotics. Neuroimaging only is appropriate in patients at risk of cerebral abscess, in those who have clinical evidence of increased intracranial pressure, in patients who have evidence of trauma, or in patients who have status epilepticus or have had a complex seizure. Children with simple febrile seizures can be cared for at home after providing parental education and making plans to follow up with the family. Routine prophylaxis using phenobarbital, valproic acid, oral diazepam, or antipyretics is controversial and usually not indicated.
Warden CR, Zibulewsky J, Mace S. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41:215–222.
22. Which of the following statements is true regarding sexual development in females?
A) The average age of menarche is earlier than it was 75 years ago.
B) African American girls usually experience menarche at an older age.
C) Breast development is usually the last physical characteristic to develop.
D) Girls who mature earlier are typically taller than girls who develop late.
E) The height spurt correlates more with pubic hair development than with breast development.
View Answer
Answer and Discussion
The answer is A. Teenagers are entering puberty at earlier ages during the 20th century because of various factors, including better nutrition and improved socioeconomic conditions. In the United States, the average age at menarche is 12.16 years in African American girls and 12.88 in White girls. However, menarche may be delayed until age 16 years or may begin as early as age 10. The first objective sign of puberty in girls is the beginning of the height spurt. This is followed by development of breast buds between ages 8 and 11 years. Although breast development usually precedes the growth of pubic hair, in some girls the sequence may be reversed. Among girls, the growth spurt starts at about age 9 years and reaches a peak at age 11.5 years. The spurt usually ends by age 14 years. Girls who mature early reach their peak height velocity sooner and attain their final height earlier. Girls who mature late attain a greater ultimate height because of the longer period of growth before the growth spurt. Final height is related to skeletal age at onset of puberty as well as genetic factors. The height spurt correlates more closely with breast developmental stages than with pubic hair stages.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Deterding RR. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:112–113.
23. Which of the following blood tests may be helpful in determining a recent strep infection in a patient that has a possible poststreptococcal complication?
A) erythrocyte sedimentation rate
B) C-reactive protein
C) complete blood count
D) antistreptolysin O titer
View Answer
Answer and Discussion
The answer is D. Group A beta-hemolytic streptococcal pharyngitis, scarlet fever, and in rare cases asymptomatic carrier states are associated with poststreptococcal complications. Children are most commonly affected in streptococcal pharyngitis, acute rheumatic fever, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection, and poststreptococcal glomerulonephritis. The hallmarks of rheumatic fever include arthritis, carditis, cutaneous disease, chorea, and subsequent acquired valvular disease. Pediatric autoimmune neuropsychiatric disorders include a subgroup of illnesses involving the basal ganglia in children with obsessive-compulsive disorders, tic disorders, dystonia, chorea encephalitis, and dystonic choreoathetosis. Poststreptococcal glomerulonephritis occurs most frequently in children between 2 and 6 years of age with a recent history of pharyngitis and a rash during the winter months. The clinical examination of a patient with possible poststreptococcal complications should include an evaluation for signs of inflammation (i.e., complete blood count, erythrocyte sedimentation rate, C-reactive protein) and evidence of a preceding streptococcal infection. Antistreptolysin O titers should be obtained to confirm a recent invasive streptococcal infection. Other important antibody markers include antihyaluronidase, antideoxyribonuclease B, and antistreptokinase antibodies.
Hahn RG, Knox LM, Forman TA. Evaluation of poststreptococcal illness. Am Fam Physician. 2005;71:1949–1954.
24. A 13-year-old girl is brought to your office by her mother. The child has experienced a recent sore throat with fevers, and now is complaining of bilateral knee pain. Laboratory evaluation shows an elevated sedimentation rate. The most likely diagnosis is
A) juvenile rheumatoid arthritis
B) acute rheumatic fever
C) Lyme disease
D) Osgood Schlatter disease
E) patellofemoral syndrome
View Answer
Answer and Discussion
The answer is B. Rheumatic fever is complication of acute group A streptococcal pharyngitis that presents as an acute systemic febrile illness. Associated findings include a migratory arthritis involving the large joints, signs and symptoms of carditis and valvulitis, the erythema marginatum rash, subcutaneous nodules, and choreoathetotic movements of Sydenham's chorea. Damage to the cardiac valves may be chronic and progressive, resulting in significant cardiac dysfunction. Although the Modified Jones Criteria help with the clinical diagnosis, no specific symptoms, clinical signs, or laboratory tests are pathognomonic for rheumatic fever. Additionally, not all patients with rheumatic fever fulfill the Modified Jones Criteria. The criteria consist of major manifestations that include carditis, erythema marginatum, polyarthritis, subcutaneous nodules, and Sydenham's chorea. Minor manifestations include clinical (e.g., arthralgia, fever) and laboratory (e.g., elevated C-reactive protein and erythrocyte sedimentation rate, prolonged PR interval on electrocardiograph) findings. A diagnosis of rheumatic fever is supported by evidence of preceding group A streptococcal infection (i.e., positive throat culture or rapid streptoccocal antigen test, elevated or rising antistreptolysin titer), and the presence of two major manifestations or of one major and two minor manifestations. Arthritis is the most frequent and least specific manifestation of rheumatic fever. It usually affects the large joints and may be the first sign of illness. The lower extremities generally are affected first, followed by the upper extremities. Joint involvement occurs early in the illness and is more common and severe in younger patients. The arthritis may be painful, but it is transient; the inflammation lasts about 2 to 3 days in each joint and 2 to 3 weeks total. Radiographic evaluation can show slight joint effusions but usually the results are normal. The arthritis is self-limited, resolves without complications, and is treated with salicylates and nonsteroidal anti-inflammatory drugs (NSAIDs). Carditis associated with rheumatic fever presents as pericarditis, myocarditis, and most commonly, endocarditis. Pericarditis can present with chest discomfort, pleuritic chest pain, pericardial friction rubs, and distant heart sounds. Myocarditis is rare in isolation and can present with signs and symptoms of heart failure. Endocarditis may be asymptomatic or present with a new heart murmur. Cardiac murmurs do not always indicate valvular involvement, and they may be transient. If valvular disease occurs, it is most likely in the mitral, aortic, tricuspid, or pulmonary valve, in that order. Electrocardiograph and echocardiogam abnormalities may be present in about one third of patients with carditis. Rheumatic heart disease is an important long-term consequence of rheumatic fever and is the major cause of acquired valvular disease internationally. Rheumatic heart disease typically occurs 10 to 20 years after the original rheumatic fever episode. Significant mitral stenosis can occur and require surgery. Sydenham's chorea is characterized by involuntary movements, muscular weakness, and emotional disturbances. It usually is more marked on one side of the body than the other, and may be completely unilateral. Atypical behavior such as crying and restlessness are seen and, in rare cases, features of a psychosis may be noted. There is no sensory loss or involvement of the pyramidal tracts. Sydenham's chorea is typically self-limited and occurs in <5 % of those affected. The condition typically lasts 2 to 3 months. Antistreptococcal prophylaxis should be maintained continuously after an attack of acute rheumatic fever or chorea to prevent recurrences.
Hahn RG, Knox LM, Forman TA. Evaluation of poststreptococcal illness. Am Fam Physician. 2005;71:1949–1954.
25. A child presents to the emergency room with abdominal pain. An abdominal series shows a “bird's beak� sign. The most likely diagnosis is
A) intussusception
B) volvulus
C) pyloric stenosis
D) malrotation
E) acute appendicitis
View Answer
Answer and Discussion
The answer is B. Sigmoid volvulus is a rare problem seen in children and adolescents. Volvulus occurs when a floppy sigmoid loop rotates around its base, producing arterial and venous obstruction of the affected segment, followed by rapid distention of the closed loop. Because the consequences can be life-threatening, sigmoid volvulus should be included in the differential diagnosis of acute and recurrent episodes of abdominal pain or bowel obstruction in children, especially if colonic dilation is seen on radiographs. Boys are more commonly affected than girls. Symptoms can be either acute or recurrent. The most common symptoms are abdominal pain that is relieved by passage of stool or flatus, abdominal distention, and vomiting. Radiographic evaluation often reveals colonic dilation. Barium enema often confirms or suggests the diagnosis, and should be performed under fluoroscopic control; a “twisted-taper� or “bird's-beak� appearance of the affected colon is characteristic. The most common associated conditions include Hirschsprung's disease and imperforate anus. Although sigmoid volvulus can resolve spontaneously, nonoperative management begins with fluid resuscitation and antibiotics, followed by barium enema detorsion of the sigmoid. Other nonoperative modalities include proctosigmoidoscopy and decompression by rectal tube. Operative management most commonly consists of sigmoidectomy.
Salas S, Angel CA, Salas N. Sigmoid volvulus in children and adolescents. J Am Coll Surg. 2000;190:717–723.
Barium enema often confirms or suggests the diagnosis of a sigmoid volvulus, and should be performed under fluoroscopic control; a “twisted-taper� or “bird's-beak� appearance of the affected colon is characteristic.
26. The drug of choice for otitis media is
A) azithromycin
B) amoxicillin
C) cefuroxime
D) amoxicillin–clavulanate
E) eftriaxone
View Answer
Answer and Discussion
The answer is B. Antibiotic resistance is growing among the organisms that commonly cause acute otitis media. Associated risk factors for resistant pathogens include recent antibiotic treatment, children in day care facilities, infections occurring in the winter, and acute otitis media in children <2 years of age. Amoxicillin remains the antibiotic of first choice, although a higher dosage (80 mg/kg/day) is recommended to ensure adequate eradication of resistant Streptococcus pneumoniae. Oral cefuroxime (Ceftin) or amoxicillin–clavulanate (Augmentin) and intramuscular ceftriaxone (Rocephin) are suggested second-line choices for treatment failure. Compliance with antibiotic regimens is enhanced by selecting medications that require less frequent dosing (such as one or two times a day) and by prescribing shorter (5 days or less) treatment courses. Selective use of tympanocentesis if the patient does not respond to empiric therapy can help confirm the diagnosis and guide effective therapy.
Pichichero ME. Acute otitis media: Part II. Treatment in an era of increasing antibiotic resistance. Am Fam Physician. 2000;61:2410–2416.
27. Which of the following is a contraindication to influenza vaccine?
A) Allergy to eggs
B) Recent strep infection
C) Allergy to aluminum
D) Age <6 years
View Answer
Answer and Discussion
The answer is A. Influenza vaccine (Fluzone, Fluvirin) should optimally be given in October and November, but can be given throughout the influenza season. Unvaccinated children younger than 9 years should be given 2 doses at least 1 month apart. Children ages 6 to 35 months are given 0.25 mL IM, whereas children ages 3 years and older are given 0.5 mL IM. (Fluvirin is indicated for use in only children ages 4 years and older.) Because vaccine viruses are first grown in eggs, the vaccine is contraindicated in persons with a history of allergy to eggs or egg products. It is also contraindicated in persons known to be sensitive to thimerosal. The FDA has approved a live attenuated influenza vaccine that is administered nasally (FluMist). It is to be used in healthy children ages 5 to 17 years and adults ages 18 to 49 years. Its safety in asthmatic individuals has not been established, and it is not currently recommended for use in patients with high-risk conditions, such as chronic cardiovascular, pulmonary, renal, or metabolic disorders, and in pregnant women. It is contraindicated in persons with a history of allergic reactions to any vaccine component, including eggs and children receiving chronic aspirin therapy or who are immunosuppressed.
Obtained from AAFP website: http://www.aafp.org/x22166.xml. Accessed 11/02/05.
28. Which of the following statements regarding immunizations is true?
A) Measles–mumps–rubella (MMR) vaccine can cause autism.
B) Hepatitis B vaccine can lead to multiple sclerosis.
C) Children with egg allergies may be given MMR vaccine.
D) Children with a prior local reaction to neomycin should avoid the varicella vaccine.
View Answer
Answer and Discussion
The answer is C. Controversy has risen about the safety of some vaccines because of rare but serious adverse effects that have been attributed to them. Pain, swelling, and redness at the injection site are common local reactions to vaccines. Fever and irritability may occur after some immunizations. Currently, no substantial evidence links MMR vaccine to autism or hepatitis B vaccine to multiple sclerosis. Thimerosal is being eliminated from routine childhood vaccines because of concerns that multiple immunizations with vaccines containing this preservative could exceed recommended mercury exposures. Children with a history of egg allergy may be given MMR vaccine, even though it is derived from chick embryo fibroblast tissue culture. However, influenza vaccine should not be given to a person with a history of egg allergy. Traces of antibiotics such as neomycin, which is present in varicella (chickenpox), trivalent inactivated poliovirus (IPV), and MMR vaccines, have been considered possible causes of adverse reactions. A history of anaphylactic reaction to neomycin is a contraindication to future immunization, whereas a local reaction is not.
Kimmel SR. Vaccine adverse events: separating myth from reality. Am Fam Physician. 2002;66:2113–2120.
29. Which of the following statements regarding pertussis is true?
A) Whole cell vaccine has been shown to be safer than acellular vaccine.
B) The incidence of pertussis is decreasing.
C) Those vaccinated against pertussis have no risk of contracting the disease.
D) Use of DTaP in adolescents is contraindicated.
E) Acellular pertussis vaccine is indicated throughout the primary vaccination series.
View Answer
Answer and Discussion
The answer is E. The annual number of pertussis cases in the United States has increased since the 1980s. Pertussis is highly contagious, affecting the majority of susceptible household contacts with epidemics occurring in the United States every 3 to 5 years. Children younger than 6 months account for the majority of pertussis hospitalizations, but children ages 10 to 19 years and adults 20 years and older account for increasing numbers of pertussis cases. Acellular pertussis vaccines combined with diphtheria tetanus (DT) are recommended for U.S. children younger than 7 years who do not have a contraindication to vaccination. These vaccines are immunogenic and produce fewer adverse local and systemic reactions than whole-cell pertussis vaccines (DTwP). The same brand of DTaP vaccine should be used throughout the primary vaccination series whenever possible, because there are few data on safety or efficacy when different formulations are interchanged. If the previously used vaccine is not known or is unavailable, any DTaP vaccine licensed for use in the primary series may be given to complete the series. Additionally, an increasing number of pertussis outbreaks have occurred in populations with a high rate of vaccination. The presentation of pertussis is less severe in vaccinated persons than it is in unvaccinated persons, leading to likely underestimation and misdiagnosis of cases. Use of DTaP results in antibody levels to tetanus, diphtheria, and pertussis in adolescents and adults. It is likely that recommendations soon will be made for its use in these groups.
Tozzi AE, Rava L, Ciofi Degli Atti ML. Clinical presentation of pertussis in unvaccinated and vaccinated children in the first six years of life. Pediatrics. 2003;112:1069–1075.
30. A child is born at 34 weeks gestation and now presents to your office for a hospital follow-up visit. What advice do you provide the mother regarding health maintenance?
A) Vaccinations should be delayed until the child is 2 months old based on the anticipated due date.
B) Hepatitis B should be delayed until the child is 1 month of age.
C) Vitamin supplements are contraindicated in breast-fed infants.
D) Supplemental iron is not recommended.
E) Adjustments are not necessary when monitoring growth and development in premature infants.
View Answer
Answer and Discussion
The answer is B. If an infant weights <2 kg at birth and the mother is antigen-negative, this infant should delay the first dose of hepatitis B vaccine until they have reached the chronological age of 1 month. If the mother is antigen-positive or if her antigen status is not known, the child should receive the first dose of hepatitis vaccine plus HBIG within 12 hours of birth, regardless of the infant's birth weight. If these infants weigh <2 kg at birth, this initial dose should not be counted toward completion of the hepatitis B vaccine series, and three additional doses should be administered beginning when the infant is 1 month of age.
Accessed from the CDC.gov website http://www.cdc.gov/nip/recs/contraindications.htm on 6/17/06.
31. Bottle-feeding at bedtime can result in
A) increased risk for aspiration
B) dental caries
C) oral candidiasis
D) nasal polyps
E) development of hiatal hernia
View Answer
Answer and Discussion
The answer is B. Baby-bottle tooth decay can occur after a child repeatedly falls asleep with a bottle in his or her mouth. It is more commonly seen in lower socioeconomic groups and can lead to major dental problems with the development of caries. Prevention should be aimed at educating the parents about this problem so that they can avoid bottle-feeding at bedtime.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1210.
32. Which of the following is true concerning DTaP vaccination?
A) The vaccine is routinely administered at 4, 6, and 12 months and again at 5 years of age.
B) The whole cell form is indicated for those who are immunocompromised.
C) The oral form is an inactivated vaccine.
D) Development of pertussis has been linked to the whole cell form.
E) The acellular form is recommended for routine vaccination of all infants.
View Answer
Answer and Discussion
The answer is E. Current recommendations for the diphtheria, pertussis, and tetanus immunization of young children state that DTaP is usually given at 2, 4, 6, and 12 to 15 months, with an additional dose at 4 to 6 years. The acellular pertussis form is preferred for all doses to help reduce the occurrence of side effects. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap adolescent preparation) is recommended at age 11 to 12 years for those who have completed the recommended childhood DTP/DTaP vaccination series and have not received a tetanus and diphtheria toxoid (Td) booster dose. Adolescents aged 13 to 18 years who missed the 11 to 12 year Td/Tdap booster dose should also receive a single dose of Tdap if they completed the recommended childhood DTP/DTaP vaccination series. Subsequent boosters are recommended every 10 years. Contraindications to the DPT vaccine include the following:
· Previous anaphylaxis to the vaccine
· Moderate or severe illness
· Previous encephalopathy within 7 days after DPT injection
· Progressive neurologic problem that is undiagnosed
· Fever higher than 105°F after previous DPT
· Continuous crying lasting 3 hours or more after previous DPT
· Seizure within 3 days after previous DPT
· Previous collapse, limp, or pale episode with previous DPT
Items 5 through 8 are relative contraindications and should be evaluated individually. The DTaP immunization should be given intramuscularly. A combined vaccine with DPT and Hib (Tetramune), which can be given at 2, 4, 6, and 12 to 15 months, is available.
Accessed from The Red Book online at http://aapredbook on 6/17/06.
33. Which of the following children would not be a candidate for Haemophilus influenzae type B immunization?
A) A 2 month old with no prior immunizations.
B) A 4 month old with one prior Hib immunization.
C) A 4 month old with human immunodeficiency virus (HIV) infection.
D) A 15 month old with a bone marrow transplant.
E) A 10 year old with up-to-date immunizations and a recent exposure to H. influenzae.
View Answer
Answer and Discussion
The answer is E. Sabin's [oral poliovirus vaccine (OPV)] vaccine for poliomyelitis prevention is an oral, live, attenuated, trivalent vaccine that was given at 2, 4, and 18 months, and 5 years. Because of cases of the risk associated with the live vaccine it is no longer used. In its place the injectable (Salk) vaccine, referred to as inactivated poliovirus vaccine, should be administered. The inactivated poliovirus vaccine has now been recommended for routine immunization in all infants because of the risk of developing polio from the live attenuated Sabin's vaccine. The schedule is the same for inactivated poliovirus vaccine.
Accessed from The Red Book online at http://aapredbook on 6/17/06.
34. Infant formula typically contains
A) 1 calorie/ounce
B) 10 calories/ounce
C) 20 calories/ounce
D) 50 calories/ounce
E) 100 calories/ounce
View Answer
Answer and Discussion
The answer is C. Commonly, formula preparations provide 20 calories/ounce. Formulas exist as cow's milk–based, soy-based, and casein-based preparations. Cow's milk–based formula is the preferred, non-breast-milk preparation for otherwise healthy term infants who do not breast-feed or for whom breast-feeding has been terminated prior to 1 year of age. Cow's milk–based formula closely resembles human breast milk and is composed of 20% whey and 80% casein with 50% more protein/dL than breast milk, as well as iron, linoleic acid, carnitine, taurine, and nucleotides. Approximately 32 ounces meets 100% of the recommended daily allowance (RDA) for calories, vitamins, and minerals. These formula preparations are diluted to a standard 20 calories/ounce and are typically whey-dominant protein preparations with vegetable oils and lactose. There are also multiple lactose-free preparations. Most standard formula preparations do not meet the RDA for fluoride, and exclusively formula-fed infants may require 0.25 mg/ day of supplemental fluoride.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:301–303.
35. Which of the following is a risk factor for the development of otitis media in children?
A) Low birth weight
B) Premature birth
C) Family history of allergies/asthma
D) African American descent
E) Pacifier use
View Answer
Answer and Discussion
The answer is E. Otitis media usually results as a complication of an upper respiratory (viral) infection. It is particularly common in children between 6 months and 3 years of age. The most common etiologic agents include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella (Branhamella) catarrhalis. In newborns, Escherichia coli and Staphylococcus aureus are major causes. Viral causes include respiratory syncitial virus (RSV), parainfluenza virus, influenza virus, enteroviruses, and adenoviruses. Risk factors include attending daycare at or before 2 months of age, in daycare >30 hours/week; bottle-feeding; exposure to cigarette smoke; pacifier use; and Polynesian, Native American, or Alaskan/Canadian Eskimo descent. Low birth weight, young gestational age, and a family history of allergies or asthma are not significantly associated with an increased risk of acute otitis media.
Symptoms include earache, nausea, vomiting, diarrhea, hearing loss, and otorrhea. Fever may be present, but it may be absent in as many as 33% of those affected. Signs include bulging of the tympanic membrane with loss of the light reflex and normal landmarks as well as tympanic membrane immobility. Perforation and vestibular dysfunction may also occur. Diagnosis is based on clinical findings and requires the presence of fluid under pressure in the middle ear plus one sign of acute local or systemic illness. Eardrum motion is best assessed by looking at the pars flaccida in the superior part of the drum. A red drum with normal mobility is common in crying children and is not diagnostic of acute bacterial infection. The drug of choice for treatment is amoxicillin in patients who are not at increased risk of being infected with a drug-resistant organism. Complications include mastoiditis, labyrinthitis, conductive and sensory neural hearing loss, and meningitis.
Semchenko A, Baroody F, Culpepper L. Management of acute sinusitis and acute otitis media. Am Fam Physician. Monograph No. 1, 2001:4.
Risk factors for otitis media include attending daycare at or before 2 months of age, in daycare more than 30 hours/week, bottle-feeding, exposure to cigarette smoke, pacifier use, Polynesian descent, Native American descent, and Alaskan and Canadian Eskimo descent.
36. Elevations in blood lead levels can result in
A) decline in IQs
B) development of personality disorders
C) hyperactivity disorder
D) clear cell carcinoma of the vagina
E) visual deficits
View Answer
Answer and Discussion
The answer is A. A significant number of preschool-age children in the United States have blood lead levels >10 µg/dL (0.50 µmol/L), and these levels have been associated with a decline in IQ. The Centers for Disease Control and Prevention (CDC) advocates the use of a screening questionnaire to identify lead exposure or toxicity in all children. Efforts to remove lead from gasoline and paint have led to a reduction of blood lead levels in children. Secondary prevention through lead paint removal is effective in homes that have a high lead burden. Children with lead levels of 45 to 69 µg/dL (2.15 to 3.35 µmol/L) should receive chelation therapy using succimer (DMSA) or edetate calcium disodium (CaNa2EDTA). Use of both CaNa2EDTA and dimercaprol (BAL in oil) is indicated in children with blood lead levels higher than 70 µg/ dL (3.40 µmol/L).
Ellis MR, Kane KY. Lightening the lead load in children. Am Fam Physician. 2000;62:545–554, 559–560.
37. A 14-year-old boy presents to your office complaining of pain in his left leg. Radiographs of the area show an aneurysmal bone cyst associated with the metaphysis and periosteal elevation of the mid tibia. The most appropriate management includes
A) leg casting for 6 to 8 weeks
B) nonsteroidal anti-inflammatory drugs (NSAIDs) and reassurance
C) administration of growth hormone
D) technetium bone scan
E) orthopedic surgery referral
View Answer
Answer and Discussion
The answer is E. Unicameral bone cysts (simple bone cysts) usually affect the metaphysis in long bones of pediatric patients (predominantly the femur, humerus). Most are asymptomatic and come to the attention of the patient, parents, and physician when a fracture occurs in the area of the bone cyst. Most small cysts heal without difficulty; a larger cyst may require surgery that involves removal of the cyst and bone grafting. Most patients recover without permanent disability. An aneurysmal bone cyst is a cyst that occasionally grows larger; these cysts usually occur before 20 years of age. Areas of involvement include expansion beyond the metaphyseal cartilage of the long bones. Patients may report pain and swelling in the region of the cyst. Radiographs may show well-circumscribed areas of rarefaction with periosteal elevation. Treatment usually involves surgery to remove the cyst. Occasionally, radiation therapy is used for vertebral lesions that threaten the spinal cord if surgery is contraindicated; however, postradiation sarcomas can occur. The prognosis for unicameral and aneurysmal bone cysts after treatment is excellent.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1721–1722.
38. The definition of amblyopia is
A) congenital cataracts noted at birth
B) retinal detachment seen in premature children
C) irregular pupillary size
D) increased distance between the medial and lateral canthus
E) subnormal visual acuity in one or both eyes despite correction of refractive error
View Answer
Answer and Discussion
The answer is E. Amblyopia is subnormal visual acuity in one or both eyes despite correction of refractive error. It results when the child suppresses the vision in one eye to avoid diplopia. Organic disease may be present but is insufficient to explain the level of vision. Normal visual development requires that a focused image form in each eye that can be fused (superimposed and integrated) by the brain into a single image. Any problem that interferes with a focused, fusible image during the first 8 to 10 years of life is capable of causing amblyopia. The most common causes of amblyopia include strabismus (misalignment of the eyes, images that are not fusible), anisometropia (unequal refractive components of eyes, images are not focused simultaneously), and deprivation (cataract, ptosis, corneal scar). Visual screening can usually detect early cases of amblyopia. If suspected, the child should be referred for ophthalmologic evaluation. Children at greatest risk for the development of amblyopia are younger than 2 to 3 years of age, and those younger than 6 months of age are at the highest risk. The key to successful outcome is early detection and treatment, which includes correction of refraction error or removal of cataract, as well as forced use of the amblyopic eye by patching the better eye. The earlier the diagnosis is made, the better the prognosis.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2445.
39. Leukocoria is most likely associated with
A) pregnancy
B) infection
C) retinoblastoma
D) leukemia
E) pyuria
View Answer
Answer and Discussion
The answer is C. An abnormal pupillary light reflex (called leukocoria if the pupil appears white) may indicate a disorder anywhere within the eye. Associated disorders include corneal opacity, blood (hyphema) or other material in the anterior chamber, cataract, vitreous opacity or retinal disease. The most serious diagnosis is retinoblastoma, a malignancy that is thought to arise from retinal germ cells. Because it may be hereditary, a family history of retinoblastoma or of enucleation is of special concern. Although retinoblastoma is almost uniformly fatal without treatment, the cure rate is better than 90% when the condition is promptly recognized and treated, and many children can be effectively treated without enucleation.
Simon JW, Kaw P. Commonly missed diagnoses in the childhood eye examination. Am Fam Physician. 2001;64:623–628.
40. Which of the following statements is true regarding hyperbilirubinemia?
A) Physiologic jaundice is rare in newborns.
B) Switching from formula feeding to breast-feeding may help decrease bilirubin levels.
C) Coombs' testing offers little information in the workup of hyperbilirubinemia.
D) For the condition of kernicterus to occur in premature infants the level of bilirubin must be higher than in term newborns.
E) Complications of kernicterus include hearing loss, seizures, and mental retardation.
View Answer
Answer and Discussion
The answer is E. Kernicterus occurs when the serum unconjugated (indirect) bilirubin becomes dangerously elevated (usually >25 mg/dL) in newborns. Symptoms include poor feeding, flaccidity, apnea, opisthotonos, and seizures; in severe cases, death may occur. Children who do survive may suffer hearing loss, seizures, and mental retardation. Risk factors include prematurity, blood incompatibilities, infection, and acidosis. Physiologic jaundice is the most common form of jaundice, and occurs in up to 50% of newborns. The condition is benign and usually resolves in 1 week. Most bilirubin levels peak in 3 to 5 days. The workup of a child with hyperbilirubinemia should include the following:
· Careful history to detect risk factors and physical examination to rule out petechiae, hepatosplenomegaly, bruising, and signs of infection
· Measurement of bilirubin levels
· Complete blood cell count, reticulocyte count, and peripheral blood smear
· Coombs' test
· Typing of mother's and infant's blood
· Thyroid function tests
Treatment for hyperbilirubinemia of newborns includes the following:
· Increasing formula feedings for the infant will increase GI motility and frequency of stools, thereby minimizing the enterohepatic circulation of bilirubin.
· Increasing frequency of breastfeeding. If the bilirubin continues to rise, switch from breast-feeding to formula for a few days until the bilirubin is <15 mg/dL (the mother should continue with breast pumping during this time)
· Phototherapy, which helps degrade unconjugated bilirubin
· Exchange transfusion for severe cases of persistent hyperbilirubinemia (usually >20 mg/dL) or hemolysis with anemia
In premature infants, kernicterus may occur with lower bilirubin levels.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2275–2279.
41. Preterm breast milk
A) has the same components as breast milk produced at term
B) persists for 1 week before the composition approaches that of term infant breast milk
C) contains lower concentrations of important electrolytes and immunoglobulins
D) typically requires fortification with human milk fortifiers
E) contains excessive amounts of calcium
View Answer
Answer and Discussion
The answer is D. The composition of breast milk in mothers of preterm infants is different from that of term infants. This difference persists for approximately 4 weeks before the composition approaches that of term infant breast milk. The difference in preterm milk composition reflects the increased nutrient demands of preterm infants. Preterm breast milk contains higher concentrations of total and bound nitrogen, immunoglobulins, sodium, iron, chloride, and medium-chain fatty acids. However, it may not contain sufficient amounts of phosphorus, calcium, copper, and zinc. Preterm infants are more likely to require fortification with human milk fortifiers (HMF) to correct these deficiencies.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:302.
42. A 12-year-old boy presents to your office complaining of gradual, increasing hip pain that radiates to the thigh and knee. Physical examination shows an obese boy with pain associated with hip abduction and adduction. Radiographs show evidence of acetabular dysplasia. The most likely diagnosis is
A) congenital dislocation of the hip
B) Osgood-Schlatter disease
C) slipped capital femoral epiphyses
D) sacral insufficiency fracture
E) transient synovitis of the hip
View Answer
Answer and Discussion
The answer is C. Slipped capital femoral epiphyses are usually seen in overweight boys between 11 and 14 years of age. The condition occurs when the femoral head slips posteriorly and inferiorly, exposing the anterior and superior aspects of the metaphysis of the femoral neck. When the condition occurs before puberty, an underlying endocrine disorder (hypothyroidism, growth hormone deficiency) should be suspected. Symptoms, including pain and a limp, are usually gradual in onset and usually involve the hips or are referred to the thigh or knee. The condition is bilateral in 20% of cases. Radiographs should be performed, including frog-leg views. Findings include abnormalities with the femoral head, including acetabular dysplasia. Treatment involves orthopedic referral with surgical pinning. Complications include avascular necrosis of the hip and erosion of cartilage.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2278–2279.
43. A 4 year old is brought to your office. The parent complains that the child's hair is falling out. Closer inspection shows the hair shafts are broken just above the scalp. There are scaly, pruritic, mildly inflamed gray patches, and scrapings of the area show the presence of hyphae. The treatment of choice is
A) topical antifungals
B) oral antifungals
C) topical hydrocortisone cream
D) permethrin cream
E) shave the hair off at the scalp and let it regrow
View Answer
Answer and Discussion
The answer is B. Tinea capitis is a fungal infection of the scalp that usually affects infants and young children. It is contagious and may become epidemic. It is caused by fungi including Trichophyton, Microsporum, and Epidermophyton. Lesions of the scalp usually cause scaly, gray patches that are pruritic. Multiple areas of hair loss may occur with hair shafts broken just above the scalp. Microscopic examination of scrapings after treatment with 10% potassium hydroxide reveals fungal hyphae. Hair examined with black light fluorescences show a greenish-yellow color in cases of microsporosis. Treatment for most tinea infections involves the use of topical antifungals but is not sufficient for tinea capitus, which requires oral administration of griseofulvin or ketoconazole. Severely inflamed lesions benefit from systemic or intralesional steroids. Until tinea capitis is cured, an imidazole or ciclopirox cream should be applied to the scalp to prevent spread, especially to other children, and selenium sulfide 2.5% shampoo should be used daily. Children can attend school during treatment, and the risk of transmission is low.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:988–992.
44. An 18-year-old high school student presents with a painless mass in his neck. He also reports a slight cough over the last 6 weeks. Additionally, he reports some fatigue and generalized pruritus. The most likely diagnosis is
A) infectious mononucleosis
B) brachial cleft cyst
C) Streptococcus pharyngitis
D) Lyme disease
E) Hodgkin's disease
View Answer
Answer and Discussion
The answer is E. The incidence of Hodgkin's disease increases throughout childhood and peaks in the late teens. The most common presenting complaint is a painless mass in the neck. Other presentations include a persistent cough secondary to a mediastinal mass or, less commonly, splenomegaly or enlarged axillary or inguinal lymph nodes. About one third of children with Hodgkin's disease present with constitutional symptoms. These symptoms may include intermittent fever, night sweats, and weight loss. These are referred to as “B� symptoms. The “A� designation refers to the absence of these symptoms. Other symptoms include anorexia, fatigue, and pruritus. Any persistent painless mass (especially a neck mass) that does not respond to antibiotics should be evaluated. This investigation should include a lymph node biopsy. Because of sampling errors and difficulties in obtaining an accurate diagnosis, excisional biopsy (rather than needle biopsy) of enlarged lymph nodes should be performed. A persistent cough, especially in the presence of any “B� symptoms, should be investigated. As part of this evaluation, a chest radiograph should be obtained. It is also important to investigate “B� symptoms associated with any lymphadenopathy or splenomegaly. Laboratory tests can often be helpful in confirming the diagnosis. Although nonspecific, elevations in the erythrocyte sedimentation rate, lactate dehydrogenase level, and ferritin level are suspicious findings in children with other signs or symptoms of Hodgkin's disease. Infrequently, the CBC reveals abnormalities, including anemia and eosinophilia.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:896–898.
The incidence of Hodgkin's disease increases throughout childhood and peaks in the late teens. The most common presenting complaint is a painless mass in the neck.
45. The condition of facial acne is associated with
A) ingestion of fatty foods
B) presence of Propionibacterium acnes
C) consumption of chocolate
D) presence of Staphylococcus aureus
E) poor hygiene
View Answer
Answer and Discussion
The answer is B. Acne is one of the most common presenting complaints in a family physician's office. Adolescent patients between 12 and 25 years of age are the most commonly affected. The condition results when keratinization blocks follicular canals. Increased sebum production occurs, and bacterial proliferation causes inflammation. Increased androgen production is often related to the development of acne. The plugged pilosebaceous unit is referred to as a “whitehead� if the lesion is a closed comedone, or a “blackhead� if the comedone is open. The most common infecting bacterium is Propionibacterium acnes, which proliferates and releases chemotactic factors that attract leukocytes. The diagnosis of acne is made by observing characteristic lesions on the face, back, shoulders, and chest. Treatment involves washing with mild soaps on a regular basis; application of benzoyl peroxide; topical tretinoin (Retin-A); or topical antibiotics such as erythromycin, clindamycin, tetracycline, or meclocycline. Oral antibiotics may be necessary for more severe cases. Severe nodulocystic acne that fails to respond to the previously mentioned measures may be treated with oral isotretinoin (Accutane). Close monitoring of liver function tests, triglyceride levels, and complete blood cell counts are required. In addition, the drug has many other side effects (i.e., xerosis, epistaxis, myalgias, and arthralgias) and is highly teratogenic. Patients should be aware that acne is not a disease of hygiene. They should not try to scrub the lesions away, and they should not use alcohol-based astringents that can dry and irritate their skin. Patients should be instructed to wash their face twice a day with a mild soap and water. Patients should also be informed that acne has no relationship to diet (e.g., chocolate, pizza, soda). Many think acne is caused by stress, but no studies support this association. It may be that the acne itself causes stress, not vice versa. Cosmetics have long been blamed for the development of acne lesions. Although the causal relationship between cosmetics and acne may be overstated, patients should be directed to use oil-free, noncomedogenic cosmetics. Oil from hair products and suntan lotions can also exacerbate acne. Female patients should be informed that acne usually worsens during the week before menses. Mechanical trauma can make acne worse. Therefore, patients should be encouraged to avoid picking at lesions, because doing so may cause more inflammation.
Russell JJ. Topical therapy for acne. Am Fam Physician. 2000;61:357–366.
46. Absence seizures are associated with which of the following features?
A) Subnormal intelligence
B) Three per second spike-and-wave electroencephalogram (EEG) pattern
C) Staring episodes that last 30 to 45 minutes
D) March-like progression of tonic–clonic activity
E) No genetic transmission
View Answer
Answer and Discussion
The answer is B. Absence seizures (formerly called petit mal seizures) are characterized by brief, 10- to 30-second staring episodes, followed by a resumption of normal activity. Attacks may occur up to 100 times daily and can be precipitated by hyperventilation. The seizures usually affect children, and there is a genetic predisposition. Affected children usually have normal intelligence, and most cases resolve before 20 years of age. EEG findings show a characteristic 3/second bilateral spike-and-wave pattern. Treatment usually involves the use of valproic acid and/or ethosuximide and clonazepam.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1825, 1833.
47. Idiopathic aseptic necrosis of the femoral head is also known as
A) slipped capital femoral epiphyses
B) Osgood-Schlatter disease
C) Legg-Calvé-Perthes disease
D) Morton's neuroma
E) transient synovitis of the hip
View Answer
Answer and Discussion
The answer is C. Idiopathic aseptic necrosis of the femoral head is also known as Legg-Calvé-Perthes disease. The disease is usually unilateral and is most common in boys 2 to 12 years of age. Symptoms include hip, groin, or thigh pain and difficulty ambulating, which is usually gradual in onset and progressive. Physical examination may show an abnormal gait (painless limp) and atrophy of the thigh muscles. Lateral radiographs (frog view) are required and show areas of lucency and fragmentation of the femoral head, which may progress to sclerosis and destruction. Radiographs are often normal early in the disease process; however, bone scans may show decreased uptake in the area of the femoral head. Treatment involves expectant observation both clinically and radiographically, abduction casts to contain the femoral head within the acetabulum, and surgery in select cases. It should be remembered that children who present with knee pain may have hip pathology.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2276–2278.
48. Which of the following is associated with infectious mononucleosis?
A) submental lymphadenopathy
B) strawberry tongue
C) cobble-stoned appearance of posterior pharynx
D) palatal petechiae
E) negative heterophile antibody test
View Answer
Answer and Discussion
The answer is D. Infectious mononucleosis is relatively common in patients 10 to 30 years of age who present with sore throat and fatigue, palatal petechiae, posterior cervical or auricular adenopathy, marked adenopathy, or inguinal adenopathy. An atypical lymphocytosis of at least 20% or atypical lymphocytosis of at least 10% plus lymphocytosis of at least 50% strongly supports the diagnosis, as does a positive heterophile antibody test. False-negative results of heterophile antibody tests are relatively common early in the course of infection. Symptomatic treatment, the mainstay of care, includes adequate hydration, analgesics, antipyretics, and adequate rest. Bed rest should not be strictly enforced, and the patient's energy level should guide activity. Corticosteroids, acyclovir, and antihistamines are not recommended for routine treatment of infectious mononucleosis, although corticosteroids may benefit patients with respiratory compromise or severe pharyngeal edema. Patients with infectious mononucleosis should be withdrawn from contact or collision sports for at least 4 weeks after the onset of symptoms. Fatigue, myalgias, and need for sleep may persist for several months after the acute infection has resolved.
Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician. 2004;70:1279–1287, 1289–1290.
49. Which of the following is routinely given at birth to prevent hemorrhagic disease of the newborn?
A) Erythromycin
B) Vitamin C
C) Vitamin K
D) Factor X
E) von Willebrand's factor
View Answer
Answer and Discussion
The answer is C. Following birth, there is a modest decrease in the vitamin K (phytonadione)—dependent factors II, VII, IX, and X—that gradually return to normal in 7 to 10 days. The cause of this decrease is inadequate free vitamin K available from the mother and the newborn's inability to synthesize vitamin K because of a lack of intestinal flora. Therefore, 1 mg of vitamin K is administered intramuscularly at birth to prevent hemorrhagic disease of the newborn in term infants. Larger doses predispose to the development of hyperbilirubinemia and kernicterus. Breast milk is a poor source of vitamin K. As a result, hemorrhagic complications occur more frequently in breast-fed infants. Mothers taking medications that interfere with vitamin K function (i.e., phenobarbital and phenytoin) may have infants at increased risk for early onset bleeding.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:606–607.
50. Which of the following statements about Down syndrome is true?
A) Younger mothers are at increased risk for having a child affected with Down syndrome.
B) There is an increased risk of leukemia in children affected with Down syndrome.
C) Most children affected have normal intelligence quotients (IQs).
D) The condition is not passed on to children of affected mothers.
E) Those affected usually have a normal life expectancy.
View Answer
Answer and Discussion
The answer is B. Down syndrome is a condition characterized by an extra chromosome 21. The incidence is reported to be 1 in 700 to 800 births, but it varies depending on maternal age. Older mothers (especially those older than 35) are at increased risk. The disease may result from trisomy 21, translocation, or mosaicism.
Signs and symptoms include a flattened, hypoplastic midface with a depressed nasal bridge, hypotonicity, retarded physical and mental development with decreased IQ, microcephaly with a flattened occiput, slanted eyes with epicanthal folds, Brushfield spots (gray to white spots around the periphery of the iris), Simian crease (single palmar crease), short fingers, and abnormal feet with a wide gap between the first and second toe. Other associated conditions include congenital heart disease (e.g., ventricular septal defects) and gastrointestinal anomalies (e.g., tracheoesophageal fistula, pyloric stenosis, duodenal atresia, and imperforate anus). The life expectancy of a child affected with Down syndrome is reduced by the presence of heart disease and an increased risk of acute leukemia. Some affected women are fertile; however, they have a 50% chance that their fetus will also have Down syndrome. Many of these affected fetuses abort spontaneously. All men with Down syndrome are infertile.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2449–2450.
Signs and symptoms of Down's syndrome include a flattened, hypoplastic midface with a depressed nasal bridge, hypotonicity, retarded physical and mental development with decreased IQ, microcephaly with a flattened occiput, slanted eyes with epicanthal folds, Brushfield spots (gray to white spots around the periphery of the iris), Simian crease (single palmar crease), short fingers, and abnormal feet with a wide gap between the first and second toe.
51. The most common cause of a limp in a 5-year-old boy is
A) stress fracture
B) transient synovitis of the hip
C) Legg-Calvé-Perthes disease
D) slipped capital femoral epiphyses
E) septic joint
View Answer
Answer and Discussion
The answer is B. Transient synovitis of the hip is the most common cause of hip pain and limping in U.S. children. The condition usually follows an upper respiratory illness and resolves spontaneously within a few days. Children 3 to 10 years of age, particularly boys, are the most commonly affected. Physical examination shows a limp and limited motion of the hip, especially with internal rotation. The hip is usually kept flexed, abducted, and externally rotated. Radiographs are usually negative but may show soft tissue swelling associated with the hip joint. A complete blood count and the erythrocyte sedimentation rate are usually normal. Treatment involves rest and anti-inflammatory drugs. Symptoms usually resolve in 7 to 10 days. Traction of the hip in slight flexion may also be used. Follow-up radiographs (at 1 and 3 months from time of presentation or perhaps sooner if the child's limp persists) are recommended because of the risk for development of avascular necrosis of the femoral head. If septic arthritis is suspected, aspiration of the hip may be necessary.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:606–607.
52. Which of the following statements concerning circumcision is true?
A) It is medically indicated for all males.
B) Premature infants should not be circumcised.
C) Infant males with posthitis should not be circumcised.
D) Hypospadias is not a contraindication for circumcision.
E) Circumcision can be performed in the office until 4 months of age.
View Answer
Answer and Discussion
The answer is B. Controversy surrounds the necessity of circumcision. UTIs are 10 to 15 times more common in uncircumcised infants. Many recommend circumcision in infants who are predisposed to UTI, such as those with congenital hydronephrosis and vesicoureteral reflux. Other indications for circumcision include recurrent balanitis (inflammation of the glans), posthitis (inflammation of the foreskin), or paraphimosis (retraction of the prepuce behind the glans that may interfere with blood flow). Routine circumcision is often more a social issue than a medical indication. Because phimosis (tightness of the foreskin so that it cannot be retracted over the glans penis) cannot usually be detected before puberty, it is not an indication for circumcision. Contraindications for circumcision include prematurity, genital anomalies (including hypospadias or ambiguous genitalia), and bleeding disorders. Circumcision should be performed at least 12 to 24 hours after birth and within 6 weeks of birth, preferably before discharge from the hospital. If delay occurs beyond 6 weeks, circumcision should be postponed until after 1 year of age with general anesthesia. Most recommend using a dorsal penile nerve block with 1% lidocaine without epinephrine for local anesthesia. EMLA cream can also be applied.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:606–607.
53. Which of the following statements is true regarding infectious mononucleosis?
A) Guillain-Barré syndrome is an associated complication.
B) The disease can result in positive rheumatoid factor formation.
C) Heterophil agglutination tests are usually positive at the onset of the disease.
D) Rupture of the aorta can be associated with the disease.
E) Glaucoma is often seen with prolonged cases.
View Answer
Answer and Discussion
The answer is A. Infectious mononucleosis is caused by the Epstein-Barr virus. It usually affects individuals between 10 and 35 years of age. Symptoms include fever, sore throat, anorexia, generalized fatigue, lymphadenopathy (especially affecting the posterior cervical chain), splenomegaly, and a maculopapular rash. Hepatitis with hepatomegaly is often seen with occasional jaundice. Laboratory findings include leukocytosis with many atypical lymphocytes (i.e., larger with vacuolated cytoplasm) and a positive monospot test (with heterophil agglutination) that becomes positive before the fourth week after the onset of the illness. The results of these tests are usually negative in infants and children younger than 4 years. False-positive rapid plasmin reagin and Venereal Disease Research Laboratory tests may occur, as well as abnormal liver function tests. Treatment involves supportive therapy with saline gargles, anti-inflammatories, and antipyretic medication. In severely ill patients with severe pharyngitis, corticosteroids can be used to help decrease inflammation. Complications include the development of Guillain-Barré syndrome, myocarditis, and encephalitis. Spleen rupture may also occur with trauma; therefore, contact sports should be avoided until the splenomegaly has resolved.
Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician. 2004;70:1279–1287, 1289–1290.
54. Which of the following is true regarding medications used in the treatment of acne?
A) A low estrogen-containing oral contraceptive can be helpful in the treatment of acne.
B) Doxycycline, tetracycline and minocycline are contraindicated before the age of 18.
C) Lipid values must be monitored when using isotretinoin.
D) Oral contraceptives are adequate to prevent pregnancy when administering isotretinoin.
View Answer
Answer and Discussion
The answer is C. Topical retinoids, benzoyl peroxide, sulfacetamide, and azelaic acid are recommended in patients with mild or moderate comedones. Topical erythromycin or clindamycin can be used in addition in patients with mild to moderate inflammatory acne or mixed acne. A 6-month course of oral erythromycin, doxycycline, tetracycline, or minocycline can be prescribed in patients with moderate to severe inflammatory acne. A low-androgen containing oral contraceptive pill is also effective in women with moderate to severe acne. Isotretinoin is reserved for use in the treatment of the most severe or refractory cases of inflammatory cystic type acne. Because of its poor side effect profile and teratogenicity, isotretinoin (Accutane) must by prescribed by a physician who is registered with the System to Manage Accutane-Related Teratogenicity (SMART) program. Serious side effects of isotretinoin include hepatitis, hypertriglyceridemia, intracranial hypertension, arthralgia, myalgias, night blindness, and hyperostosis. Serum liver function tests and triglyceride levels must be monitored monthly in patients receiving isotretinoin. Isotretinoin is teratogenic and can result in severe fetal abnormalities involving several systems. As a result two forms of contraception must be used during isotretinoin therapy and for 1 month after treatment has been discontinued. To ensure that female patients are not pregnant when treatment is initiated, two negative urine pregnancy tests are required before isotretinoin is prescribed. Pregnancy status is rechecked at monthly visits. The link between isotretinoin and depression is controversial.
Feldman S, Careccia RE, Barham KL, et al. The diagnosis and treatment of acne. Am Fam Physician. 2004;69:2123–2130, 2135–2136.
55. A 2 year old presents with an erythematous rash on the face (slapped-cheek appearance) that has spread to involve the trunk; the extremities are spared. She also has a low-grade fever and malaise. Which of the following is the most likely diagnosis?
A) Measles
B) Congenital syphilis
C) Erythema infectiosum
D) Meningococcemia
E) Rubeola
View Answer
Answer and Discussion
The answer is C. Erythema infectiosum is referred to as fifth disease, because it represents the fifth major viral childhood illness (which also includes measles, mumps, rubella, and rubeola). The disease is caused by parvovirus B19 and is characterized by mild constitutional symptoms, such as low-grade fever, malaise, and joint pain (particularly in adult women). Also, there is a classic indurated, erythematous maculopapular facial rash that may progress to the trunk and extremities (but spares the palms and soles). The rash is often pronounced on extensor surfaces. The rash is often referred to as a “slapped-cheek� appearance and can be exacerbated with exposure to sunlight, heat, emotional stress, or fever. The illness usually lasts 5 to 10 days, and only symptomatic treatment is necessary. Occasionally complications include arthropathies, myocarditis and a transient aplastic crisis. Fifth disease may occasionally cause fetal death secondary to fetal hydrops; therefore, pregnant women should avoid contact with affected patients. Children are not infectious once the rash develops because the rash and arthropathy (when present) are immune-mediated, postinfectious reactions. Therefore isolation from school and/or daycare is not necessary.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1048–1050.
56. The treatment of choice for iron poisoning is
A) pralidoxime chloride
B) deferoxamine
C) penicillamine
D) edetate calcium disodium
E) plasmapheresis
View Answer
Answer and Discussion
The answer is B. There are five stages described for iron intoxication:
· Stage 1. Hemorrhagic gastroenteritis, which occurs 30 to 60 minutes after the ingestion. Lasting for 4 to 6 hours, this may result in hematemesis, abdominal pain, irritability, explosive diarrhea, shock, coma, and metabolic acidosis.
· Stage 2. After these findings there is usually a symptom-free period that lasts up to 24 hours.
· Stage 3. The next 48 hours after ingestion is usually a period of delayed shock with iron levels >500 mg/dL. Cerebral dysfunction, fever, seizures, and coma may occur.
· Stage 4. Two to five days after ingestion liver damage starts to appear and may lead to hepatic failure. Other manifestations include coagulopathies and hypoglycemia.
· Stage 5. Gastrointestinal scarring, bowel obstruction, and pyloric stenosis may develop 2 to 5 weeks after the initial ingestion.
In addition to the previously mentioned symptoms, vomiting, hyperglycemia, leukocytosis, and an abdominal radiograph that shows the iron particles are usually related to a serum iron level >300 mg/dL. Severe cases may cause seizures, coma, pulmonary edema, and vascular collapse. Treatment involves inducing vomiting, as well as gastric lavage, followed by use of the chelating agent deferoxamine. Charcoal does not bind iron. In severe cases, hemodialysis and exchange transfusion may be necessary.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2667–2668.
57. A 1-year-old infant is brought into the office by a concerned mother. The child has an erythematous diaper rash with small satellite lesions that have not improved with application of petroleum jelly. The most appropriate treatment is
A) zinc oxide
B) clotrimazole (Lotrimin) ointment
C) Neosporin ointment
D) mupirocin (Bactroban) ointment
E) hydrocortisone cream
View Answer
Answer and Discussion
The answer is B. Diaper dermatitis secondary to Candida albicans is an intensely red and scorched-appearing rash that involves the perineal area. The rash may be well demarcated and possess vesicles that weep, pustules, papules, and the characteristic satellite lesions. Treatment consists of antifungal ointment (i.e., clotrimazole or nystatin) and, possibly, short-term use of hydrocortisone cream for severe dermatitis. Soothing cream (zinc oxide) should be applied with each diaper change. Also, keeping the area dry can help deter the development of yeast dermatitis.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2234–2235.
58. Which of the following medications is recommended in the treatment of mild to moderate croup?
A) Acyclovir
B) Dexamethasone
C) Theophylline
D) Atropine
E) No medications have been found to be useful.
View Answer
Answer and Discussion
The answer is B. Viral croup is the main cause of airway obstruction in children 6 months to 6 years of age. For children with mild croup, symptomatic care and mist therapy may be all that is necessary. Epinephrine has been used in the past to treat more severe cases of croup, but recent studies have found that glucocorticoid use is associated with shorter hospital stays, improvement in croup scores, and less use of epinephrine. Studies have shown that treatment with oral dexamethasone is as effective as intramuscular dexamethasone or nebulized budesonide. While more studies are needed to establish guidelines, oral dexamethasone can be used to treat mild to moderate croup with close follow-up and instructions for further care, if needed.
Knutson D, Aring A. Viral croup. Am Fam Physician. 2004;69:535–540, 541–542.
59. Which of the following medications would not be a suitable alternative for second-line treatment of otitis media in a 6 year old?
A) Azithromycin
B) Cefaclor
C) Cefixime
D) Ciprofloxacin
E) Erythromycin
View Answer
Answer and Discussion
The answer is D. Ciprofloxacin is generally not indicated for patients under age 18 because of the risk of damage to cartilage development. Although amoxicillin is considered the drug of choice the other options can be used as second line agents.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1788.
60. Immunizations (excluding hepatitis B) for premature infants should be
A) delayed because of the infant's immaturity
B) administered at same designated times as normal infants based on their age
C) withheld for 1 year
D) given earlier to help prevent diseases to which they are more susceptible
E) given in reduced amounts based on the child's weight
View Answer
Answer and Discussion
The answer is B. Premature infants are predisposed to certain problems, including poor sucking and diminished gag and cough reflexes, which can lead to an increased risk of aspiration and difficulty feeding. Other problems include pulmonary immaturity, decreased ability to maintain body temperature, impaired renal excretion, limited iron stores with a predisposition to develop anemia, metabolic disturbances, and decreased ability to fight infection. Immunizations should take place at the same designated times as for term infants with no adjustments made for premature age. One exception to this recommendation is that hepatitis B vaccination should be delayed for 1 month if mothers are negative for hepatitis B surface antigen.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1182.
Premature infants are predisposed to certain problems, including poor sucking and diminished gag and cough reflexes, which can lead to an increased risk of aspiration and difficulty feeding.
61. Which of the following conditions is associated with children of teenage mothers?
A) Cognitive delays in IQ
B) Schizophrenia
C) Major depression
D) Manic–depressive disorder
E) Suicide
View Answer
Answer and Discussion
The answer is A. The children of teenage mothers have been shown to have cognitive delays on IQ and vocabulary tests. They may also show problems of emotion, including rebelliousness, aggressiveness, uncontrollable anger, and impulsiveness. They are at greater risk for low birth weight and they have an increased risk of experiencing an accident within the home and of being hospitalized before the age of 5 years. There appears to be no link with major affective disorders.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:673.
62. A 3-year-old boy presents with a bilateral conjunctivitis, cracking of his lips, cervical lymphadenopathy and swelling of his hands. The most likely diagnosis is
A) Kawasaki disease
B) infectious mononucleosis
C) scarlet fever
D) Rocky Mountain fever
E) Lyme disease
View Answer
Answer and Discussion
The answer is A. Kawasaki disease was previously referred to as mucocutaneous lymph node syndrome. The cause of Kawasaki disease is unclear, and unfortunately a specific diagnostic test for its detection does not exist. The majority of affected patients are younger than age 5 years, and males are more frequently affected. Diagnosis is based on the following criteria and include fever for more than 5 days and at least four of the following features: (1) bilateral, painless, nonexudative conjunctivitis, (2) lip cracking and fissuring, strawberry tongue, inflammation of the oral mucosa, (3) cervical lymphadenopathy (≥1.5 cm in diameter and usually unilateral), (4) exanthema, and (5) redness and swelling of the hands and feet with subsequent desquamation. Adverse cardiovascular effects are the most serious component of Kawasaki disease. Cardiovascular complications include myocarditis, pericarditis, valvular heart disease (usually mitral or aortic regurgitation), and coronary arteritis. Coronary artery lesions range from mild transient dilation of a coronary artery to large aneurysm formation. Those at greatest risk of aneurysm formation are males, children under the age of 6 months, and those not treated with intravenous immunoglobulin (IVIG). The gold standard for diagnosing coronary artery aneurysms is angiography, however two-dimensional echocardiography is highly sensitive and is the current standard screening test in children with Kawasaki disease. Fortunately, most coronary artery aneurysms resolve within 5 years of diagnosis. Giant aneurysms (>8 mm) are much less likely to resolve, and about half become stenotic. Of additional concern, acute thrombosis of an aneurysm can occur, resulting in a myocardial infarction, and can be fatal. The treatment of Kawasaki disease consists of therapy with IVIG and high-dose aspirin. This therapy is effective in decreasing the incidence of coronary artery dilation and aneurysm formation. Currently, corticosteroids are not felt to be effective in Kawasaki disease.
During the acute and subacute phases of the illness, patients should be monitored closely by serial electrocardiography, chest radiograph, and echocardiography. Selective coronary angiography is recommended in patients with evidence of myocardial ischemia.
American Heart Association: Diagnostic guidelines for Kawasaki disease. Circulation 2001;103(2):335.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:582–583.
63. A 2-year-old child is seen in the emergency room and diagnosed with multiple contusions in various stages of healing and a spiral-type fracture of the left radius secondary to falling down the stairs at home. The most appropriate initial treatment is
A) splinting of the fracture with orthopedic referral
B) hospitalization
C) social service consult
D) immediate reduction of the fracture and safety counseling for the child's parents
E) open reduction and internal fixation and follow-up in 3 days
View Answer
Answer and Discussion
The answer is B. Child abuse is a difficult problem that must be identified as quickly as possible. Most children who die of child abuse are younger than 5 years. Most child abuse takes place in the home and is instituted by persons known to and trusted by the child. Although widely publicized, abuse in daycare and foster-care settings accounts for only a minority of confirmed cases of child abuse. Child abuse is 15 times more likely to occur in families in which spousal abuse occurs. Children are three times more likely to be abused by their fathers than by their mothers. Once a health care worker has any suspicion of child abuse, he or she is legally required to report the case for investigation. Protection of the child is the most important goal. The child should be hospitalized in a safe environment while further investigation by social workers is performed. Children younger than 3 years are the most commonly abused. Clinical findings include multiple fractures (especially spiral-type fractures), multiple bruises in different stages of healing, intestinal trauma injuries, burns, poor nutrition, poor development, and bizarre accidents reported by parents. More than 50% of fractures in children younger than 1 year are secondary to abuse. Before discharge from the hospital, the child's home environment must be determined to be safe by the appropriate protection agency. Further counseling for the child and family should be initiated after discharge. Unfortunately, therapy for child-abusing adults fails in approximately 33% of cases. As adults, children who were abused have a higher incidence of depression and drug abuse.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:121–131.
64. Which of the following animal bites requires rabies postexposure prophylaxis?
A) Fox
B) Squirrel
C) Hamster
D) Gerbil
E) Rat
View Answer
Answer and Discussion
The answer is A. Rabies in humans is rare in the United States, but the CDC estimates that as many as 39,000 persons receive postexposure prophylaxis annually. The risk of infection must be carefully evaluated by the clinician in the management of potential human rabies exposures. Bats, skunks, raccoons, foxes, and most other carnivores should receive post exposure prophylaxis. Bites of squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, other small rodents, rabbits, and hares almost never require antirabies postexposure prophylaxis. The CDC considers administration of postexposure prophylaxis to be a medical urgency, not a medical emergency, although ACIP emphasizes that decisions about using prophylaxis should not be put off.
From the Centers for Disease Control and Prevention. Human rabies prevention—United States, 1999; Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1999;48(RR-1):6.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1104.
65. Which of the following is a clinical finding of coarctation of the aorta?
A) Bounding femoral pulses
B) Blood pressure higher in the legs than in the arms in infants older than 1 year of age
C) Rib notching on chest radiograph
D) Diastolic murmur heard at the apex, radiating to the axilla
E) Dilation of the thoracic aorta near the ligamentum arteriosus
View Answer
Answer and Discussion
The answer is C. Coarctation of the aorta is one of the more common congenital heart defects. Boys are more commonly affected than girls. The condition occurs when there is discrete narrowing of the thoracic aorta near the ligamentum arteriosus, leading to proximal hypertension and left ventricular overload. Other findings include a ventricular septal defect, patent ductus arteriosus, and bicuspid aortic valve. In most cases, those affected are asymptomatic during infancy. However, congestive heart failure can occur and may require immediate surgical intervention. Signs associated with coarctation of the aorta include diminished or absent femoral pulses, blood pressure higher in the arms than in the legs in infants older than 1 year, 2/6 to 3/6 systolic ejection murmur heard over the apex and upper left sternal border, rib notching on chest radiograph (which is a result of enlargement of the intercostal arteries), and left ventricular hypertrophy. Diagnosis is based on physical findings and echocardiography or with CT or MRI angiography. Treatment depends on the severity of coarctation and the heart's ability to maintain perfusion. In severe cases, prostaglandin E1 may be used to keep a patent ductus arteriosus dilated until surgery or balloon angioplasty can be performed. In more stable patients, β-blockers and afterload-reducing agents can be used to postpone definitive treatment until the child is 3 to 5 years of age, when the treatment can be performed electively. Those patients who do well initially without evidence of congestive heart failure and requiring no surgery usually do quite well regarding further complications in childhood and adolescence. Those affected are at risk for hypertension and cardiac dysfunction as well as subacute infective endocarditis.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2667–2668.
66. Which of the following statements about cystic fibrosis is true?
A) It is an autosomal-dominant transmitted disease.
B) The condition is associated with pancreatic insufficiency.
C) It is commonly diagnosed with a pulmonary function test.
D) Those affected do not live beyond 20 years of age.
E) Fertility is not affected in those with cystic fibrosis.
View Answer
Answer and Discussion
The answer is B. Cystic fibrosis is the most common fatal genetic disease in the United States. It is transmitted as an autosomal-recessive trait. The incidence in the United States is reported to be approximately 1:3,500 in whites and 1:17,000 in African Americans. Those who are heterozygous are unaffected. The disorder involves exocrine glands and affects predominantly the gastrointestinal and respiratory systems. Complications include meconium ileus present at birth, chronic cough and wheezing with copious mucous production, pancreatic insufficiency with possible development of insulin-dependent diabetes (up to 8%), retarded growth, infertility, and chronic obstructive pulmonary disease. The diagnosis is made by the pilocarpine iontophoresis sweat test. Levels of sodium and chloride >60 mEq/L are usually diagnostic. Survival beyond 30 years of age is occurring more frequently. Death usually results from pulmonary complications such as infections with S. aureus, Pseudomonas aeruginosa, and H. influenzae.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1437–1450.
67. Of the following antibiotics, which one would be acceptable to use when treating penicillin-resistant S. pneumoniae otitis media?
A) Azithromycin
B) Clarithromycin
C) Cefuroxime
D) Cefaclor
E) Cephalexin
View Answer
Answer and Discussion
The answer is C. Only five antibiotics—high-dose amoxicillin (80 mg/kg/day), amoxicillin–clavulanate (Augmentin), cefuroxime (Ceftin), cefprozil (Cefzil), and ceftriaxone (Rocephin)—have demonstrated a modest degree (60% to 80%) of clinical efficacy in the treatment of acute otitis media caused by penicillin-resistant S. pneumoniae.
Pichichero ME. Acute otitis media: Part II. Treatment in an era of increasing antibiotic resistance. Am Fam Physician. 2000;61:2410–2416.
Block SL, Harrison CJ, Hedrick JA, et al. Penicillin-resistant Streptococcus pneumoniae in acute otitis media: risk factors, susceptibility patterns and antimicrobial management. Pediatr Infect Dis J. 1995;14:751–759.
68. A 3-year-old boy presents to your office with a history of seven ear infections over the last year. Appropriate management of this child consists of
A) tonsillectomy and adenoidectomy
B) single-dose prophylactic antibiotics given at night
C) tympanostomy tube placement
D) long-term use of antihistamine-decongestant preparations
E) continued observation
View Answer
Answer and Discussion
The answer is B. Chronic otitis media usually results from acute otitis media and eustachian tube dysfunction. Despite short courses of antibiotics, affected children have recurrent infections that appear to be more prevalent in the winter months. Persistent chronic otitis media may lead to hearing deficits and subsequent language delays. Prophylaxis should be attempted if the child experiences more than four infections in 1 year or three or more infections within 6 months. Treatment for this difficult problem consists of prophylactic antibiotics given in a single dose at bedtime. Medications for chronic suppression therapy include amoxicillin, sulfisoxazole, or trimethoprim-sulfamethoxazole. If a sulfonamide is used, the child should have a complete blood cell count periodically, and parents or guardians should be instructed to discontinue the medication immediately if a rash or mouth sore develops. Steroid use has not been advocated, and myringotomy tube placement should be reserved for children in whom prophylactic therapy fails.
Semchenko A, Baroody F, Culpepper L. Management of acute sinusitis and acute otitis media. Am Fam Physician. Monograph No. 1, 2001:16–17.
69. Which of the following statements about breast-feeding is true?
A) The infant should feed on each side for 8 to 15 minutes every 2 to 3 hours after birth.
B) Colostrum is excreted 7 to 10 days after delivery and contains important antibodies, high calories, and other nutrients.
C) The mother should weigh infants before and after feeding to quantify the amount consumed.
D) Breast-feeding usually provides adequate nutrition for 2 to 4 months—supplementation should begin at that point.
E) Breast-feeding should be based on timed intervals rather than on demand.
View Answer
Answer and Discussion
The answer is A. Breast-feeding is encouraged for all mothers. Currently, as many as 50% of mothers (especially those in higher socioeconomic groups) are breast-feeding. In most cases, the infant should feed at each breast for 8 to 15 minutes every 2 to 3 hours after birth and can be started immediately after delivery. Colostrum, a yellowish fluid excreted from the breast immediately after delivery, contains important antibodies, high calories, and high proteins, as well as other nutrients and helps stimulate the passage of meconium. Some studies have shown that delaying breast-feeding, trying to quantify amounts of feeding with prefeed and postfeed weights, and providing infant formula decrease the percentage of women who breast-feed by discouraging the practice. Breast-feeding is usually adequate nutrition for 6 to 9 months. If mothers develop sore nipples, they should be counseled with regard to proper positioning of the baby's mouth on the breast. The production of a lubricant from Montgomery's glands occurs and helps protect the breast from excessive drying. Typically, breast-fed infants require more frequent feedings than bottle-fed infants. Breast-feeding should occur based on demand rather than by the clock. Breast engorgement can be avoided with more frequent feedings or manual expression of excessive milk production with breast pumps. New mothers should initiate breast-feeding as soon as possible after giving birth. When mothers initiate breast-feeding within one-half hour of birth, the baby's suckling reflex is strongest, and the baby is more alert. Early breast-feeding is associated with fewer nighttime feeding problems and better mother-infant communication. Babies who are put to breast earlier have been shown to have higher core temperatures and less temperature instability.
Moreland J, Coombs J. Promoting and supporting breast feeding. Am Fam Physician. 2000;61:2093–2100, 2103–2104.
70. The most common bacterial pathogen associated with lung infections in adolescents is
A) adenovirus
B) Streptococcus pneumoniae
C) H. influenzae
D) Mycoplasma pneumoniae
E) Chlamydia
View Answer
Answer and Discussion
The answer is D. Mycoplasma is the most common pathogen responsible for lung infections in patients between 5 and 35 years of age. It may involve close contacts, school children, military recruits, and family members and is spread via respiratory droplets. Symptoms include malaise, sore throat, coryza, myalgias, and an increasing productive cough of mucopurulent or blood-streaked sputum. A maculopapular rash occurs in 10% to 20%. Unlike Spneumococcal pneumonia, the course is less severe. Bullous myringitis has also been associated with Mycoplasma infections. Chest radiographs of those affected with Mycoplasma pneumonia show patchy infiltrates in the lower lobes and, rarely, lobar consolidation. The white blood cell count may be normal or mildly elevated. Diagnosis can be made with acute and convalescent titers but is unnecessary. The drug of choice for treatment is a macrolide antibiotic. Alternative medications include fluoroquinolones and tetracyclines. Because the Mycoplasma organism does not have a cell wall, the β-lactam antibiotics are ineffective.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1487.
Mycoplasma is the most common pathogen responsible for lung infections in patients between 5 and 35 years of age.
71. The major complication of slipped capital femoral epiphysis is
A) avascular necrosis of the hip
B) osteochonditis dissecans
C) leg length discrepancy
D) transient synovitis of the hip
E) in-toeing
View Answer
Answer and Discussion
The answer is A. Slipped capital femoral epiphysis typically occurs during the adolescent growth spurt and is most frequent in obese children. In many cases both hips are affected. Most cases of slipped capital femoral epiphyses are stable and have a good prognosis if diagnosed early in their course. Unstable slipped capital femoral epiphysis has a worse prognosis because of the high risk of avascular necrosis. Early radiographic clues are the metaphyseal blanch sign and Klein's line. Once diagnosed, treatment in most cases includes surgical pinning.
Loder RT. Slipped capital femoral epiphysis. Am Fam Physician. 1998;57:2135.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2278–2279.
72. In December, a 4-month-old infant is brought to the emergency room. The parents report the child has had a runny nose, fever, cough, and audible wheezing. The child is attending a daycare center, and other children have had similar symptoms. On examination, the child has some rales, wheezing, and intercostal retractions with grunting. The most likely infecting organism is
A) S. pneumoniae
B) H. influenzae
C) adenovirus
D) respiratory syncytial virus (RSV)
E) coxsackievirus
View Answer
Answer and Discussion
The answer is D. Respiratory syncytial virus (RSV) is a pneumovirus that usually affects children between 1 and 6 months of age, with a peak incidence at 2 to 3 months of age. The commonly encountered virus gives rise to bronchiolitis and pneumonia. The virus occurs during the winter months and is characterized by rhinorrhea, fever, cough, and wheezing; in more severe cases, tachypnea, dyspnea, and hypoxia are present. The virus is spread by close contacts via fomites and respiratory secretions and tends to occur in outbreaks in places such as daycare centers. Physical examination shows nasal flaring, rales, and wheezing as well as intercostal retractions with grunting in infants. Laboratory evaluation usually shows a normal leukocyte count with elevated granulocytes. Chest radiographs may show hyperexpansion, areas of atelectasis, and/or bronchopneumonia. The virus may be quickly detected by immunofluorescence microscopy of nasal swabs or enzyme-linked immunoassay antigen detection tests. Treatment of upper respiratory infections is usually symptomatic. Lower respiratory infections may be treated with supplemental oxygen and hydration. Bronchodilators and corticosteroids are not generally helpful. Aerosolized ribavirin (an antiviral agent) is no longer recommended except in severely immunocompromised patients. Respiratory support may be necessary in severe cases.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1600.
73. Of the following, which is the first sign of sexual development in girls?
A) The presence of axillary hair
B) The development of pubic hair
C) Menstruation
D) Development of breast buds
E) Closure of the epiphyseal growth plate
View Answer
Answer and Discussion
The answer is D. The development of breast buds (subareolar tissue) is usually the first sign of puberty (8 to 13 years of age). This is followed closely by the development of pubic hair (6 to 12 months later) and then axillary hair. The growth spurt often begins even before the development of breast buds. Menarche usually occurs 2.0 to 2.5 years after the development of the breast buds. Growth in height occurs predominantly before menarche and then slows thereafter. As the young girl's body changes, the percentage of body fat increases and redistributes, giving rise to adult contours. Precocious puberty is defined as the presence of breast development or pubic hair before 8 years of age. Pubertal delay is defined as absence of breast development before the age of 13 years or the lack of menstruation 5 years after breast growth.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:53–55, 1863.
74. Which of the following patient group-treatment scenarios is appropriate for the treatment/exposure of bacterial meningitis?
A) Neonates—ampicillin and cefotaxime
B) 1 month to 10 years of age—ampicillin and gentamicin
C) 10 to 18 years old—cefuroxime and erythromycin
D) Adults—ampicillin and metronidazole
E) Isoniazid for individuals exposed to meningococcal meningitis
View Answer
Answer and Discussion
The answer is A. The treatment of bacterial meningitis depends on the age of the patient. In neonates, the common infecting organisms include group B or D streptococci, Listeria, and gram-negative organisms such as E. coli. Recommended treatment includes ampicillin and cefotaxime until susceptibilities are known. In infants and children 1 month to 10 years of age, the common infecting organisms include pneumococci and meningococci. Combination therapy is recommended and includes ampicillin, vancomycin, and cefotaxime or ceftriaxone. Various combinations should be confirmed based on local sensitivities and most recent recommendations. For patients allergic to penicillin, vancomycin and rifampin may be considered. Family members, nursery school children, and other close contacts of those affected by meningococcal or H. influenzae meningitis should also receive rifampin as a prophylactic measure.
In addition to intravenous antibiotics, dexamethasone may decrease the incidence of permanent neurologic and audiologic complications and should be administered.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1860–1862.
75. Conductive hearing loss noted in children may be caused by
A) meningitis
B) medications
C) chronic eustachian tube dysfunction
D) intracranial hemorrhage
E) chronic exposure to loud noises
View Answer
Answer and Discussion
The answer is C. Signs of hearing loss may include delayed speech development, behavioral problems, and impaired comprehension. Hearing loss can be categorized as conductive or sensorineural. Conductive hearing loss is usually caused by otitis media with effusion. Other causes include foreign bodies in the ear, allergies, or chronic eustachian tube dysfunction. Sensorineural hearing loss can be caused by meningitis and other congenital infections, intracranial hemorrhage, chronic noise exposure, congenital defects, medications that are ototoxic, and trauma. Although hearing screening has been mandated in 34 states for all children absolute indications for audiologic evaluation include premature birth (birth weight <2,500 g or birth weight >2,500 g with complications including asphyxia, seizures, intracranial hemorrhage, hyperbilirubinemia, persistent fetal circulation, and assisted ventilation), intrauterine infection, bacterial meningitis, anomalies of the first or second branchial arch, anomalies of the neural crest or ectoderm, family history of hereditary or unexplained deafness, parental concern, and delayed speech or language development or other disabilities (including mental retardation, autism, cerebral palsy, and blindness). Infants are tested using either otoacoustic emissions (OAE) or auditory brain stem–evoked responses (ABR). The auditory brain stem–evoked response uses external scalp electrodes to detect waveforms that occur in predictable patterns after an auditory stimulus. The prompt recognition of hearing problems in children can help prevent delays in language development.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2131.
76. In males, the first sign of puberty is
A) development of pubic hair
B) testicular enlargement
C) spermarche
D) enlargement of the penis
E) skeletal growth spurt
View Answer
Answer and Discussion
The answer is B. At the onset of puberty males have testicular enlargement followed by the appearance of pubic hair, enlargement of the penis and spermarche. Skeletal and muscle growth are late events in male puberty. The age at which pubertal milestones are attained varies among the population studied and is influenced by activity level and nutritional status.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:53–55, 1863.
Blondell RD, Foster MB, Dave KC. Disorders of puberty. Am Fam Physician. 1999;60:209–224.
77. Which of the following conditions is associated with giving whole milk to infants younger than 1 year?
A) Iron deficiency anemia
B) Inflammatory bowel disease
C) Mental retardation
D) Hirschsprung's disease
E) None of the above
View Answer
Answer and Discussion
The answer is A. This condition has a variety of causes, including inadequate iron stores at birth because of prematurity, fetal-maternal blood loss, iron-deficient mother, or lack of iron ingestion by the child that fails to keep up with expanding blood volume as the child grows (especially between 9 and 18 months of age); in older adolescent patients, it may be caused by menstrual blood loss. Whole milk given to infants younger than 1 year may also cause chronic irritation of the colon, resulting in blood loss and development of iron deficiency anemia. The U.S. Preventative Services Task Force recommends that high-risk infants be screened for iron deficiency anemia between 6 and 12 months of age. Screening for iron deficiency anemia is not recommended in the general infant population because of low overall prevalence. The Centers for Disease Control and Prevention has developed specific criteria for anemia: hemoglobin levels <11.0 g/dL (110 g/L) for children between 6 months and 5 years of age. In 1993, it was estimated that the prevalence of iron deficiency anemia among children younger than 5 years was <3%, and most cases were mild; however, among high-risk groups, the prevalence may be up to 30%. Increased prevalence of iron deficiency anemia occurs among African Americans, Native Americans, Alaska Natives, persons of low socioeconomic status, preterm and low-birth-weight infants, immigrants from developing countries, and infants whose primary nutritional source is unfortified cow's milk.
Strategies to prevent iron deficiency anemia among infants are recommended. Family physicians should discuss issues of infant nutrition with expectant and new parents and encourage the consumption of iron-fortified formulas and cereals or encourage breast-feeding supplemented with iron-fortified cereals between the ages of 4 and 6 months.
Mahoney MC. Screening for iron deficiency anemia among children and adolescents. Am Fam Physician. 2000;62:671.
78. A 14-year-old boy presents with tenderness associated with the right breast. There are no other findings. Testicular examination is unremarkable. Appropriate management of this patient includes
A) mammogram
B) ultrasound of the breast
C) genetic typing
D) biopsy
E) reassurance and continued observation
View Answer
Answer and Discussion
The answer is E. Benign gynecomastia of adolescence is a very common finding among boys in middle to late puberty. The breast tissue is usually asymmetric and often tender to palpation. Provided the history and physical examination, including palpation of the testicles, are unremarkable, reassurance and periodic reevaluation are all that is necessary. Most cases resolve in 1 to 2 years. Familial gynecomastia is a common genetic disorder transmitted as an X-linked recessive trait or a sex-limited dominant trait causing limited breast development around the time of puberty. It requires no further evaluation in an otherwise normal boy unless there is evidence of hypogonadism. In rare cases those with severe gynecomastia may require cosmetic surgery. Pathologic gynecomastia occurs in cases of Klinefelter's syndrome and prolactin-secreting adenomas and with a wide variety of drug use including marijuana and phenothiazines.
Blondell RD, Foster MB, Dave KC. Disorders of puberty. Am Fam Physician. 1999;60:209–224.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1930.
79. Which of the following is the medication of choice for the treatment of pinworms (Enterobius vermicularis)?
A) Mebendazole (Vermox)
B) Permethrin (Elimite)
C) Metronidazole (Flagyl)
D) Oral vancomycin (Vancocin)
E) Tetracycline (Achromycin)
View Answer
Answer and Discussion
The answer is A. Pinworms is a common pediatric infection caused by the parasite Enterobius vermicularis. The parasite is a small (1 cm) white worm that lives in the bowel (usually the cecum) and often migrates out of the anus at night to deposit eggs on the perianal skin, giving rise to severe and intense pruritus. Children ages 5 to 10 years are predominantly affected. Young children may not be able to sleep, and rectal and vulvar inflammation may be evident. In many cases, the entire family may be affected through a fecal-oral route. Diagnosis can be made by visualizing the worms or applying cellophane tape to the anal area in the morning before bathing and observing for ova with microscopy (cellophane tape test). Treatment involves the administration of mebendazole (Vermox) in one dose, followed by a repeat dose 2 weeks later. Albendazole or pyrantel pamoate may be substituted for mebendazole. In most cases, the entire household should be treated. Other treatment recommendations include laundering of all bedclothes and underwear.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1551–1552.
Treatment of pinworms (Enterobius vermicularis) involves the administration of mebendazole (Vermox) in one dose, followed by a repeat dose 2 weeks later.
80. Which of the following drugs is concentrated in breast milk and should be avoided by women who are breast-feeding?
A) Heparin
B) Alcohol
C) Digoxin
D) Penicillin
E) Amitriptyline
View Answer
Answer and Discussion
The answer is B. Medications that are classified as weak bases are usually concentrated in breast milk. Contraindicated drugs include anticancer drugs, therapeutic doses of radiopharmaceuticals, ergot and its derivatives (e.g., methysergide), lithium, chloramphenicol, atropine, thiouracil, iodides, and mercurials. These drugs should not be used in nursing mothers, or nursing should be stopped if any of these drugs is essential. Other drugs to be avoided in the absence of studies on their excretion in breast milk are those with long half-lives, those that are potent toxins to the bone marrow, and those given in high doses long-term. However, drugs that are so poorly absorbed orally that they are given (to the mother) parenterally pose no threat to the infant, who would receive the drug orally but not absorb it.
Nicotine and alcohol are concentrated in breast milk and should be avoided by mothers who are breast-feeding. Other drugs, including heparin, acetaminophen, insulin, diuretics, digoxin, β-blockers, penicillins, cephalosporins, most over-the-counter cold remedies, amitriptyline, codeine, and ibuprofen, do not show up in significant amounts in breast milk. Some oral contraceptives can depress lactation (particularly large-dose, estradiol-containing birth control pills), but in most cases are considered safe.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2227.
81. A 3 year old who attends day school is seen in the middle of June. The parent reports that the child has had profuse watery diarrhea. Laboratory tests of the stool sample show leukocytes, red blood cells, and small comma-shaped bacteria that have a corkscrew motion. The most likely diagnosis is
A) Salmonella infection
B) Shigella infection
C) Rotavirus infection
D) Campylobacter infection
E) Escherichia coli infection
View Answer
Answer and Discussion
The answer is D. Campylobacter is an intestinal infection that can lead to profuse watery diarrhea. It is considered one of the most common causes of bacterial gastroenteritis. In many cases it affects young infants, particularly those in daycare centers; it is more common in the summer months. Associated foods include contaminated milk or water, poultry, and beef. Chickens are the classic source of Campylobacter; however, essentially all food sources can harbor the bacteria. In addition, pets can carry Campylobacter. Symptoms include loose, watery stools or bloody and mucus-containing stools. Fever, vomiting, malaise, and myalgia are common. Abdominal pain is usually periumbilical and cramping in nature. Children severely affected may show signs of dehydration. Laboratory tests of stool samples show leukocytes, red blood cells, and small comma-shaped bacteria that have a characteristic corkscrew motion. In most cases, antibiotics are unnecessary; however, because there is a carrier state, the use of antibiotics such as the quinolones (not used in children), erythromycin, doxycycline, and gentamicin can help to clear the stool of infecting organisms, particularly in an institutional setting. After treatment, repeat stool cultures should be performed to ensure eradication. Fecal shedding of the organisms can last up to 2 to 3 weeks in untreated patients. Severe cases or those immunosuppressed should be treated.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:928.
82. In the United States, which of the following deficiencies is common in adolescents?
A) Iron
B) vitamin B12
C) folate
D) thiamine
E) calcium
View Answer
Answer and Discussion
The answer is E. In the United States, only a minority of adolescents receive the recommended daily allowance of calcium. As a result there is the possibility of a future epidemic of osteopenia or even osteoporosis in normal individuals who have calcium deficiency.
Greenspan FS, Gardner DG. Basic and Clinical Endocrinology, 7th ed. New York: McGraw-Hill; 2004.
83. A 6-month-old infant is brought in for a well-child visit. The growth chart shows the child's growth has slowed when compared to the growth curve expected for his age despite adequate caloric intake. The most appropriate action is
A) to increase feeding amounts
B) to reassure the family that this is a common finding and that no further workup is necessary
C) to order laboratory tests, including a complete blood cell count, electrolyte levels, serum glucose levels, and urinalysis
D) to consult social services
E) to start nutritional supplement
View Answer
Answer and Discussion
The answer is C. Failure to thrive is a condition of infants. It is caused by a number of different factors. The condition is detected by following age-adjusted normals for height, weight, and head circumference. When the graph shows abnormalities (failure to meet the third percentile) or if there is a decrease in the expected rate of growth based on the child's previously defined growth curve, failure to thrive must be considered. Causes include birth defects (e.g., fetal infections, chromosomal abnormalities, inborn errors of metabolism), nutritional deficiencies with malabsorption, endocrine abnormalities, disturbances of bone development, disorders of oxygenation, malignancy, and neglect. Symptoms include poor weight gain, vomiting, diarrhea, muscle spasticity or hypotonia, developmental delay, apathy, withdrawn behavior, and poor hygiene. The diagnosis usually involves a detailed history and physical examination followed by an initial screening test, such as complete blood count, electrolyte levels, serum glucose levels, urinalysis, erythrocyte sedimentation rate, stool studies for ova, parasites, and blood. Other tests (e.g., thyroid function tests) may be indicated based on each case.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2395–2398.
84. Variation in a young patient's electrocardiogram pattern is noted with respiration. The rhythm remains sinus rhythm. The most appropriate action is
A) reassurance to patient and family
B) Holter monitoring
C) cardiology consultation
D) administration of β-blockers
E) synchronized cardioversion
View Answer
Answer and Discussion
The answer is A. Sinus arrhythmia is usually noted in young, healthy patients and represents no concern for underlying pathology. The variation in heart rate is affected by normal respirations and is associated with the alternating increases and decreases in vagal and sympathetic tone. Patients report no symptoms, and no treatment is required.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:676.
85. A 3-year-old boy is diagnosed with constitutional growth delay. The workup is unremarkable. The most appropriate management is
A) vitamin E supplementation
B) administration of prednisone
C) monitoring of thyroid function tests every 3 months
D) reassurance to parents
E) nutritional consult
View Answer
Answer and Discussion
The answer is D. Constitutional growth delay is one variant of normal growth. Length and weight measurements of affected children are normal at birth, and growth is normal for the first 4 to 12 months of life. Growth then decelerates to near or below the third percentile for height and weight. By 2 to 3 years of age, growth resumes at a normal rate of 5 cm/year or more. The majority of these children are male and have a bone age that is appropriate for height age but are delayed relative to their chronologic age. Some of these children experience delayed puberty but eventually complete normal development without complications. Reassurance to the parent is the most appropriate management for children who are at Tanner stage 2 or 3, do not have underlying chronic disease, and have skeletal age-appropriate height as they grow older. The parents can be reassured that the child will go through a growth spurt in the near future, and no further testing is warranted. Although the child may end up being shorter than his or her peers, the child usually follows growth patterns of the parents. Only in extreme severe cases are medications such as anabolic and androgenic steroids considered.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1851.
86. A 3-year-old child presents with high fever, prostration, and purpuric rash. Appropriate management should be
A) administration of oral antibiotics with next-day follow-up
B) hospitalization, intravenous antibiotics, and close observation
C) to obtain throat culture and treat if positive for strep
D) symptomatic measures for likely viral infection
E) to check Lyme disease titers
View Answer
Answer and Discussion
The answer is B. Meningococcemia is a severe infection that is caused by Neisseria meningitidis. The mode of transmission is through infected respiratory secretions. The onset is usually abrupt, and the course can be fulminant despite treatment. Symptoms include fever, chills, fatigue, and prostration. A distinctive petechial or purpuric rash develops. Fulminant disease can result in disseminated intravascular coagulopathy and septic shock. Children younger than 5 years are the most commonly affected. In many cases, meningitis results and can be fatal (5% of patients). Diagnosis can be made with an antigen detection test of the blood, cerebrospinal fluid, and urine. Cultures can also be used but typically require longer amounts of time. Treatment involves the use of high-dose intravenous penicillin G, ampicillin, central nervous system–penetrating cephalosporins, and chloramphenicol in an intensive care unit setting. Exposed household, day school, or school contacts should receive chemoprophylaxis with rifampin. Ceftriaxone and ciprofloxacin are also prophylactic substitutes for adults. Meningococcal vaccination should be given to individuals at risk (e.g., asplenic individuals, travelers in high-risk areas, college students living in dorms, military recruits, and patients with complement deficiencies). Newer recommendations may include universal administration.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:896–899.
87. Which statement regarding metatarsus adductus is true?
A) metatarsus adductus is the rarest of foot disorders to affect children
B) intoeing rarely occurs as a result of metatarsus adductus
C) males are more commonly affected
D) surgery is rarely needed
E) stretching exercises are rarely effective
View Answer
Answer and Discussion
The answer is D. Metatarsus adductus is the most common congenital foot deformity seen in children. Females are more commonly affected and the left side is more commonly affected. The most likely cause is positioning while in utero. Examination reveals adduction of the forefoot with a convex lateral border. The ankle has normal motion. The foot should be assessed for flexibility by holding the heel in neutral position and abducting the forefoot to at least a neutral position. If this cannot be done, then the deformity is rigid (i.e., metatarsus varus). The majority of cases of metatarsus adductus noted at birth resolve without treatment by 1 year of age. Flexible metatarsus adductus is managed by stretching exercises during the first 8 months of life. Parents are instructed to hold the infant's hindfoot in one hand, the forefoot in the other, and stretch the midfoot, opening the “C�-shaped curve and slightly overcorrecting it. Flexible deformities that persist beyond 8 months, and rigid deformities, may need a cast application. Improved results occur if treatment is started before 8 months of age. Casts should be changed biweekly with correction usually achieved after three or four casts. Residual adductus causes no long-term disability. Surgery is not typically recommended because of the risk of complications.
Sass P, Hassan G. Lower extremity abnormalities in children. Am Fam Physician. 2003;68:461–468.
88. Which of the following immunizations may result in a false negative PPD tuberculosis test?
A) Tetanus
B) Hepatitis B
C) Pneumococcal
D) Influenza
E) Measles, mumps, and rubella (MMR)
View Answer
Answer and Discussion
The answer is E. Some persons (e.g., anergic patients, those with recent viral infections or those recently treated with live virus vaccines) may not react to the tuberculin skin test even though they are truly infected with Mycobacterium tuberculosis. Of those discussed, only the MMR is a live virus.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:964.
89. Which of the following is the treatment of choice for pertussis?
A) Penicillin G
B) Amphotericin B
C) Erythromycin
D) Ciprofloxacin
E) Metronidazole
View Answer
Answer and Discussion
The answer is C. Pertussis is a highly contagious (gram-negative rod) bacterial disease caused by Bordetella pertussis. The disease is characterized by a short paroxysmal cough that ends with an inspiratory whoop. The incubation period is usually 7 to 21 days. Transmission occurs through a respiratory route. The disease is divided into three stages:
· The catarrhal stage is characterized by sneezing, lacrimation, decreased appetite, fatigue, coryza, and a cough that usually becomes diurnal and lasts 10 to 14 days.
· The paroxysmal stage is characterized by the whooping cough; vomiting as a result of the persistent cough may occur; this stage may last up to 4 weeks.
· The convalescent stage involves a slow improvement of the cough and constitutional symptoms.
The entire illness may last up to 3 months. Diagnosis is made by obtaining a nasopharyngeal swab and performing an antibody test for detection of the gram-negative organism in the secretions. Treatment involves the use of erythromycin. Household or other close contacts should also be treated with oral erythromycin. Most patients may return to their regular activity 5 days after the administration of erythromycin. Routine childhood immunization is effective in the prevention of the disease, but not in all cases. Recently, B. pertussis has been increasingly responsible for chronic cough in adults. In adults and infants younger than 6 months, the classic whoop may not occur, but the diagnosis should be considered with a cough lasting more than 2 weeks. Parapertussis, caused by Bordetella parapertussis, is a similar illness and is clinically indistinguishable from pertussis, except it usually has a milder course and fewer complications.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia; WB Saunders; 2004:908–912.
Parapertussis, caused by Bordetella parapertussis, is a similar illness and is clinically indistinguishable from pertussis, except it usually has a milder course and fewer complications.
90. A 4 year old presents with impetigo associated with the knee. No other areas are involved. The most appropriate treatment is
A) topical mupirocin
B) topical bacitracin
C) topical neomycin
D) topical polymyxin B
E) oral cefalexin
View Answer
Answer and Discussion
The answer is A. Impetigo is a contagious superficial skin infection most commonly seen in children, with a peak incidence between the ages of 2 and 6 years. The condition is the most common skin infection affecting children. Causative agents include group A beta-hemolytic streptococci (GABHS) and Staphylococcus aureus. Complications such as cellulitis, lymphangitis, and septicemia are rare and result from spread of the infection. The infection is transmitted via direct contact with the lesion. Antibiotic administration is the mainstay of therapy. If the area of affected skin is limited, mupirocin is an effective topical therapy and has been shown to be more effective than the other topical antibiotics (i.e., neomycin, bacitracin, polymyxin B, and gentamicin). There is insufficient evidence to determine whether oral antibiotics are better than topical agents in patients with more extensive disease, although there are obvious practical reasons to choose oral agents if large amounts of skin are involved. Antibiotic categories to consider include penicillins, cephalosporins, and macrolides. Oral antibiotics have significantly more side effects, especially gastrointestinal effects, than topical agents.
Koning S, Verhagen AP, van Suijlekom-Smit LW, et al. Interventions for impetigo. Cochrane Database Syst Rev. 2004;(3):CD003261.
91. Which of the following is the most appropriate management of an asymptomatic umbilical hernia in a newborn?
A) Immediate surgical correction
B) Reassurance to parents that most hernias resolve in 6 to 8 weeks
C) Surgical correction if the hernia does not resolve before school age
D) Application of an elastic support to the mid-abdomen
E) None of the above
View Answer
Answer and Discussion
The answer is C. Umbilical hernias are more commonly seen in premature, female, and African American infants. The condition results from imperfect closure or weakness of the umbilical ring. If noted before 6 months of age, most resolve spontaneously before 1 year of age. Although rare, incarceration of the bowel is the most dangerous condition associated with abdominal hernias. If the hernia does not close before school age, incarcerates the bowel, or becomes symptomatic, surgical correction should be considered. Reduction of the hernia with strapping devices is not useful.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:609.
92. Early breast-feeding is associated with
A) improved growth in the first 2 months
B) lower risk of aspiration
C) less temperature instability
D) fewer apneic spells
E) higher rates of postpartum depression
View Answer
Answer and Discussion
The answer is C. Mothers of newborn infants should initiate breast-feeding as soon as possible after giving birth. When mothers initiate breast-feeding within one-half hour of birth, the baby's suckling reflex is strongest, and the baby is more alert, which facilitates feeding. Early breast-feeding has been shown to be associated with fewer nighttime feeding problems and better mother-infant bonding. Additionally infants who are breast fed earlier have been shown to have higher core temperatures and less temperature instability.
Moreland J, Coombs J. Promoting and supporting breast-feeding. Am Fam Physician. 2000;61:2093–2100, 2103–2104.
93. A 5-year-old boy is brought in for a well-child visit. The child's parents are noted to be relatively short, and they have concerns because their child is shorter than most of the other children in his class. The child's skeletal maturation is consistent with his chronologic age. The most likely diagnosis is
A) parental neglect
B) hypothyroidism
C) genetic short stature
D) acromegaly
E) dwarfism
View Answer
Answer and Discussion
The answer is C. Genetic short stature is a delay in growth and development that patterns the parents' growth and development. Typically, if the child has tall parents, the child will eventually be tall; if the parents are short, the child will eventually be short. Also, if the parents developed late in adolescence, then the child will mirror this development. Constitutional growth delay can be differentiated from genetic short stature by the level of skeletal maturation, which is consistent with chronologic age in the latter condition. There is no treatment necessary; however, the family may need reassurance that the child is normal and that no further treatment or evaluation is necessary.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:54–57.
94. A 40-year-old woman who received killed measles vaccination in 1965 presents with high fever, headaches, abdominal pain, and a rash that began on her arms and spread to her trunk and face. Which of the following factors makes you suspicious that this is not typical measles?
A) Development of cough
B) Development of high fever
C) Presence of abdominal pain
D) Distribution of rash
E) Development of headaches
View Answer
Answer and Discussion
The answer is D. A typical measles syndrome occurs in individuals who were immunized with the original killed virus vaccine, which was administered from 1963 to 1967. Some cases have been linked to the newer, live attenuated vaccine that was improperly stored. The disease is thought to result from a hypersensitive response in persons who have partial immunity. Symptoms are similar to regular measles and include high fever, headache, abdominal pain, cough, and a rash that begins on the extremities (unlike regular measles, in which the rash tends to form on the face first) 1 to 2 days after the onset of the initial symptoms. The rash may become purpuric or hemorrhagic. Koplik's spots are rarely seen in atypical measles.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1028.
95. Which of the following malignancies is most common in childhood?
A) Wilm's tumor
B) Retinoblastoma
C) Melanoma
D) Acute lymphoblastic leukemia (ALL)
E) Osteosarcoma
View Answer
Answer and Discussion
The answer is D. Leukemia is the most common malignancy diagnosed in childhood. Acute lymphoblastic leukemia (ALL) is the most common type of leukemia in children. ALL typically occurs in children between 1 and 10 years of age, although it can occur at any age. This leukemia is more common in males and in Caucasians. Diagnosing acute lymphoblastic leukemia can be challenging. Frequently, the diagnosis is delayed because early symptoms are nonspecific and may resemble viral infections. Most children affected present with generalized malaise, loss of appetite and a low-grade fever. Additional symptoms include pallor, petechiae or ecchymoses, bone pain, and significant weight loss. The physical examination may not be revealing, but significant lymphadenopathy or hepatosplenomegaly should raise suspicion for leukemia. Hepatosplenomegaly is always an abnormal finding. A practical approach to the child with suspicious findings is to obtain a complete blood count (CBC) with a white blood cell differential and a reticulocyte count. The presence of blast cells on the peripheral smear is diagnostic of leukemia. However, many patients with leukemia only have blast cells in their bone marrow. The finding of anemia, especially if accompanied by reticulocytopenia or a high mean corpuscular volume, thrombocytopenia, leukopenia, or leukocytosis is likely associated with leukemia and deserves further evaluation. Illnesses that may mimic leukemia include infectious mononucleosis caused by Epstein-Barr virus or, less frequently, cytomegalovirus infection, collagen vascular disease, and aplastic anemia.
Young G, Toretsky JA, Cambell AB, et al. Recognition of childhood malignancies. Am Fam Physician. 2000;61:2144–2154.
96. Which of the following foods have been associated with the development of botulism in children younger than 1 year?
A) Corn syrup
B) Peanuts
C) Honey
D) Cereal
E) Animal crackers
View Answer
Answer and Discussion
The answer is C. Botulism is caused by a toxin produced by the anaerobe Clostridium botulinum. Symptoms usually occur within 24 hours after ingestion of contaminated food (usually canned food). These symptoms include dry mouth, diplopia, dysarthria, dysphagia, decreased visual acuity, nausea, vomiting, abdominal cramps, and diarrhea. Neurologic disorders include weakness and eventual paralysis, which can lead to respiratory failure and death. Sensory function remains intact. Diagnosis is made by discovery of the botulinum toxin in the affected food or stool of affected patients. Treatment involves supportive therapy, including mechanical ventilation and the administration of a trivalent antitoxin. Mortality rates approach 25%. Prevention involves the use of pressure cookers, which provide temperatures higher than 100°C (212°F), for at least 10 minutes when canning vegetables; boiling food for at least 10 minutes before eating destroys any toxins present. Infant botulism is caused by the ingestion of botulinum spores, which produce the toxin in vivo. Unlike food-borne botulism, infant botulism is not caused by ingestion of a preformed toxin. Constipation is initially present in 90% of cases of infant botulism and is followed by neuromuscular paralysis beginning with the cranial nerves and proceeding to peripheral and respiratory musculature. Cranial nerve deficits typically include ptosis, extraocular muscle palsies, weak cry, poor suck, decreased gag reflex, pooling of oral secretions, and an expressionless face. Severity varies from mild lethargy and slowed feeding to severe hypotonia and respiratory insufficiency. Most infants affected are between the ages of 2 and 3 months. Finding C. botulinum toxin or organisms in the feces establishes the diagnosis. Honey has been shown to contain botulinum spores, and thus should be avoided in children younger than 1 year. Administration of the antitoxin may be considered (not in infants). Additionally antibiotics may be useful to treat secondary infections. Aminoglycosides should be avoided because they may potentiate the effects of the toxin. A clinical trial is being performed to determine the usefulness of human botulism immune globulin (derived from the plasma of persons immunized with C. botulinum toxoid) in the treatment of infant botulism.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1498–1499.
97. Which of the following is true regarding management of head lice?
A) Children should be kept out of school until no visible evidence of nits is noted.
B) Household members should only be treated if live lice or eggs are noted within 1 cm of the scalp.
C) Head lice programs have had a significant impact on lowering the incidence of head lice.
D) Cleaning of bedding has little impact on lice eradication.
E) The health of those exposed is more important than the confidentiality of the child affected.
View Answer
Answer and Discussion
The answer is B. Practice guidelines published by the American Academy of Pediatrics (AAP) state that if a case of head lice is identified, all household members should be checked, and only those with live lice or eggs within 1 cm of the scalp should be treated. It is recommended to treat family members who share a bed with the person who is infected and to adequately clean hair care items and bed linens belonging to that person. A child with active head lice has likely had the infestation for a month or more by the time it is discovered and poses little risk to others. The child does not have a resulting hygiene or health problem and should stay in class but be discouraged from close, direct head contact with others. The child's parents should be notified immediately, and confidentiality should be maintained so the child is not embarrassed. A child should be allowed to return to school after proper treatment and should not miss school because of head lice. Head lice screening programs have not had a significant effect on the incidence of head lice in the school setting over time and are not cost effective.
Ressel GW. AAP releases clinical report on head lice. Am Fam Physician. 2003;67:1309.
98. Which of the following statements about osteoid osteoma is true?
A) It is a malignant tumor of long bones.
B) It is more common in girls.
C) It usually presents as a pathologic fracture.
D) Radiographs show radiolucent areas surrounded by sclerosis.
E) Treatment involves systemic chemotherapy.
View Answer
Answer and Discussion
The answer is D. Osteoid osteoma is a benign tumor that usually involves the long bones of pediatric and adolescent patients. They are found more commonly in boys. Most cases present with pain, not fracture. Radiographs show a characteristic radiolucent area surrounded by sclerosis, which is usually associated with the ends of the tibia or femur. Technetium bone scans are helpful in determining the area involved. Treatment for severe refractory cases involves surgical resection, which is curative. Anti-inflammatories are often helpful for mild cases and can relieve the pain.
Adkins SB, Figler RA. Hip pain in athletes. Am Fam Physician. 2000;61:2109–2118.
99. Which of the following is not a suitable treatment for molluscum contagiosum?
A) Curettage
B) Cryotherapy
C) Trichloroacetic acid
D) Imiquimod (Aldara)
E) All are considered acceptable treatment.
View Answer
Answer and Discussion
The answer is E. Molluscum contagiosum (MC) is a benign superficial eruption resulting from viral infections of the skin. Molluscum contagiosum eruptions are usually self-limited and without sequelae, although they can be more extensive especially in immunocompromised persons. In patients with HIV, MC infection frequently is not self-limited and can be much more extensive and even disfiguring. MC may serve as a cutaneous marker of severe immunodeficiency and sometimes is the first indication of HIV infection. Lesions usually spontaneously disappear but treatment by local destruction or immunologic modulation can shorten the disease course. Spontaneous disappearance of MC lesions with no residual scarring is common. This may occur after a period of inflammation and minor tenderness. Autoinoculation is associated with scratching of the lesions and transmission to others can occur. Lesion destruction may be mechanical (curettage, laser, or cryotherapy with liquid nitrogen or nitrous oxide cryogun), chemical [trichloroacetic acid, tretinoin (Retin-A)], or immunologic [imiquimod (Aldara)]. Advantages to imiquimod therapy include minimal side effects and convenience of application.
Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician. 2003;67:1233–1240, 1243–1244.
Molluscum contagiosum lesion destruction may be mechanical (curettage, laser, or cryotherapy with liquid nitrogen or nitrous oxide cryogun), chemical (trichloroacetic acid, tretinoin [Retin-A]), or immunologic (imiquimod [Aldara]).
100. Which of the following statements about lead poisoning in children is true?
A) Symptoms include vomiting, irritability, weight loss, and abdominal pain.
B) Repeated ingestion of small amounts of lead is less dangerous than a single large ingestion.
C) All paints used in the home should be <25% lead.
D) It is treated with deferoxime.
E) Neurologic deficits are not routinely associated with lead poisoning.
View Answer
Answer and Discussion
The answer is A. Lead poisoning is a particular concern for young children. Also known as plumbism, the condition is characterized by generalized weakness, vomiting, irritability, weight loss, changes in personality, ataxia, headache, and abdominal pain. Radiographic particles are often seen on abdominal films, and there is usually a visible lead line on the gums and involving bones at the metaphyseal zone. Further complications include delayed development with diminished IQ, decreased hearing, peripheral neuropathy, seizures, and coma in severe cases. The syndrome usually affects children younger than 5 years who have ingested lead. Some common sources of lead include leaded paint chips, solder, glazed pottery, and fumes from burning batteries. Repeated ingestion of small amounts of lead (>0.5 mg of lead absorbed per day) is more dangerous than one single large dose. All paints used in the home should be <1% lead. Drinking water is another important source of lead exposure if there are lead pipes or lead fixtures or fittings. The diagnosis of lead poisoning is made by laboratory determination of lead levels and is recommended for children at risk. Most experts recommend testing between 6 and 7 months unless it can be shown that the community in which the children live does not have a lead-poisoning problem. Levels >10 µg/dL should be further evaluated by public health officials to determine environmental exposure risk. The treatment of acute lead poisoning is achieved by the induction of vomiting and chelation therapy with the use of dimercaprol and edetate calcium disodium, followed by penicillamine once the patient can take oral medication. Close monitoring should be instituted to watch for renal failure and the development of seizures. Children should not be allowed to return to lead-contaminated environments until they are deemed safe by environmental agents.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2669–2670.
101. The first solid foods (iron-fortified cereal) should typically be administered to an infant at
A) 2 to 4 months
B) 4 to 6 months
C) 6 to 8 months
D) 8 to 12 months
E) only after 1 year
View Answer
Answer and Discussion
The answer is B. Iron-fortified cereals should be the first solid food introduced to young infants at 4 to 6 months of age. These can be continued until approximately 18 months of age. When to start solid foods depends on the infant's needs and readiness, but infants do not need solids before 6 months of age. Neurologic development has progressed sufficiently for tongue and mouth movement to handle solids at approximately 4 months in full-term infants. Solid feedings given earlier than 4 months of age are extremely difficult to manage, because the infant's extrusion reflex causes the tongue to push solid food out of the mouth. Other foods, including fruit and vegetable baby food, may be started soon after the introduction of cereal. Typically one new food is added per week. Baby food meats can be added at 6 to 7 months; table food can be added at 8 to 12 months. Foods easily aspirated such as chunks of meat, popcorn, or nuts should be avoided. Whole milk can replace formula or breast milk at 12 months of age. And reduced fat milk is usually given at 2 years of age. To prevent food sensitivities, peanuts, eggs, and cow's milk should be avoided until the child is 1 year old. Honey should be avoided in children <1 year of age because of the risk of infant botulism.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2230.
102. A 4-year-old girl complains of vaginal itching, especially at night when she is going to bed. The most likely diagnosis is
A) ascariasis
B) cutaneous larva migrans
C) pinworms
D) pubic lice
E) molluscum contagiosum
View Answer
Answer and Discussion
The answer is C. Enterobius (pinworms) is the most common parasite affecting children in the United States. Its prevalence approaches 100% in institutionalized children. Infestation usually results from hand to mouth transfer of ova from the perianal area to fomites (clothing, bedding, furniture, rugs, toys), from which the ova are picked up by the new host, transmitted to the mouth, and swallowed. Although less common, airborne ova may be inhaled and then swallowed. The pinworms reach maturity in the lower GI tract within 2 to 6 weeks. The female worm migrates to the perianal region (usually at night) to deposit ova. Movements of the female worm cause pruritus. The ova can survive on fomites as long as 3 weeks under normal conditions. Most persons who harbor pinworms have no symptoms or signs. Some will, however, experience the perianal itching and develop perianal excoriations from persistent scratching. Vaginitis in young females may be due to irritation from pinworms. Pinworm infestation can be diagnosed by finding the female worm, which is about 10 mm long (males average 3 mm), in the perianal region 1 or 2 hours after the child goes to bed at night or by microscopic identification of the ova. The ova are obtained in the early morning before the child arises by patting the perianal skinfolds with a strip of transparent adhesive tape. This procedure should be repeated on 5 successive mornings if necessary to rule out pinworm infestation. A single dose of mebendazole (regardless of age) is effective in eradicating pinworms (but not ova) in about 90% of cases. Pyrantel pamoate is also used and repeated after 2 weeks. Because multiple infestations within the household are the rule, treatment of the entire family is recommended. Extensive handwashing and housekeeping have little effect on the control or treatment of pinworm infestation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1551–1552.
103. Retinopathy of prematurity is associated with
A) gestational diabetes
B) excessive oxygen administration
C) maternal hypothyroidism
D) maternal rubella infection
E) development of congenital cataracts
View Answer
Answer and Discussion
The answer is B. Retinopathy of prematurity (ROP), or retrolental fibroplasia, is thought to be related to exposure of retinal vessels of premature infants to excessive oxygen concentrations; the condition rarely occurs otherwise. Other risk factors include respiratory distress, apnea, bradycardia, heart disease, infection, hypoxia, hypercarbia, acidosis, anemia and the need for transfusion. Most affected infants weigh <1,500 g, and the mechanism of injury is believed to be excessive oxygen exposure leading to the development of free radicals and neovascularization and eventual retinal detachment. Occasionally, if the neovascularization is mild, the abnormal vessels may spontaneously regress, preserving vision but usually leaving the infant with significant myopia. Prevention is aimed at carefully monitoring oxygen supplementation in minimal amounts to preserve brain tissue and, ultimately, prevention of premature birth. However, oxygen alone is neither sufficient nor necessary to produce ROP and no safe level of oxygen has been determined. Treatment involves the use of cryotherapy and laser photocoagulation, which may be beneficial in select cases. All infants who weigh <1,500 g should be evaluated by an ophthalmologist before discharge from the hospital and at least once at 6 months after birth.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2113–2114.
104. The definition of delayed sexual maturation in boys includes
A) no testicular development by age 10 years
B) more than 5 years between the initial and completed growth of genitalia
C) lack of axillary hair growth by 13 years of age
D) lack of pubic hair growth 1 year after the growth spurt
E) no pubertal-related voice changes before age 15 years
View Answer
Answer and Discussion
The answer is B. Delayed sexual maturation is defined as follows:
· In boys: no testicular development by age 14 years, no pubic hair by age 15 years, and more than 5 years between the initial and completed growth of the genitalia
· In girls: no breast development by age 13 years, no pubic hair before age 14 years, and no menstruation within 5 years of the development of breast buds, or if menstruation does not occur by age 16.
One of the major causes is constitutional delay, which is defined as an inherited delayed maturation affecting the child that is also often noted in the parents. In these cases, the prepubertal growth is normal, but the skeletal growth and adolescent growth spurt is delayed. Those affected develop sexually late but are considered completely normal. The condition is more common in males and can be treated with the use of testosterone supplementation. Girls with severe pubertal delay should be investigated for primary amenorrhea.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2370–2371.
105. Which of the following is a negative predictor for streptococcal pharyngitis?
A) Fever >38.3°C (100.9°F)
B) Exposure to a known Streptococcus pharyngitis contact
C) Pharyngeal or tonsillar exudates
D) Recent cough
View Answer
Answer and Discussion
The answer is D. According to the Walsh Prediction Scale, the following are given equal weight in the diagnosis of strep pharyngitis:
· Fever >38.3°C (100.9°F)
· Exposure to a known streptococcus pharyngitis contact
· Pharyngeal or tonsillar exudates, enlarged or tender nodes
Recent cough actually was a negative predictor for strep pharyngitis. In patients with a low probability of streptococcal pharyngitis (score of -1), only follow-up is needed. Those in the intermediate group (score of zero or 1) could be tested further, treated, or followed, depending on physician preference. Patients with a high probability of disease (score of 2 or 3) should be treated empirically with an antibiotic.
McGinn TG, Deluca J, Ahlawat SK. Validation and modification of streptococcal pharyngitis clinical prediction rules. Mayo Clin Proc. 2003;78:289–293.
106. Which of the following statements about posterior urethral valves is true?
A) They affect only male children.
B) They cannot be detected by prenatal ultrasound.
C) Most cases resolve spontaneously.
D) They are secondary to abnormal valves found in the posterior calices of the kidney, giving rise to urinary diverticula.
E) They are not detected by a voiding cystourethrogram.
View Answer
Answer and Discussion
The answer is A. Children with urinary tract infections do not always present with symptoms such as frequency, dysuria, or flank pain. Infants may present with fever and irritability or other subtle symptoms such as lethargy. Older children may also have nonspecific symptoms such as abdominal pain or unexplained fever. A urinalysis should be obtained in a child with unexplained fever or symptoms that suggest a urinary tract infection.
Posterior urethral valves are commonly the cause of urinary tract infections in young boys only. These valves are secondary to abnormal folds in the prostatic urethra that enlarge with voiding and cause obstruction of the urethral lumen. Symptoms include decreased urinary stream, overflow incontinence, and urinary tract infections with dysuria. Affected boys can be identified prenatally with maternal ultrasound, which shows bilateral hydronephrosis; a distended bladder; and, if obstruction is severe, oligohydramnios. Urinary tract infections noted in boys suspected of posterior urinary valves should undergo further evaluation, including voiding cystourethrogram, or perineal ultrasound, as soon as the diagnosis is suspected; this will help reduce the risk of kidney damage. Treatment involves surgical resection of the valves.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1802–1803.
107. Of the following, the most appropriate treatment for cradle cap is
A) topical ketoconazole
B) aloe vera shampoo
C) topical moisturizers
D) vitamin E
E) topical hydrocortisone
View Answer
Answer and Discussion
The answer is E. Newborns frequently develop seborrheic dermatitis, with a thick, yellow, crusted scalp lesion (cradle cap); fissuring and yellow scaling behind the ears; red facial papules; and an irritated diaper rash. In infants, a baby shampoo is used daily and 1% hydrocortisone cream is applied twice daily. Additionally the dermatitis usually responds to frequent zinc or tar shampoos.
Rudolph CD, Rudolph AM, Hostetter MK, et al. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill; 2003:1175.
108. A 4-year-old boy swallows a small button battery. The child undergoes a chest radiograph and abdominal series. The battery is located in the lower esophagus, above the lower esophageal ring. The most appropriate management is
A) observation
B) endoscopy to remove the battery
C) barium swallow study
D) ipecac administration
E) none of the above
P.151
View Answer
Answer and Discussion
The answer is B. Children younger than 4 years are at particular risk for the ingestion of foreign bodies such as button batteries used in wristwatches and cameras. If a child ingests a battery, a radiograph of the child's chest and abdomen is indicated to locate the battery's position. If the battery is located distal to the lower esophageal ring, no further therapy is needed; however, if the battery is larger than 1.5 cm, a follow-up radiograph should be performed 48 hours later to make sure the battery has passed through the pylorus. If the battery is lodged in the esophagus, endoscopy should be performed to remove the foreign body. A battery lodged in the esophagus can lead to perforation if left for more than 4 hours.
Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2,382 cases. Pediatrics. 1992;89:747–757.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:126–127.
109. A 12-year-old boy presents with pain over the tibial tubercle. His mother reports a recent growth spurt. The most likely diagnosis is
A) Legg-Calvé-Perthes disease
B) shin splints
C) Osgood-Schlatter disease
D) osteosarcoma
E) stress fracture
View Answer
Answer and Discussion
The answer is C. Osgood-Schlatter disease is caused by inflammation of the tibial tubercle that usually occurs at the time of a child's growth spurt. It is aggravated by strenuous physical activity such as climbing or running. Boys are more affected than girls, the condition is usually unilateral, and most patients are between 10 and 15 years of age. Symptoms include pain, swelling, and tenderness over the tibial tubercle. The cause is repeated traction of the inferior patellar tendon on the developing epiphyseal insertion. Radiographs of the knee, although unnecessary for the diagnosis, usually show bone fragments at the site of the tibial tubercle. Treatment includes rest (especially from deep-knee bends), ice therapy, and anti-inflammatories. In severe cases, more aggressive therapy, including casting, cortisone injections, and surgery, to remove loose bodies may be necessary but is infrequent.
Rudolph CD, Rudolph AM, Hostetter MK, et al. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill; 2003:2432.
110. A 4-year-old boy is brought to your office by his mother. The child has evidence of a stomatitis and a vesicular rash that affects his hands and feet. The most likely cause is
A) coxsackievirus
B) adenovirus
C) syphilis
D) varicella
E) measles
View Answer
Answer and Discussion
The answer is A. The coxsackievirus is responsible for several infections that usually affect the pediatric population. There are two types of the virus:
· Coxsackievirus A
o A16 is responsible for hand, foot, and mouth disease, which is characterized by stomatitis and a vesicular rash that affects the hands and feet. It is usually mild, affects young children, and may occur in epidemics.
o A2, A4, A5, A6, A7, and A10 are responsible for herpangina, which is a more severe febrile illness that sometimes leads to febrile seizures. Other symptoms include a severe sore throat; vesiculoulcerative lesions that affect the tonsils, soft palate, and posterior pharynx; headaches; myalgias; and vomiting.
· Coxsackievirus B
o B1, B2, B3, B4, and B5 are responsible for pleurodynia with pain associated with the area of diaphragmatic attachment. Other symptoms include fever, headache, sore throat, malaise, and vomiting. Orchitis and pleurisy may also occur.
Coxsackievirus B infection is rare in persons older than 60 years and is more common in children and young adults. The infection is transmitted by hand-to-mouth contact and may become widespread in certain populations. This virus has been called “the great pretender� because of the variety of clinical syndromes it can produce. Many infections that are caused by the virus are subclinical. More serious conditions caused by coxsackievirus B include myocarditis, orchitis, myalgia, and pleurodynia. Pleurodynia may be severe and can occur in epidemics referred to as Bornholm disease, named after the original description of an early epidemic on the Danish island of Bornholm. Patients with pleurodynia are usually children or young adults who present with severe pleuritic pain, tachypnea, and systemic upset. The condition is usually self-limiting, but there can be serious, though rare, long-term sequelae. In most cases, the treatment of coxsackievirus is symptomatic, and most infections are self-limited. Antibiotics are usually unnecessary unless concomitant bacterial infection is suspected.
Walling AD. Family practice international—clinical information from the international family medicine literature. Am Fam Physician. 2000;61(12):3733.
In most cases, the treatment of coxsackievirus is symptomatic, and most infections are self-limited.
111. The most common cause of metabolic pancreatitis in children is
A) type I diabetes mellitus
B) primary hyperparathyroidism
C) primary hyperthyroidism
D) diabetes insipidus
E) Cushing's syndrome
View Answer
Answer and Discussion
The answer is B. Hypercalcemia and hyperlipidemia are 2 recognized causes of pancreatitis, both in children and in adults. The hypercalcemia may be masked by the transient calcium-lowering effect of acute pancreatitis. Primary hyperparathyroidism related to adenoma or hyperplasia (sometimes secondary to multiple endocrine neoplasia, type IIa) is the most common cause of the hypercalcemia.
Uretsky G, Goldschmiedt M, James K. Childhood pancreatitis. Am Fam Physician. 1999;59:2507.
112. A 3-month-old boy is brought to your office by his parents. The child has an erythematous rash that spares the skin folds of the groin area. The most likely diagnosis is
A) diaper dermatitis
B) yeast dermatitis
C) heat rash
D) varicella
E) childhood eczema
View Answer
Answer and Discussion
The answer is A. Diaper dermatitis, also known as primary irritant dermatitis, results from chronic exposure to urine and feces and its subsequent skin irritation. It is a shiny, erythematous rash that spares the skin folds in the groin area and usually affects infants after 3 months of age. In severe cases, the skin may ulcerate. Treatment involves adequate drying of the area with exposure to air. Frequent diaper changes may also speed recovery, as well as application of petroleum jelly and zinc oxide to the affected areas. If the condition lasts more than a few days, the diagnosis of candidiasis must be considered. Rubber or plastic pants inhibit moisture evaporation and should be avoided.
Rudolph CD, Rudolph AM, Hostetter MK, et al. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill; 2003:1176.
113. The anterior fontanel usually closes at
A) 3 months
B) 6 months
C) 12 months
D) 2 years
E) 5 years
View Answer
Answer and Discussion
The answer is C. The diagnosis of an abnormal fontanel requires the physician to appreciate the wide variation of normal. At birth, an infant has six fontanels. The anterior fontanel is the largest and most important for clinical evaluation. The average size of the anterior fontanel is 2.1 cm, and the median time of closure is around 1 year of age. The most common causes of a large anterior fontanel or delayed fontanel closure are achondroplasia, hypothyroidism, Down syndrome, increased intracranial pressure, and rickets. A bulging anterior fontanel can be a result of increased intracranial pressure or intracranial and extracranial tumors, and a sunken fontanel usually is a sign of dehydration. A physical examination helps the physician determine which imaging modality, such as plain films, ultrasonography, computed tomographic scan, or magnetic resonance imaging, to use for diagnosis.
Kiesler J, Ricer R. The abnormal fontanel. Am Fam Physician. 2003;67:2547–2552.
114. An adequate level of fluoride supplementation in drinking water is equal to
A) 1,000 parts/million (ppm)
B) 500 ppm
C) 100 ppm
D) 10 ppm
E) 1 ppm
View Answer
Answer and Discussion
The answer is E. Fluoride helps reduce the formation of dental caries. It is most effectively administered in drinking water. The need for supplementation depends on the amount of fluoride in the drinking water. Adequate levels are usually 1 ppm. Water with levels <0.6 ppm may require supplementation. Fluoride toothpaste is not a suitable alternative supplement. Supplementation should be initiated for infants given ready-to-feed formulas that do not contain fluoride and for infants who are breast-fed after 6 months of age. Excessive fluoride supplementation can cause fluorosis. The following recommendations are given by the American Academy of Pediatrics:
Supplemental Fluoride Dosage Schedule
|
Fluoride in Home Water (ppm) |
|||
|
Age |
<0.3 |
0.3–0.6 |
>0.6 |
|
Birth–6 mo |
0a |
0 |
0 |
|
6 mo–3 yr |
0.25 |
0 |
0 |
|
3–6 yr |
0.50 |
0.25 |
0 |
|
6–16 yr |
1.0 |
0.50 |
0 |
|
aMilligrams of fluoride per day. |
|||
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1212.
115. A 5-year-old boy is brought to the emergency room with inspiratory and expiratory stridor, high fever, and drooling. Initial treatment consists of
A) oxygen therapy
B) airway management by trained personnel
C) inhaled bronchodilators
D) lying the child in the supine position
E) administration of epinephrine
View Answer
Answer and Discussion
The answer is B. Epiglottitis is a severe, life-threatening condition usually seen in children between 3 and 10 years of age. The condition was usually the result of a Haemophilus type B(Hib) infection. In recent years, the occurrence of epiglottitis has been reduced dramatically by the widespread use of the Hib vaccine. Other causes include bacterial infections by Streptococcus and Staphylococcus species. Manifestations include stridor with inspiration and expiration, high fever, dysphagia, drooling, and toxic appearance. Children may lean forward with their neck outstretched to minimize airway obstruction. Laboratory findings include an elevated white blood cell count and positive blood cultures. Arterial blood gases may show hypoxia. Lateral neck radiographs show a swollen epiglottis with obstruction of the airway (positive thumb sign). Treatment involves securing the child's airway, but this should be accomplished only by trained personnel. Before intubation, the child should not be moved nor placed in a supine position. Oxygen should also be avoided because of the risk of aggravating the child and possible complete obstruction of the airway. Intravenous antibiotics should be started immediately, and the child should be monitored in an intensive care setting.
Rudolph CD, Rudolph AM, Hostetter MK, et al. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill; 2003:1276.
116. The most appropriate treatment for school avoidance is
A) to return the child to school and then determine reasons for school avoidance
B) to allow the child to remain at home until reasons for avoidance are determined
C) to prescribe methylphenidate (Ritalin)
P.153
D) to begin inpatient psychotherapy
E) to change teachers or schools
View Answer
Answer and Discussion
The answer is A. School avoidance/refusal is a problem encountered in many family physicians' offices. Children may manifest numerous complaints to their parents and teachers to avoid attending school. The beginning of the school year appears to increase significantly the incidence of headache. The first step in the treatment of a child refusing to go to school is to get him or her back into the classroom and, once that is accomplished, identify reasons why the child is avoiding school. Some common problems include difficulty with peer relationships; family discord at home; and poor school performance that may be caused by attention deficit disorder, dyslexia, and visual or hearing difficulties. Working closely with the child's family and teachers can be beneficial.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1212.
117. The normal heart rate for newborns is
A) 60 to100 beats/minute
B) 100 to 120 beats/minute
C) 120 to 160 beats/minute
D) 140 to 160 beats/minute
View Answer
Answer and Discussion
The answer is C. The normal heart rate in newborns is 120 to 160 beats/minute.
Fuloria M, Kreiter S. The newborn examination: Part I. Emergencies and common abnormalities involving the skin, head, neck, chest, and respiratory and cardiovascular systems. Am Fam Physician. 2002;65:61–68.
118. Which of the following is a description of Prader-Willi syndrome?
A) Tall, large arm span, increased risk of aortic rupture
B) Obese, hypotonic, mental retardation, hypogonadism
C) Short, obese, frontal bossing, precocious puberty
D) Normal size, mental retardation, precocious puberty
View Answer
Answer and Discussion
The answer is C. Prader-Willi syndrome is characterized by decreased fetal activity, obesity, hypotonia, mental retardation, and hypogonadotropic hypogonadism. The syndrome is caused by a defect on the proximal long arm of the paternal chromosome 15 or by a defect on the maternal chromosome 15. Associated features include failure to thrive due to hypotonia and feeding difficulties, which generally improve after 6 to 12 months of age. From about 12 to 18 months and beyond, uncontrollable appetite causes worsening weight gain as well as psychologic problems, as insatiable hunger with significant obesity becomes the most noticeable feature. Rapid weight gain continues but with ultimate short stature in adulthood. Behavioral features include emotional lability, poor gross motor skills, cognitive impairment, and insatiable hunger. Facial abnormalities include a narrow bitemporal dimension, almond-shaped eyes, and a mouth with thin upper lips and down-turned corners. Hypogonadotropic hypogonadism, cryptorchidism, and a hypoplastic penis and scrotum in males or hypoplastic labia in females are present. Skeletal abnormalities include scoliosis, kyphosis, and osteopenia. Limb abnormalities include small hands and feet.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2369.
119. A 6 month old is brought to your office in mid-January. The child's mother reports that the infant has had a low-grade fever, wheezing with coughing, and diminished appetite. The most likely diagnosis is
A) bronchiolitis secondary to RSV
B) pneumonia secondary to S. pneumoniae
C) aspiration pneumonia
D) asthma
E) bronchitis secondary to H. influenzae
View Answer
Answer and Discussion
The answer is A. Bronchiolitis is a common disease of the lower respiratory tract of infants and results from inflammatory obstruction of the small airways. The condition affects young children (younger than 2 years), and the peak incidence is in infants 6 months of age. Bronchiolitis is caused in most cases (>50%) by respiratory syncytial virus (RSV). Other causes include parainfluenza virus and adenoviruses and Mycoplasma. It most commonly occurs in the winter months. Signs and symptoms include coughing, wheezing, fever, nasal flaring, tachypnea, delayed expiration, and chest wall retractions. The white blood cell count and differential are usually normal. Nasal swabs can be used for RSV cultures, and rapid antigen assays may be performed to aid in diagnosis. Chest radiographs are usually normal; however, hyperinflation and increased interstitial markings in the perihilar area may be noted. Treatment is accomplished with bronchodilators, humidified oxygen via a croup tent, and intravenous fluids. In severe cases, ribavirin aerosol, an antiviral agent, can be administered. Bronchiolitis is more likely to develop in infants who are exposed to cigarette smoke. RSV immune globulin given just before and during RSV season is effective in preventing severe RSV disease in at-risk infants with chronic lung disease.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1076–1079.
120. Most children affected with rotavirus are
A) younger than 6 months
B) between 6 months and 2 years of age
C) older than 2 years
D) between 2 and 4 years of age
E) between 5 and 7 years of age
View Answer
Answer and Discussion
The answer is B. Rotavirus is a viral intestinal infection commonly seen in children, predominantly during the winter months. Epidemics are common in daycare centers. Most of the children affected are between 6 months and 2 years of age, but any child can be affected. Symptoms include profuse, watery diarrhea with the absence of blood, mild fevers, mild abdominal cramping, and vomiting (which may precede the onset of diarrhea). Some children may have associated respiratory complaints. The diagnosis is usually made by the clinical presentation but can be confirmed with viral antigen detection kits. Stool tests for white blood cells are negative, supporting the diagnosis of a viral infection.
Treatment involves oral rehydration for mild cases and intravenous fluid replacement for moderate to severe dehydration. Lactose-containing foods should be avoided if they appear to exacerbate the symptoms. Breast-feeding should be continued during rehydration. The bananas, rice, cereal, applesauce, and toast diet has not been shown to be superior to a regular diet. Most cases resolve in 5 to 7 days. The rotavirus vaccine approved in 1998 was suspended from use in July of 1999 because of an association of intussusception.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1081–1083.
Stool tests for white blood cells are negative with rotavirus, supporting the diagnosis of a viral infection.
121. Which of the following congenital heart defects is considered a cyanotic lesion?
A) Ventricular septal defect
B) Atrial septal defect
C) Patent ductus arteriosis
D) Coarctation of the aorta
E) Tetralogy of Fallot
View Answer
Answer and Discussion
The answer is E. Congenital heart defects are classified into two broad categories: acyanotic and cyanotic lesions. The most common acyanotic lesions are ventricular septal defect, atrial septal defect, atrioventricular canal, pulmonary stenosis, patent ductus arteriosus, aortic stenosis, and coarctation of the aorta. Congestive heart failure is the primary risk in infants with acyanotic lesions.
· Ventricular septal defect: Ventricular septal defect is the most common CHD. It may occur in any location on the septal wall. The significance of a ventricular septal defect is related to the size of the defect and ranges from insignificant to severe. Spontaneous closure within the first 6 months of life occurs in 30% to 40% of defects and is more likely to occur in smaller defects than in larger defects. Congestive heart failure, which may begin to develop at 6 to 8 weeks of age, is managed with diuretics and digoxin (Lanoxin). Indications for surgical closure include impaired growth that is not responsive to medical management and development of pulmonary hypertension. Postoperative complications include conduction defects, such as transient right bundle branch block.
· Atrial septal defect: Atrial septal defects may occur as sinus venosus, secundum or primum type. The overall rate of spontaneous closure of the secundum type of atrial septal defect is approximately 85% in the first 4 years of life. Primum and sinus venosus types with defects >8 mm rarely close spontaneously, and surgical intervention is usually necessary. Most children with an atrial septal defect remain asymptomatic, but in those who develop congestive heart failure, medical management with diuretics and digoxin can be beneficial. Indications for surgical closure are persistence of the defect beyond 4 years of age, refractory congestive heart failure, and the presence of other associated defects, such as ventricular septal defect or valvular anomalies. Cardiac dysrhythmias and mitral valve prolapse may be late sequelae of treated or untreated atrial septal defect in children or adults. Pulmonary hypertension may develop in adults with an untreated atrial septal defect. Atrial flutter or fibrillation may also occur in adults with a history of atrial septal defect, regardless of the treatment.
· Atrioventricular canal: Atrioventricular canal is characterized by a combination of a primum type of atrial septal defect, a common atrioventricular valve, and an inlet type of ventricular septal defect. Most of the hemodynamic problems associated with this abnormality are caused by the ventricular septal defect, although mitral regurgitation or left-ventricle-to-right-atrium regurgitation, or both, may lead to pulmonary overload. The treatment of congestive heart failure in association with atrioventricular canal, the indications for surgical repair, and the postoperative complications are similar to those described for ventricular septal defect. Surgery should be performed before the onset of pulmonary vascular occlusive disease. Palliative pulmonary artery banding may be performed in infants who have refractory congestive heart failure and are too small for definitive repair.
· Pulmonary stenosis: Pulmonary stenosis may be valvular, subvalvular or supravalvular. The clinical manifestations of pulmonary stenosis may vary from an asymptomatic lesion to frank congestive heart failure. Newborns may respond to prostaglandin E1 infusion. Balloon valvuloplasty, performed during cardiac catheterization, is the preferred method of treatment for the valvular type of pulmonary stenosis. If this treatment is not successful, surgery is necessary.
· Patent ductus arteriosus: Patent ductus arteriosus is a common problem in premature infants. Closure may be spontaneous; if medical closure is required, indomethacin is effective. In term infants, spontaneous closure is unlikely, and indomethacin is not effective. Congestive heart failure and recurrent pneumonia are likely complications if the flow through the ductus is substantial. Surgical ligation remains the preferred method of closure and should be performed as soon as possible. Cardiopulmonary bypass is not necessary. Nonsurgical techniques for correction of patent ductus arteriosus, such as catheter placement of an embolic device in term infants and indomethacin therapy in premature infants, are gaining in popularity. Patent ductus arteriosus is the only CHD that may be considered surgically “cured,â€� with no long-term sequelae.
· Aortic stenosis: Aortic stenosis may be valvular, subvalvular or supravalvular. It may be asymptomatic or may cause symptoms of congestive heart failure. The pressure gradient across the stenosis increases with the child's growth, as the cardiac output increases. Surgical correction is the preferred treatment. Timing of the surgery is dependent on the child's cardiopulmonary status, the type of procedure planned (valvulotomy versus valve replacement), and the size of the valve if a graft is needed. Lifelong anticoagulation therapy is required if a prosthetic valve replacement is performed.
· Coarctation of the Aorta: Narrowing of the aorta may occur anywhere along its length, but the vast majority of cases occur just below the origin of the left subclavian artery. The classic clinical sign of coarctation of the aorta is a higher blood pressure in the arms than in the legs and pulses that are bounding in the arms but decreased in the legs. Surgical repair is usually performed between the ages of 2 and 4 years. Urgent surgical repair is performed in cases of circulatory shock, cardiomegaly, severe hypertension, or severe congestive heart failure.
The most common cyanotic lesions are tetralogy of Fallot and transposition of the great arteries. In infants with cyanotic lesions, hypoxia is more of a problem than congestive heart failure.
· Tetralogy of Fallot: Tetralogy of Fallot is the most common CHD seen after infancy, with surgical repair usually undertaken when the child reaches 3 years of age. It consists of a large ventricular septal defect, right outflow tract obstruction, right ventricular hypertrophy, and overriding of the aorta. The classic clinical presentation is characterized by hyperpnea, irritability, cyanosis, and decreased murmur intensity. Squatting decreases systemic venous return by trapping blood in the legs, breaking the overload-hypoxia cycle. If this maneuver is ineffective, pharmacologic treatment may be necessary. Medical management of tetralogy of Fallot includes education on ways to treat the symptoms, prevention of anemia, and prophylaxis for subacute bacterial endocarditis. Surgical palliation consists of placement of a shunt from the subclavian artery to the ipsilateral pulmonary artery. Several different types of shunt procedures are currently performed. Total repair includes placement of a ventricular septal defect patch and right ventricular outflow tract widening. Total repair is performed before the child is 4 years of age.
· Transposition of the Great Arteries: Complete transposition of the great arteries occurs in a small percentage of children with CHD. The aorta and pulmonary arteries are transposed, so that the two circulations are separate and parallel rather than in sequence. Infants with transposition of the great arteries are cyanotic at birth and often have congestive heart failure. Associated defects such as an atrial septal defect or patent ductus arteriosus, which permit the mixing of blood from the two sides of the vascular tree, are necessary for the infant's survival. Transposition of the great vessels requires that the ductus should be kept open by prostaglandin infusion until surgery can be performed. Metabolic abnormalities and severe hypoxia should be corrected before surgical repair is undertaken. The definitive surgical procedure of choice is the arterial switch operation, in which the aorta and the pulmonary artery are divided and reattached to their proper positions, resulting in a physiologic repair. It should be performed as soon as possible. Associated defects, such as ventricular septal defect, pulmonary stenosis, and patent ductus arteriosus, may necessitate a staged repair. Late complications of surgical repair include pulmonary or aortic stenosis, coronary artery obstruction, ventricular dysfunction, arrhythmias, and mitral regurgitation.
Suspicion of a congenital heart defect should be raised by the presence of feeding difficulties in association with tachypnea, sweating and subcostal recession, or severe growth impairment. More frequent follow-up is required if congestive heart failure is present.
Saenz RB, Beebe DK, Triplett LC. Caring for infants with congenital heart disease and their families. Am Fam Physician. 1999;59:1857.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2404–2421.
122. Which of the following is true regarding hepatitis B vaccination in healthy infants?
A) The first immunization should be given by 2 months of age, second immunization 1 to 2 months later, and third immunization given between 6 and 18 months.
B) Injections should be given in the buttock to increase immunogenicity.
C) Only infants at risk should receive hepatitis B vaccination.
D) Two doses will provide optimal results.
E) None of the above
View Answer
Answer and Discussion
The answer is A. Hepatitis B immunizations currently available in the United States are recombinant vaccines (Recombivax, Engerix-B). Three intramuscular doses are required to induce optimal protective antibody responses. The vaccine should be administered in the anterolateral thigh muscle in infants and in the deltoid muscle in children, adolescents, and adults; injection in the buttocks or via the intradermal route may lead to diminished immunogenicity with lower seroconversion rates and serologic titers. Universal vaccination of infants is recommended. A three-dose schedule is required and should be initiated during the newborn period or by 2 months of age, a second dose given 1 to 2 months later, and a third dose given by 6 to 18 months of age. Most school districts now require hepatitis B immunization before admission to kindergarten or first grade. Susceptibility testing before vaccination is not routinely indicated, and postvaccination testing for immunity is not necessary after routine immunization.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1328.
123. A child is found to have higher blood pressures in the arms than in the legs and pulses are bounding in the arms but decreased in the legs. The most likely condition is
A) ventricular septal defect
B) tetralogy of Fallot
C) transposition of the great arteries
D) coarctation of the aorta
E) aortic stenosis
View Answer
Answer and Discussion
The answer is D. Coarctation of the aorta involves narrowing of the aorta that may occur anywhere along its length, but the vast majority of cases occur just below the origin of the left subclavian artery. The classic clinical sign of coarctation of the aorta is a higher blood pressure in the arms than in the legs and pulses that are bounding in the arms but decreased in the legs. Surgical repair is usually performed between the ages of 2 and 4 years. Emergent surgical repair is performed in cases of circulatory shock, cardiomegaly, severe hypertension, or severe congestive heart failure.
Saenz RB, Beebe DK, Triplett LC. Caring for infants with congenital heart disease and their families. Am Fam Physician. 1999;59:1857.
124. A 4-year-old girl is brought to the emergency room. The mother reports that the child recently recovered from a viral upper respiratory tract infection, but over the past few days has developed nosebleeds and bleeding from the gums. She also has noticed bruising of the extremities. The most likely diagnosis is
A) meningococcemia
B) idiopathic thrombocytopenic purpura (ITP)
C) hemophilia A
D) ingestion of warfarin
E) vitamin K deficiency
P.156
View Answer
Answer and Discussion
The answer is B. Ideopathic thrombocytopenic purpura (ITP) is a disorder that usually affects children between 2 and 6 years of age. Boys and girls are equally affected. The condition usually follows a febrile, viral illness (particularly varicella, Epstein-Barr, and cytomegalovirus) during the winter months. Petechiae, purpura, and bleeding from mucous membranes develop within 3 weeks after the infection. Laboratory results often show thrombocytopenia (platelet counts <20,000 mm3), and bone marrow studies show an increase in megakaryocytes. Prothrombin time and partial thromboplastin time are normal, but bleeding times are increased. No treatment is necessary in mild cases. In more severe cases with platelet counts below 20,000 mm3 or with active bleeding, corticosteroids, γ globulin, or other immunosuppressant agents that transiently elevate the platelet count can be used, but they do not alter the course of the illness. In severe cases, splenectomy or plasmapheresis may be necessary to achieve remission. Intracranial hemorrhage is the primary cause of death in severe cases. Most cases are mild and patients recover completely without complications.
There is a chronic form of ITP that usually affects patients between 20 and 50 years of age; women tend to be affected more than men. Treatment for this form is similar to acute ITP, and psychosocial issues involving the chronic state are similar to those of hemophilia.
Rudolph CD, Rudolph AM, Hostetter MK, et al. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill; 2003:1556–1557.
125. Which of the following congenital heart defects can be surgically cured with no permanent sequelae?
A) Coarctation of the aorta
B) Tetralogy of Fallot
C) Patent ductus arteriosis
D) Ventricular septal defect
E) Transposition of the great vessels
View Answer
Answer and Discussion
The answer is C. Patent ductus arteriosus is the only congenital heart defect that may be considered surgically “cured,� with no long-term sequelae.
Saenz RB, Beebe DK, Triplett LC. Caring for infants with congenital heart disease and their families. Am Fam Physician. 1999;59:1857.
126. A 2 year old is seen in your office. The parent reports that the child shows toeing in when walking. On examination, the child exhibits femoral anteversion. The most appropriate treatment is
A) reassurance to the parent that the condition usually corrects itself as the child grows older
B) referral to an orthopedist
C) referral to a physical therapist
D) bracing to correct internal rotation of the femurs
E) fitting for corrective shoes
View Answer
Answer and Discussion
The answer is A. Femoral anteversion is a common orthopedic finding in young children. The condition results when femoral anteversion leads to excessive internal rotation of the femur. As a result, the child may exhibit “kissing knees,� toeing-in, and the appearance of lack of coordination of the lower extremities. Maximal femoral anteversion occurs between 1 and 3 years of age. This abnormality usually corrects itself as the child becomes older. Significant abnormalities found after 8 years of age should be referred to an orthopedist. Activities that may help correct the condition include ballet, bicycling, and skating because of the rotation exercises involved. In most cases, bracing is not beneficial. Severe cases may require osteotomy for rotational correction.
Rudolph CD, Rudolph AM, Hostetter MK, et al. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill; 2003:2422–2424.
127. A 2 year old is brought into your office. The parent reports a purulent, malodorous, bloody discharge from the child's left nostril. The most likely diagnosis is
A) foreign body in the nose
B) acute sinusitis
C) Wegener's granulomatosis
D) cerebrospinal fluid leak
E) chronic tonsillitis
View Answer
Answer and Discussion
The answer is A. Young children often lodge foreign bodies in their noses. Symptoms include unilateral purulent, malodorous, and often bloody nasal discharge. Other symptoms include nasal congestion and abnormal nasal sounds. Some children with clear nasal discharge or mild sinus congestion may harbor a foreign body. Foreign bodies should be removed anteriorly. An attempt at lavage should not be made because of the risk of pushing the foreign body further into the nasal cavity. Radiographs of the nasal area and sinuses may help localize the foreign body. There are several methods to remove nasal foreign bodies, including the use of an alligator forceps, ear curettes, and a Fogarty catheter (which is slipped behind the foreign body, inflated, and removed pulling the foreign body along with it); if the foreign body does not appear to have sharp edges, the practitioner can simply have the child blow the nose, forcing the foreign body out. If removal is unsuccessful, ear, nose, and throat referral and perhaps general anesthesia is in order. Inspection of the unaffected side and the ears should also be performed to ensure they are unaffected.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:829.
128. Varicella-zoster immunoglobulin (VZIG) is recommended for which of the following groups?
A) All newborns
B) Newborns of mothers with onset of varicella 5 days before delivery
C) Hospitalized premature infants older than 28 weeks' gestation, regardless of the mother's history of chickenpox
D) Pregnant women just before delivery who have no history of varicella and were exposed at the time of conception
E) Newborns >4,500 g regardless of exposure history or mother's exposure history
View Answer
Answer and Discussion
The answer is A. VZIG is indicated for the prevention of varicella and zoster infections in the following groups:
· Full-term infant born to mother who has chickenpox <1 week before delivery
· Every premature infant born to a mother with active chickenpox (even if present longer than 1 week)
· Newborns whose mothers had onset of varicella 5 days before delivery or within 2 days after delivery who are exposed to varicella
· Hospitalized premature infants (gestation of 28 weeks or more) whose mothers have no history of chickenpox
· Hospitalized premature infants (gestation of <28 weeks or ≤1,000 g) regardless of maternal history
VZIG is given by intramuscular injection. One vial (125 U) is given for each 10 kg of body weight, with a maximum dose of 625 U (five vials). For maximal effectiveness, VZIG should be given within 48 hours and preferably not more than 96 hours after exposure. Side effects are usually related to local discomfort at the injection site.
Current recommendations include routine vaccination of all infants with a single dose of live varicella virus vaccine (Varivax) at 12 to 18 months of age. Those older than 13 years with negative varicella titers require two doses given 4 to 8 weeks apart. The live virus is contraindicated in immunocompromised children. Varicella may occur in up to 6% of patients despite immunization; however, the illness is usually mild.
Gunn, VL, Nechyba C. The Harriet Lane Handbook: A Manual for Pediatric House Officers. St. Louis: Mosby; 2002:339–340.
129. The most common cause of lead exposure is
A) playing with toys made with lead
B) exposure to water from lead pipes
C) breathing lead particles from the atmosphere
D) ingesting food contaminated with lead
E) ingesting contaminated paint chips or house dust
View Answer
Answer and Discussion
The answer is E. More than 4% of children in the United States have lead poisoning. Rates of lead poisoning are even higher in large cities and among people with low incomes. The most common cause of lead poisoning today is old paint with increased lead content. Lead has not been used in house paint since 1978. However, many older houses and apartment buildings (especially those built before 1960) have lead-based paint on their walls. Children can get lead poisoning by chewing on pieces of peeling paint or by swallowing house dust or soil that contains tiny chips of the leaded paint from these buildings (pica). Lead can also be in air, water, and food. Lead levels in the air have gone down greatly since lead was taken out of gasoline in the 1970s. Lead is still found in some old water pipes, although using lead solder to mend or put together water pipes is no longer allowed in the United States. Lead can also be found in food or juice stored in foreign-made cans or improperly fired ceramic containers.
Ellis MR, Kane KY. Lightening the lead load in children. Am Fam Physician. 2000;62:545–554, 559–560.
130. Which of the following statements about night terrors is true?
A) They affect adults more than children.
B) They are often remembered in vivid detail.
C) They occur during stage 3 or 4 of non–rapid eye movement (NREM) sleep.
D) They occur during REM sleep.
E) They are unaffected by benzodiazepines.
View Answer
Answer and Discussion
The answer is C. Night terrors occur more frequently in children than in adults. Boys between 5 and 7 years are more commonly affected. Symptoms include sudden onset, fearful, screaming episodes that disrupt stages 3 and 4 NREM sleep cycle. They may accompany sleepwalking. They differ from nightmares in that nightmares occur during REM sleep and are frequently remembered in vivid detail, whereas night terrors are not remembered. A short course of diazepam (which suppresses stages 3 and 4 of sleep) or imipramine (Tofranil) is often helpful in patients with severe night terrors but is not helpful for patients who suffer from nightmares. An underlying emotional disorder should be investigated in children with persistent or prolonged night terrors.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:18, 2010.
Symptoms of night terrors include sudden onset, fearful, screaming episodes that disrupt stages 3 and 4 NREM sleep cycle. Night terrors are not remembered.
131. Which of the following statements is true regarding short stature in children?
A) Those with short stature and delayed bone age are considered to have constitutional short stature.
B) Those with genetic short stature rarely reach the height of their parents.
C) Those with constitutional short stature should undergo a comprehensive evaluation looking for secondary causes.
D) Chromosome studies should be performed on children suspected of genetic short stature.
E) Children with constitutional growth delay rarely reach normal adult height.
View Answer
Answer and Discussion
The answer is A. Assessment of a child's growth rate is necessary when evaluating short stature. Most children in or below the fifth percentile for height have normal growth rates. In the absence of other clinical findings, no further assessment is needed; however, the child should be followed to ensure that the growth rate remains normal. Among children with short stature but normal growth rates, two specific groups can be identified based on bone age: those with (1) genetic short stature and (2) those with constitutional short stature. Children with short stature who have normal growth rates and normal bone age are considered to have genetic short stature. Their eventual adult stature will likely be similar to that of their parents. On the other hand, children with short stature and delayed bone age are considered to have constitutional short stature. Following a period of decreased growth rate in infancy, the growth rate in these children will return to normal for the remainder of their childhood. While these children may be considered short at some points during their childhood, they can be expected to eventually acquire normal adult height. In both groups, no further medical assessment or treatment is necessary. Children with short stature and decreased growth rates warrant a comprehensive evaluation for an underlying pathologic condition. The assessment should include a complete blood count, a urinalysis, a chemistry profile, and thyroid studies. Children should undergo a sweat chloride test if they have a history of recurrent pulmonary or gastrointestinal symptoms. Chromosome studies should be obtained if there are physical signs of Turner's syndrome. Growth hormone studies should not consist of a single random determination. Growth hormone stimulation methods are necessary. Consultation is warranted if the initial evaluation fails to reveal an etiology for the decreased stature.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:61.
132. Measles (rubeola) is associated with which of the following conditions?
A) Small erythematous ulcerations on the tongue
B) Joint pain, rash, infertility
C) Unexplained brain deterioration with seizure formation, behavioral and intellectual deterioration, motor abnormalities, and possible death years after a measles attack
D) Petechial rash that develops on the trunk and spreads to involve the face and extremities
E) Disseminated intravascular coagulopathy
View Answer
Answer and Discussion
The answer is C. Measles is a highly contagious disease that was common in children before the advent of immunization. Symptoms include the three Cs (cough, coryza, conjunctivitis), high fever, maculopapular rash, and pathognomonic Koplik's spots (small white spots that resemble flecks of sand surrounded by areas of erythema) on the buccal mucosa, usually opposite the first and second upper molar. The cause is a paramyxovirus that is spread by respiratory secretions. The disease is communicable 2 to 4 days before the onset of the characteristic rash, which usually develops on the face and spreads to involve the entire body approximately 2 weeks from the time of exposure. In 3 to 5 days, the patient usually improves and the fever and rash subside. Measles is usually self-limited and has a low mortality rate unless significant complications develop. Complications include pneumonia, bacterial superinfection, acute thrombocytopenic purpura, encephalitis, and subacute sclerosing panencephalitis (unexplained brain deterioration with seizure formation, motor abnormalities, and possible death years after the measles attack). Treatment for measles is directed toward the relief of symptoms and appropriate medication for any secondary infections. The use of immunoglobulin may also be indicated. Children should be immunized with the live attenuated MMR vaccination at 12 to 15 months and again at age 4 to 6 years. Measles vaccine is not recommended for pregnant women, immunocompromised patients, or HIV patients.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1026–1031.
133. Diagnosis of mental retardation is
A) easily identified by clinicians
B) typically made by chromosomal analysis
C) dependent on a complete history, physical examination, and developmental assessment of the child
D) easily associated with an underlying etiology
View Answer
Answer and Discussion
The answer is C. Mental retardation in young children is often missed by clinicians. The condition is present in 2% to 3% of the population, either as an isolated finding or as part of a syndrome or broader disorder. Causes of mental retardation are numerous and include genetic and environmental factors. In at least 30% to 50% of cases, physicians are unable to determine etiology despite thorough evaluation. Diagnosis is highly dependent on a comprehensive personal and family medical history, a complete physical examination and a careful developmental assessment of the child. These will guide appropriate evaluations and referrals to provide genetic counseling, resources for the family and early intervention programs for the child. The family physician is encouraged to continue regular follow-up visits with the child to facilitate a smooth transition to adolescence and young adulthood.
Daily DK, Ardinger HH, Holmes GE. Identification and evaluation of mental retardation. Am Fam Physician. 2000;61:1059–1067, 1070.
134. Which of the following conditions is associated with congenital cataracts?
A) Maternal rubella infection
B) Maternal varicella infection
C) Congenital hypothyroidism
D) Acromegaly
E) Fetal hydrops
View Answer
Answer and Discussion
The answer is A. A cataract is a proteinaceous opacity of the lens. Causes of congenital cataracts include ocular trauma, maternal rubella, diabetes mellitus, galactosemia, Marfan's syndrome, and Down syndrome. Monocular cataracts should be corrected as soon as possible (within the first 3 months of birth) so that vision can develop properly. Delayed intervention can lead to development of abnormal vision. Treatment of the amblyopia may be the most demanding and difficult step in the visual rehabilitation of infants and children with cataracts.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2105–2106.
135. A child with Down syndrome is born, and you explain to the family
A) heart defects are very rare in Down syndrome children
B) some females are fertile; however, there is a 50% chance their children will have Down syndrome
C) fertility is not affected in males
D) IQ scores are rarely affected in Down syndrome children
E) the most common site for heart defects is associated with the atrial septum
View Answer
Answer and Discussion
The answer is B. Newborns affected with Down syndrome are often placid, rarely cry, and demonstrate muscular hypotonia. Excess skin around the neck is common and can be detected by fetal ultrasound as edema of the neck. Physical and mental development are impaired; the mean intelligence quotient (IQ) is about 50. Microcephaly, a flattened occiput, and short stature are characteristic. The outer sides of the eyes are slanted upward, and epicanthal folds at the inner corner of the eye usually are present. Brushfield's spots (gray to white spots resembling grains of salt around the periphery of the iris) usually are visible and disappear during the first 12 months of life. The bridge of the nose is flattened, the mouth is often kept open because of a large protruding tongue that is furrowed and lacks the central fissure, and the ears are small and rounded. Hands are short and broad and often have a single palmar crease (simian crease); the fingers are short, with clinodactyly (incurving) of the fifth finger, which often has only two phalanges. The feet may have a wide gap between the first and second toes, and a plantar furrow often extends backward on the foot. Hands and feet show characteristic dermal prints (dermatoglyphics). Congenital heart disease, most commonly affecting the ventricular septum or the atrioventricular canal, occurs in about 40% of affected newborns. There is an increased incidence of almost all other congenital anomalies, particularly duodenal atresia. Many people with Down syndrome develop thyroid problems, which may be difficult to detect unless blood tests are done. Additionally, they are prone to developing hearing problems and problems with vision. Regular screening may be appropriate. At autopsy, all adult Down syndrome brains show the microscopic findings of Alzheimer's disease, and many persons also develop the associated clinical signs. Some affected women are fertile, and they have a 50% chance that their fetus will also have Down syndrome; however, many of these affected fetuses abort spontaneously. All men with Down syndrome are infertile.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2449–2450.
136. Which of the following findings is most commonly associated with fetal alcohol syndrome?
A) low birth weight
B) seizures
C) palmar erythema
D) peripheral neuropathy
E) cirrhosis
View Answer
Answer and Discussion
The answer is A. Fetal alcohol syndrome is a constellation of symptoms in a newborn and is a result of maternal alcohol consumption. Physical findings include low birth weight, short palpebral fissures, midface hypoplasia, abnormal palmar creases, and cardiac abnormalities. Varying degrees of mental retardation may be present. Severe symptoms are usually the result of heavy ethanol consumption (i.e., 5 or more drinks daily); however, milder effects may be associated with consumption of smaller amounts. Because a safe level of alcohol consumption during pregnancy has not been established, pregnant women should be counseled to avoid all alcohol use during pregnancy.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:612.
137. Klinefelter's syndrome is associated with
A) short stature and hirsutism
B) tall stature with disproportionately long arms and legs
C) increased development of homosexual behavior
D) low urinary excretion of FSH
E) universal cognitive defects
View Answer
Answer and Discussion
The answer is B. Klinefelter's syndrome occurs in about 1/800 live male births. The extra X chromosome comes from the mother in 60% of cases. Affected persons tend to be tall, with disproportionately long arms and legs. They often have small, firm testes, and about one third develop gynecomastia. Puberty usually occurs at the normal age, but facial hair growth is often light. There is a predisposition for learning difficulties, and many have significant deficits. However, clinical variation is varied, and many 47, XXY males are normal in appearance and intellect and are found in the course of an infertility workup (probably all 47, XXY males are sterile) or in chromosomal surveys of normal populations. Boys from the latter group have been followed developmentally. There is no increased incidence of homosexuality. Testicular development varies from nonfunctional tubules to some production of spermatozoa, and urinary excretion of follicle-stimulating hormone is frequently increased. Some affected have 3, 4, and even 5 X chromosomes along with the Y. The more X chromosomes, the greater the severity of mental retardation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2454.
138. A 5-year-old child has a chronic relapsing and pruritic superficial inflammation of the skin that affects the antecubital and popliteal fossas. The most likely diagnosis is
A) Rhus dermatitis
B) atopic dermatitis
C) hereditary angioedema
D) Cushing's disease
E) Lyme disease
View Answer
Answer and Discussion
The answer is B. Atopic dermatitis is a condition characterized by chronic relapsing, superficial inflammation of the skin. The skin disorder is associated with severe pruritus and eczematous changes with erythematous papules or plaques that may show excoriations or lichenification. Many patients may show three different stages. The first stage is an infantile stage that begins at 2 to 3 months of age and lasts until 18 months of age. The eczematous rash affects the cheeks and scalp, may form oval-shaped patches on the trunk, and may eventually affect the extensor surfaces. The inflammation resolves in most cases. However, in 33% of patients, the rash progresses into stage 2, which is usually referred to as childhood eczema. The rash during this stage usually affects the flexor surfaces of the antecubital and popliteal fossas. Other areas of involvement include the neck, wrists, and, occasionally, the hands and feet. The third stage is adolescent eczema, which usually occurs around the age of 12 years. Only 33% of children with childhood eczema progress to adolescent eczema, which usually only involves the hands. Atopic dermatitis is less common after 30 years of age. The condition appears to be associated with asthma, hay fever, elevated IgE levels, and urticaria. There also appears to be a genetic predisposition to develop atopic dermatitis. Triggering factors include certain foods (e.g., cheese, wheat, nuts, legumes, egg whites) and inhaled irritants (e.g., pollens, perfumes, toxic fumes). Treatment involves the use of antihistamines, corticosteroid creams, emollients (Eucerin or Aquaphor), wet-to-dry dressing changes with Burow's solution, and antibiotics for secondary bacterial infections. Bathing should be kept to a minimum. A short course of oral steroids may be helpful for severe cases. The avoidance of triggering factors is also important. Extremes of temperature and humidity should be avoided.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:774–778.
139. A child is born with excessive dorsal lymphedema of the hands and feet and with lymphedema or loose folds of skin over the posterior aspect of the neck. There is a low hairline on the back of the neck, ptosis, a broad chest with widely spaced nipples, multiple pigmented nevi, short 4th metacarpals and metatarsals, prominent finger pads, hypoplasia of the nails, and coarctation of the aorta. Based on the findings the most likely diagnosis is:
A) Klinefelter syndrome
B) Turner syndrome
C) Down syndrome
D) Marfan's syndrome
E) Prader-Willie syndrome
View Answer
Answer and Discussion
The answer is B. Affected newborns with Turner syndrome may present with excessive dorsal lymphedema of the hands and feet and with lymphedema or loose folds of skin over the posterior aspect of the neck. However, many females with Turner syndrome are very mildly affected. Typically, short stature, webbing of the neck, low hairline on the back of the neck, ptosis, a broad chest with widely spaced nipples, multiple pigmented nevi, short fourth metacarpals and metatarsals, prominent finger pads, hypoplasia of the nails, coarctation of the aorta, bicuspid aortic valve, and increased carrying angle at the elbow occur. Renal anomalies and hemangiomas are common. Occasionally, telangiectasia occurs in the gastrointestinal tract, with resultant intestinal bleeding. Mental retardation is rare, but many have some diminution of certain perceptual ability and thus score poorly on performance tests and in mathematics, even though they score average or above in verbal IQ tests. Gonadal dysgenesis with failure to go through puberty, develop breast tissue, or begin menses occurs in the majority of affected persons. Replacement with female hormones will bring on puberty. The ovaries are replaced by bilateral streaks of fibrous stroma and are usually devoid of developing ova. However, 5% to 10% of affected girls do go through menarche spontaneously, and very rarely, affected women have been fertile and have had children.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2453–2454.
140. A 10-month-old girl is brought into the emergency room. The mother reports that the child pulls her legs up to her abdomen and cries for 5 to 10 minutes followed by episodes of relaxed silence. She also reports the child is passing blood and mucus in her stools. On examination, a tubular mass is felt in the upper right quadrant. The most likely diagnosis is
A) intussusception
B) volvulus
C) pyloric stenosis
D) viral gastroenteritis
E) ascariasis
View Answer
Answer and Discussion
The answer is A. Intussusception is a cause of acute abdominal pain in young pediatric patients between 2 months and 6 years of age. The condition is rare before 3 months of age and decreases in frequency after 36 months. It is most commonly seen between the ages of 6 and 12 months. It is three times more common in males than in females. The cause is a telescoping of the bowel, which compromises blood flow. Symptoms include periumbilical, colicky, abdominal pain that occurs in periodic waves with some painless periods. Affected infants often pull their legs up to their abdomen to help relieve the discomfort and then rest comfortably after the waves of pain. Blood and mucus are passed in the stool (50% of patients), giving the stool a “currant jelly� appearance. There is usually a tender, sausage-like mass palpated in the right upper abdominal area. Vomiting is also usually present, especially in the early stages. Diagnosis and treatment may be achieved using a barium enema, which usually provides enough hydrostatic pressure to reduce the intussusception. In severe cases, laparotomy may be necessary to reduce the intussusception. A lead point may occur as a result of a polyp, duplication cyst, lymphoma, parasite, Meckel's diverticulum, hematoma associated with Henoch-Schönlein purpura, hypertrophied Peyer's patches, or ventriculoperitoneal shunt.
Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:616–617.
With intussusception blood and mucus are passed in the stool (50% of patients), giving the stool a “currant jelly� appearance. Additionally there is usually a tender, sausage-like mass palpated in the right upper abdominal area.
141. Which of the following conditions is associated with atopic dermatitis?
A) Asthma
B) Vasomotor rhinitis
C) Elevated Ig A levels
D) Melanoma
E) Retinitis pigmentosa
View Answer
Answer and Discussion
The answer is A. Atopic dermatitis is a chronic inflammatory condition of the skin that occurs in persons of all ages but is more common in children. The condition is characterized by intense pruritus and a course associated with exacerbations and remissions. Atopic dermatitis has been reported to affect as many as 10% of children. In the United States the symptoms of atopic dermatitis typically resolve by adolescence in 50% of affected children, but the condition can persist into adulthood. Poor prognostic features include a family history of the condition, early disseminated infantile disease, female gender, and coexisting allergic rhinitis and asthma. The diagnosis of atopic dermatitis is based on the findings of the history and physical examination. Exposure to possible exacerbating factors, such as aeroallergens, irritating chemicals, foods, and emotional stress, can cause exacerbations. There are no specific laboratory findings or histologic features that define atopic dermatitis, although elevated IgE levels are found in a majority of affected patients. In infants and young children with atopic dermatitis, pruritus commonly is present on the scalp, face (cheeks and chin), and extensor surfaces of the extremities. Over 50% of patients with atopic dermatitis have or develop asthma or allergic rhinitis. The majority of patients have a positive family history of atopy. Even if atopic dermatitis resolves with age, the predisposition for asthma and rhinitis persists.
Correale CE, Walker C, Murphy L, et al. Atopic dermatitis: a review of diagnosis and treatment. Am Fam Physician. 1999;60:1191–1210.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:774–778.
142. Which of the following would concern a physician about a child's development?
A) Rolls over at 4 months
B) First words at 15 months
C) Walks at 12 months
D) Ties shoes at 5 years
E) Copies a circle at 3 years
View Answer
Answer and Discussion
The answer is B. Some important developmental milestones for children include the following:
· 4 to 5 months: Rolls over to supine position
· 6 months: Sits without support
· 9 months: Says “mamaâ€� and “dadaâ€� indiscriminately
· 9 months: Creeps and crawls, pulls to stand, waves bye-bye
· 10 months: Says “mamaâ€� and “dadaâ€� discriminately
· 12 months: Walks alone
· 15 months: Creeps up stairs, builds two-block towers, walks independently
· 18 months: Points to four body parts
· 24 months: Jumps, kicks ball, removes coat, verbalizes wants
· 3 years: Copies circle; gives full name, age, and gender; throws ball overhand
· 4 years: Hops on one foot, dresses with little assistance, shoes on the correct feet
· 5 years: Ties shoes, prints first name, plays competitive games
Impairments in hearing can relate to delayed development. Therefore, the first step in the evaluation of a child with language delay is hearing assessment.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:33–34.
143. The main reason the premature infants have difficulty maintaining body temperature is secondary to
A) large body surface to body mass index
B) inadequate hypothalamic function
C) poor sympathetic tone
D) excessive circulating norepinephrine
E) inability to produce neuromediated chills
View Answer
Answer and Discussion
The answer is A. Premature infants have a large body surface area to body mass ratio; therefore, when exposed to temperatures below the neutral thermal environment they rapidly lose heat and have difficulty maintaining their body temperature.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2265.
144. Which of the following statements about measles immunizations is true?
A) Allergies to eggs or neomycin are not contraindications to the measles vaccine.
B) Those who received killed virus immunization between 1963 and 1967 should receive a live attenuated booster vaccination.
C) Infants receiving vaccination before 15 months of age do not need booster vaccinations.
D) The present immunization is a genetically derived recombinant vaccine.
E) Those born before 1956 should receive a measles booster vaccination.
View Answer
Answer and Discussion
The answer is B. Measles immunization is accomplished with a live attenuated virus given at 12 to 15 months of age in the MMR vaccine and then as a booster with the preschool physical at 4 to 6 years of age. Those vaccinated with the killed virus (available in the United States from 1963 to 1967) should be given the live attenuated vaccine, because ineffectiveness is associated with the killed virus given during that period. Those born before 1956 are, in most cases, immune as a result of natural infection and therefore require no additional vaccination. Also, infants vaccinated before 12 months of age should receive two additional boosters. Prior anaphylactic reactions to eggs or neomycin are relative contraindications to the administration of the measles vaccine. A pediatric allergist or immunologist should be consulted before administration.
Abramson JS, Baker CJ, Baltimore RS. Red Book Online 2003: Report of the Committee on Infectious Diseases, American Acad-emy of Pediatrics, accessed at http://aapredbook.aappublications.org on 6/19/06.
145. Premature infants are at increased risk for kernicterus. Which of the following statements is true regarding bilirubin in these children?
A) Decreased bowel motility increases the amount of excreted bilirubin in the stools.
B) Early feedings increase bowel motility and promote bilirubin excretion.
C) Feeding has little impact on the level of bilirubin excretion.
D) Enterohepatic circulation does not occur until the infant reaches 40 weeks.
E) Delayed clamping of the umbilical cord allows for better excretion of bilirubin.
View Answer
Answer and Discussion
The answer is B. Premature infants develop hyperbilirubinemia more often than do full-term infants, and kernicterus may occur at serum bilirubin levels as low as 10 mg/dL (170 µmol/L) in underweight premature infants who are ill. The higher bilirubin levels in premature infants may be partially due to inadequately developed hepatic excretion mechanisms, including deficiencies in bilirubin's uptake from the serum, its hepatic conjugation to bilirubin diglucuronide, and its excretion into the biliary tree. Decreased bowel motility enables more bilirubin diglucuronide to be deconjugated within the intestinal lumen by enterohepatic circulation of bilirubin. On the other hand, early feedings increase bowel motility and reduce bilirubin reabsorption and can thereby significantly decrease the incidence and severity of physiologic jaundice. Uncommonly, delayed clamping of the umbilical cord can also increase the risk of significant hyperbilirubinemia by allowing the transfusion of a large RBC mass; RBC breakdown and bilirubin production are thus increased.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2267–2268.
146. Which of the following statements about insulin-dependent diabetes mellitus type I is true?
A) It usually develops in patients older than 30 years.
B) The disease is associated with insensitivity of the body's tissues to insulin.
C) Ninety percent of those affected present in nonketotic hyperosmolar coma.
D) There is a lack of insulin production as a result of destruction to the β cells in the islets of Langerhans.
E) Diabetic ketoacidosis is not associated with insulin-dependent diabetes mellitus type I.
View Answer
Answer and Discussion
The answer is D. Insulin-dependent diabetes is the result of an insulin deficiency and appears to be a chronic autoimmune destruction of the β cells of Langerhans' islets. There is an increased risk among family members, and it is more common in individuals younger than 30 years. The most common symptoms are polyphagia, polyuria, polydipsia, increased thirst, weight loss despite increased appetite, fatigue, and blurred vision. One-third of patients have diabetic ketoacidosis at the time of presentation. Signs include severe dehydration, labored respirations (Kussmaul's respirations), altered mental status, abdominal pain, enuresis, and fruity breath. Laboratory results show hyperglycemia and glycosuria. Treatment involves the administration of exogenous insulin. Many patients (approximately 66%) experience a period of total or partial remission (“honeymoon period�) within a few weeks or months after initiation of medication. The goals of treatment are replacing insulin, instituting diet and exercise regimens, and monitoring glucose levels.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1947–1952, 1962–1963.
147. Which of the following is not associated with the development of acne?
A) Excessive sebum production
B) Diets high in fat
C) Hyperkeratinization with development of microcomedo
D) Accumulation of lipids and cellular debris
E) Bacterial colonization
View Answer
Answer and Discussion
The answer is B. Acne is a disease associated with the pilosebaceous units in the skin. It is thought to be caused by four important factors.
· Excessive sebum production secondary to sebaceous gland hyperplasia.
· Subsequent hyperkeratinization of the hair follicle prevents normal shedding of the follicular keratinocytes, which then obstruct the follicle and form an inapparent microcomedo.
· Lipids and cellular debris soon accumulate within the blocked follicle.
· This microenvironment encourages colonization of Propionibacterium acnes, which provokes an immune response through the production of numerous inflammatory mediators. Inflammation is further enhanced by follicular rupture and subsequent leakage of lipids, bacteria, and fatty acids into the dermis.
Feldman S, Careccia RE, Barham KL, et al. Diagnosis and treatment of acne. Am Fam Physician. 2004;69:2123–2130, 2135–2136.
148. A 4-year-old boy is brought to the emergency room by his parents. They report that the child swallowed a penny. On examination, the child has no abdominal tenderness. Radiographs of the abdomen localize the coin in the duodenum. The appropriate management includes
A) laxative administration
B) esophagogastroduodenoscopy with removal of the coin
C) ipecac administration
D) charcoal administration
E) observation
View Answer
Answer and Discussion
The answer is E. It is not uncommon for infants and small children who swallow coins to present to the family physician's office or emergency room. Most children are completely asymptomatic. A radiograph of the chest, neck, and abdominal area should help locate the radiopaque coin. If it is found below the diaphragm, the child only needs to be observed until the coin is passed. If the coin is lodged in the esophagus or if the child exhibits symptoms related to the ingested coin, an esophagogastroduodenoscopy may be necessary to remove the foreign body. In most cases, sharp objects should be retrieved by endoscopy (if possible) if they have not entered the small intestine. Follow-up radiographs of the abdomen can help locate and mark the progress of coins in the intestines. Hand-held metal detectors have also been used to locate the position of the coin. The use of ipecac, charcoal, or laxatives is not indicated.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:126–127.
149. Which of the following statements is true regarding breast-feeding and nipple confusion?
A) The World Health Organization recommends avoiding the use of pacifiers or bottle-feeding to establish successful breast-feeding.
B) There is compelling evidence that pacifier use and bottle-feeding is detrimental to successful breast-feeding.
C) Early pacifier use is associated with increased breast-feeding at 1 month.
D) Supplementation with a cup or bottle increases the duration of breast-feeding.
E) Cup feeding was associated with a shorter duration of breast-feeding in comparison to bottle-feeding in mothers who had cesarean sections.
View Answer
Answer and Discussion
The answer is A. The UNICEF/World Health Organization Baby Friendly Hospital Initiative recommends avoiding the use of pacifiers or bottle-feeding to ensure successful breast-feeding; however, the evidence supporting this recommendation is limited. Cup feeding has been advocated as a safe alternative to bottle-feeding in breastfed infants who require supplemental feedings to prevent “nipple confusion� or future problems with breastfeeding. Researchers conclude that early pacifier introduction is associated with fewer mothers exclusively breast-feeding at 1 month and decreased overall breast-feeding duration when compared with later pacifier introduction. Supplementation by cup or bottle led to a decrease in overall breast-feeding duration compared with infants receiving no supplementation. In mothers who had cesarean delivery, cup feeding was significantly associated with higher rates of exclusive breast-feeding and overall duration of breast-feeding compared with bottle-feeding.
Howard CR, Howard FM, Lanphear B. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics. 2003;111:511–518.
150. Which of the following statements about scoliosis is true?
A) The most common form is congenital.
B) The patient has a normal Adam's test.
C) Patients with abnormalities >5 degrees should be referred to an orthopedist.
D) Most curvature is to the right in the thoracic spine, causing the right shoulder to be higher than the left.
E) Syringomyelia is not associated with scoliosis.
View Answer
Answer and Discussion
The answer is D. Scoliosis is defined as the presence of a lateral spinal curvature of 11 degrees or more. Its prevalence during adolescence is estimated to be between 2% and 3%. Curvatures >100 degrees can contribute to restrictive pulmonary disease; however, deviations of this magnitude are extremely rare. Scoliosis is classified as idiopathic (80% of cases), congenital (5%), neuromuscular (10%), or miscellaneous (5%). Severe scoliosis is more common in females. Idiopathic scoliosis is an inherited autosomal-dominant condition that occurs with variable penetrance. Most patients are asymptomatic; however, they may report backaches. The child should be examined with his or her back facing the examiner. The patient is asked to flex forward, and the scapula height is observed (known as the Adam's test). If scoliosis is present, asymmetry in scapular height is noted. In most cases, the right shoulder is higher than the left because of a convex curve of the spine to the right in the thoracic area and to the left in the lumbar area. Hip height and symmetry may also be affected. Radiographs should only be considered when a patient has a curve that might require treatment or could progress to a stage requiring treatment (usually 40 to 100 degrees). Radiographs should include posteroanterior and lateral views of the spine with the patient standing. Magnetic resonance imaging should be obtained in patients with an onset of scoliosis before 8 years of age, rapid curve progression of more than 1 degree/month, an unusual curve pattern such as left thoracic curve, neurologic deficit, or pain. Treatment depends on the degree of curvature. The primary goal of treating adolescent idiopathic scoliosis is preventing progression of the curve magnitude. Curves <10 to 15 degrees require no active treatment and can be monitored, unless the patient's bones are very immature and progression is likely. Moderate curves between 25 and 45 degrees in patients lacking skeletal maturity used to be treated with bracing, but this treatment has never been proven to prevent curve progression. Poor compliance with wearing a brace obviates any potential usefulness of the therapy. Much controversy surrounds brace indications, and trends since the mid-1980s have moved toward no bracing or bracing only the more significant curves (20 to 50 degrees). In more severe cases, braces (e.g., Milwaukee brace) or surgery may be indicated. Painful scoliosis may indicate underlying neurologic problems, such as syringomyelia or spinal cord lesion, and is less likely to be idiopathic.
Greiner KA. Adolescent idiopathic scoliosis: radiologic decision making. Am Fam Physician. 2002;65:1817–1822.
Mahoney MC. Screening for adolescent idiopathic scoliosis. Am Fam Physician. 2000;62:265.
When evaluating for scoliosis the patient is asked to flex forward, and the scapula height is observed (known as the Adam's test). If scoliosis is present, asymmetry in scapular height is noted.
151. Which of the following organisms is most commonly associated with dental caries in children?
A) Staphylococcus aureus
B) Bacteroides fragilis
C) Pasteurella multicida
D) Eikenella corrodens
E) Streptococcus mutans
View Answer
Answer and Discussion
The answer is E. The mutans streptococci (i.e., Streptococcus mutans and Streptococcus sobrinus) have been reported as the principal bacteria responsible for the initiation of dental caries in humans.
Douglass JM, AB Douglass. A guide to infant oral health. Am Fam Physician. 2004;70:2113–2120, 2121–2122.
152. A 3 year old is brought into the emergency room by her parents. The child has had a high fever, sore throat, and now has stridor. The child is sitting on a stretcher leaning forward with her neck extended. The most likely diagnosis is
A) strep throat
B) herpangina
C) meningitis
D) epiglottitis
E) herpes stomatitis
View Answer
Answer and Discussion
The answer is D. Epiglottitis is a rapidly progressive and potentially fatal infection that causes swelling of the epiglottis and may lead to compromise of the child's airway. In the past it was most commonly caused by H. influenzae. The highest incidence occurs in children between 2 and 5 years of age. In recent years, the occurrence of epiglottitis has been reduced dramatically by the widespread use of the Hib vaccine. Symptoms include a sore throat, high fever, hoarseness, and dysphagia with drooling and stridor. Children affected usually lean forward and hyperextend the neck to open the compromised airway. Bacteremia is common. Because of the rapid course of the infection, the child should be immediately hospitalized and the airway secured. Inspection of the pharynx can precipitate a complete obstruction of the airway and should not be performed unless there are qualified personnel present who can simultaneously intubate the child during the inspection procedure if necessary. Lateral and anteroposterior soft tissue radiographs should be taken and can confirm the diagnosis. The characteristic “thumb sign� is noted on the lateral radiograph. In addition to securing an airway, parenteral antibiotics should be administered and the child monitored closely in an intensive care setting.
Rudolph CD, Rudolph AM, Hostetter MK, et al. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill; 2003:1276.
153. The most likely suspected cause for positional head deformities in children is
A) supine positioning
B) premature birth
C) genetic influences
D) child abuse
E) poorly developed sternocleidomastoid muscle
View Answer
Answer and Discussion
The answer is A. In 1993, the American Society of Craniofacial Surgeons documented an increase in the incidence of posterior cranial deformities (occipital plagiocephaly) in infants who had no predisposing risk factors. The relationship of this increased incidence to the “Back to Sleep� campaign was proposed in 1996 and was supported by evidence of a rapid increase in positional head deformity without any significant change in the rate of synostotic plagiocephaly.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1992.
Argenta LC, David LR. Observations and thoughts on the changing constellation of cranial deformities. J Craniofac Surg. 1998;9:491–492.
154. Which of the following statements about Duchenne's muscular dystrophy is true?
A) Girls are affected more commonly than boys.
B) Early symptoms include mental retardation.
C) Distal muscles are affected before proximal muscles, and pseudohypertrophy of muscles can occur.
D) Creatinine kinase levels are low or undetectable.
E) Cardiomyopathy may result.
View Answer
Answer and Discussion
The answer is E. Duchenne's muscular dystrophy is a genetically linked disorder (usually X-linked recessive) that usually affects boys between 2 and 5 years of age. The condition is caused by a mutation at the Xp21 locus, which results in the absence of dystrophin, a protein found inside the muscle cell membrane. It affects 1 in 3,600 live male births. Becker muscular dystrophy is the same fundamental disease with a genetic defect at the same locus but a milder clinical disease.
Many affected individuals have no family history of the disorder. Early manifestations include rapid fatigue on ambulation or running, clumsiness, waddling gait, and a distinctive pattern of climbing up on the legs from a sitting to standing position known as Gowers' maneuver. The proximal muscles are usually affected before the distal muscles; pseudohypertrophy of the gastrocnemius (seen in 90% of patients), triceps, and vastus lateralis may occur. Cardiomyopathy and mental retardation may occur in advanced cases, although intellectual impairment occurs in all patients. Diagnosis is usually accomplished by muscle biopsy, which shows degeneration of muscle fibers and proliferation in connective tissue. Electromyelography studies often distinguish between neuropathic and myopathic processes. Laboratory tests show a significantly elevated creatinine kinase level. Dystrophin analysis of muscle samples is also very helpful in the diagnosis; dystrophin is extremely low (<3%) or undetectable in patients with Duchenne's dystrophy. Mutation analysis of DNA isolated from peripheral blood leukocytes identifies deletions or duplications in the dystrophin gene in approximately 65% of patients and point mutations in approximately 25% of patients. Treatment involves physical therapy and braces. The prognosis is usually poor, with most patients dying of pneumonia before the age of 20 years.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2060–2064.
155. Infant botulism is associated with
A) contaminated formula
B) ingestion of honey
C) baby food contamination
D) infant cereal
View Answer
Answer and Discussion
The answer is B. Although the worldwide incidence of infant botulism is rare, the majority of cases are diagnosed in the United States. An infant can acquire botulism by ingesting Clostridium botulinum spores, which are found in soil or honey products. According to testing, up to 25% of honey products have been found to contain spores. A history of honey consumption is seen in 15% of the botulism cases reported to the CDC. As a result, honey should not be given to infants younger than 1 year.
Cox N, Hinkle R. Infant botulism. Am Fam Physician. 2002;65:1388–1392.
156. A 4-year-old girl is seen in the emergency room and is suspected of having meningitis. A positive Brudzinski's sign is noted. Which of the following describes a positive Brudzinski's sign?
A) The child dorsiflexes her feet when her head is flexed forward.
B) The child shows resistance when her legs are extended from a flexed position.
C) The child involuntarily flexes the hips with flexion of the neck.
D) The child involuntarily blinks with gentle tapping of the forehead.
E) The child shows extension-type posturing when her arms are flexed.
View Answer
Answer and Discussion
The answer is C. Symptoms of bacterial meningitis include high-pitched cry, fever, anorexia, irritability, obtundation, lethargy, nausea, vomiting, neck stiffness, and a full fontanel (in infants).
In neonates, clinical clues to the presence of meningitis include temperature instability (hypothermia or hyperthermia), listlessness, high-pitched crying, fretfulness, lethargy, refusal to eat, a weak sucking response, irritability, vomiting, diarrhea, and respiratory distress. Because neonates usually do not have meningismus, a change in the child's affect or state of alertness is one of the most important signs. A bulging fontanel may occur late in the course of the disease in one-third of neonates. About 30% of neonates have seizures. Meningeal signs and fever are not always present in infants; however, meningeal signs are more reliable in older children and include the following:
· Brudzinski's sign: flexion of neck with the patient supine causes involuntary flexion at the hips
· Kernig's sign: attempts to extend the knees from a flexed position are met with resistance
The most common causes of bacterial meningitis include the following:
· Neisseria meningitis (meningococcal meningitis): usually seen in the first year of life
· H. influenzae: the Hib vaccination has dramatically reduced the incidence
· Streptococcal pneumoniae: the most common form of adult meningitis; immunization can help prevent this in children and adults
· Group B or D streptococci and gram-negative organisms: most common in neonates
Among U.S. children, there has been a substantial decrease in deaths and hospitalization from H. influenzae meningitis but not S. pneumoniae or N. meningitidis meningitis in the years after Hib conjugate vaccine licensure. This observation suggests that the declines in H. influenzae meningitis are due primarily to the use of Hib conjugate vaccines. The most common sequelae after meningitis include hearing loss and seizure disorders.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1860–1862.
157. Which of the following statements regarding colic is true?
A) Infants affected with colic are usually <10% on height and weight growth curves.
B) Symptoms are usually more severe at night.
C) The onset of colic occurs at birth.
D) Symptoms of colic last for approximately 1 year.
E) Colic has lasting negative effects on maternal mental health.
View Answer
Answer and Discussion
The answer is B. Infant colic is characterized by excessive and inconsolable crying, hypertonicity, and wakefulness, mainly in the evening. An estimated 5% to 28% of infants have colic during the first few months of life. The widely cited “rule of threes� defines a colicky infant as one who is healthy and well-fed but cries for a total of at least 3 hours/day, more than 3 days in any 1 week. Onset is usually between the second and sixth weeks of life, and remission of symptoms generally occurs by 3 months of age. Although colic is thought to be a self-limited condition, it can be overwhelming to parents over a substantial number of weeks. One concern, moreover, is the potential lasting impact of colic on maternal mental health. Studies have shown that colic usually is a self-limited condition that does not result in long-lasting negative effects on maternal mental health.
Clifford TJ, Campbell MK, Speechley KN. Sequelae of infant colic. Evidence of transient infant distress and absence of lasting effects on maternal mental health. Arch Pediatr Adolesc Med. 2002;156:1183–1188.
158. A 7-year-old girl is seen in the emergency room. Her mother reports that she pulled the child up from the ground after the child fell. The child holds her left arm in a pronated position and refuses to use it. The most appropriate management is
A) radiographs to rule out fracture
B) firm stabilization of a flexed elbow and gentle pronation of the distal wrist
C) ice, anti-inflammatory medication, and rest
D) shoulder sling use for 2 weeks followed by physical therapy
E) orthopedic referral
View Answer
Answer and Discussion
The answer is B. Nursemaid's elbow results when subluxation of the radial head occurs. The mechanism of injury occurs when a child's arm that is fully extended at the elbow is pulled. The injury usually affects children between 2 and 7 years of age. This injury occurs predominantly in toddlers, with a peak incidence between 2 and 3 years of age. Episodes in children younger than 6 months of age have been noted in the literature.
When examined, the child usually holds the forearm pronated and refuses to use it. Symptoms include pain and lack of movement of the affected extremity. Radiographs are unnecessary in most cases. Diagnosis is made by the history and usually involves a child that has been pulled abruptly from the ground with the elbow fully extended. To treat this, the physician places a finger on the head of the radius, and then firmly but gently supinates and flexes the distal arm until a pop is felt over the head of the radius. The child should then be observed for normal movement of the extremity. Parents should be counseled concerning the mechanism of injury to prevent recurrence. Usually there is sufficient development of the radial head to prevent subluxation of the annular ligament by age 4.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2290–2291.
159. An 8 year old with a 5-year history of cystic fibrosis comes in to your office with increasing respiratory symptoms consisted with infection. Which of the following organisms is most likely involved?
A) Streptococcus pneumoniae
B) Haemophilus influenzae
C) Mycoplasma pneumoniae
D) Pseudomonas aeruginosa
E) Moraxella catarrhalis
View Answer
Answer and Discussion
The answer is D. Early in the course of cystic fibrosis, Staphylococcus aureus is the pathogen most often isolated from the respiratory tract, but as the disease progresses, Pseudomonas aeruginosa is most frequently isolated. A mucoid variant of Pseudomonas is uniquely associated with CF.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2308–2313.
Early in the course of cystic fibrosis, Staphylococcus aureus is the pathogen most often isolated from the respiratory tract, but as the disease progresses, Pseudomonas aeruginosa is most frequently isolated.
160. Which of the following conditions may represent a contraindication for immunization?
A) Increase in body temperature to 38.5°C (101°F) after previous immunization
B) Allergy to neomycin
C) Recent mild upper respiratory infection in an otherwise healthy child
D) Current antibiotic use
E) Family history of seizure disorder
View Answer
Answer and Discussion
The answer is B. The following conditions are in most cases contraindications to immunization practices:
· Previous severe reaction to the vaccine (anaphylaxis or persistent temperature >40.5°C [105°F])
· Allergy to eggs for influenza, yellow fever, and MMR vaccines
· Allergy to neomycin for MMR vaccine
· Immunocompromised patients or contacts for live attenuated vaccines such as MMR and varicella
· Chronic steroid therapy at moderate or high doses
Some health-care providers inappropriately consider certain circumstances to be contraindications to immunization. For example,
· Reaction to a previous DPaT dose that involved only soreness, redness, or swelling at the site of the injection or a temperature <105°F (40.5°C)
· Mild acute illness with low-grade fever in an otherwise healthy child
· Current antibiotic use
· Prematurity (however, hepatitis B immunization in most cases should be delayed)
· History of nonspecific allergies
· Allergies to duck meat or feathers
· Family history of convulsion in persons considered for pertussis or measles vaccination
Abramson JS, Baker CJ, Baltimore RS. Red Book Online 2003: Report of the Committee on Infectious Diseases, American Acad-emy of Pediatrics. Accessed at http://aapredbook.aappublications.org on 6/21/06.
161. A 15-year-old presents with a painful area associated with the lower right leg. She is a volleyball player for her high school team. The pain is described as a dull, aching pain that has been present for the last several months. Recently it has become worse and is especially present at night. The most likely diagnosis is
A) osteosarcoma
B) shin splints
C) “growing pains�
D) Osgood-Schlatter's disease
E) stress fracture
View Answer
Answer and Discussion
The answer is A. Patients with osteosarcoma typically present with dull, aching pain of several months' duration that may suddenly become more severe. The increase in pain severity may correlate with tumor penetration of cortical bone and irritation of the periosteum, or with pathologic fracture. Night pain is common and may awaken the patient from sleep. Chronic indolent night pain should not be dismissed as “growing pains,� especially when it isunilateral. Patients frequently have a history of a minor injury, sprain, or muscle pull incurred while participating in a sport. The physical examination may reveal localized tenderness, restricted range of motion of the adjacent joint, a limp or muscle atrophy, and may confirm the presence of a mass, swelling, or deformity. Children frequently have referred pain; therefore, it is essential to perform a comprehensive examination of the joint above and below the area of complaint, as well as spinal and reflex examinations.
Wittig JC, Bickels J, Priebat D, et al. Osteosarcoma: a multidisciplinary approach to diagnosis and treatment. Am Fam Physician. 2002;65:1123–1132, 1135–1136.
162. A 2-year-old girl is brought in by her mother. The child has evidence of high fever for the past 9 days, conjunctivitis (without exudate), erythematous pharynx, and swollen lips that have fissured and cracked. The child is also noted to have a generalized erythematous, maculopapular rash associated with the hands and feet and early desquamation of the superficial layer of skin. The most likely diagnosis is
A) Lyme disease
B) scarlet fever
C) Kawasaki disease
D) Henoch-Schönlein purpura
E) herpangina
View Answer
Answer and Discussion
The answer is C. Kawasaki disease, or mucocutaneous lymph node syndrome, is a disease of young children and is associated with an idiopathic vasculitis of the small- and medium-size blood vessels. The condition is characterized by prolonged high fever (>39°C [102°F]) that is often not relieved with antipyretics and the following:
· Conjunctival injection without exudate
· Erythematous mouth and pharynx with the development of strawberry tongue and red swollen lips, which may progress to fissuring and cracking by day 6 of disease
· Generalized maculopapular rash
· Induration of the hands and feet with erythema associated with the feet and hands, with desquamation during the second and third week of disease
· Unilateral cervical lymphadenopathy
For the diagnosis to be made, patients must have a fever for 5 days or more plus at least four of the aforementioned criteria. The rash appears within 3 days of the onset of fever and can vary in character. Frequently, the rash is scarlatiniform on the trunk and erythematous on the palms and soles with subsequent distal desquamation. Mucous membrane involvement is common and includes hyperemic bulbar conjunctiva; injected oropharynx; dry, cracked lips; and a strawberry tongue. Other symptoms include sterile pyuria, arthritis or arthralgias, aseptic meningitis, carditis with congestive heart failure, hydrops of the gallbladder, pericardial effusion, and arrhythmias. The physical examination may reveal nonsuppurative cervical lymphadenopathy (>1.5 cm in diameter). Coronary artery abnormalities develop in 20% to 25% of patients with Kawasaki disease. Cardiovascular complications are the major cause of short-term and long-term morbidity and mortality. Laboratory findings include leukocytosis with a bandemia, anemia, thrombocytosis, and an elevated erythrocyte sedimentation rate. Most affected individuals are younger than 5 years, with peak occurrence between 1 and 2 years of age. The condition is rare in children younger than 6 months and older than 12 years. Treatment involves supportive care and the use of aspirin and intravenous γ globulin. Steroid use is contraindicated and may increase the risk for coronary aneurysms. Antibiotics are unnecessary. Close follow-up with electrocardiography, chest radiographs, and echocardiography is necessary. Some patients may require coronary angiography to rule out aneurysm formation.
McKinnon HD, Howard T. Evaluating the febrile patient with a rash. Am Fam Physician. 2000;62:804–816.
163. An appropriate first step in the management of gastroesophageal reflux is
A) H2-receptor antagonist
B) prokinetic agent
C) proton pump inhibitor
D) thickening feedings with dry rice cereal added to formula
View Answer
Answer and Discussion
The answer is D. A common condition in infants is gastroesophageal reflux (GER), which causes parental anxiety resulting in numerous visits to the physician. The term GER implies a physiologic process in a healthy infant with no underlying systemic abnormalities. GER is a common condition involving regurgitation, or “spitting up,� which is the passive return of gastric contents retrograde into the esophagus. The prevalence of GER peaks between 1 and 4 months of age, and usually resolves by 6 to 12 months of age. There is no gender predilection or definite peak age of onset beyond infancy. A more severe form is gastroesophageal reflux disease (GERD). GERD is a pathologic process in infants manifested by poor weight gain, signs of esophagitis, persistent respiratory symptoms, and changes in neurobehavior. After the first year of life, GERD is more resistant to complete resolution. Risk factors for GERD include: a history of esophageal atresia with repair; neurologic impairment and delay; hiatal hernia; bronchopulmonary dysplasia; asthma; and chronic cough. GERD is also associated with pulmonary aspiration, chronic bronchitis, and bronchiectasis. Conservative treatment for mild symptoms of GER involves thickened feedings and positional changes in infants, and dietary modification in children. Healthy infants who regurgitate without signs of GERD may be managed by thickening feedings with dry rice cereal added to formula. Thickened feeding reduces regurgitation and fussiness, and increases daily caloric intake. Smaller, more frequent feedings are recommended in older infants and children. The medications used for GERD include H2-receptor antagonists, prokinetic agents, and proton pump inhibitors such as omeprazole (Prilosec) or lansoprazole (Prevacid) for patients with persistent esophagitis. Lansoprazole is also available in a liquid alkaline form for use in the childhood population.
Tsou VM, Bishop PR. Gastroesophageal reflux in children. Otolaryngol Clin North Am. 1998;31:419–434.
Jung AD. Gastroesophageal reflux in infants and children. Am Fam Physician. 2001;64:1853–1860.
164. The primary bacteria associated with the development of dental caries is
A) Streptococcus mutans
B) Staphylococcus aureus
C) Streptococcus pneumoniae
D) Enterobacter species
E) Streptococcus viridans
View Answer
Answer and Discussion
The answer is A. Dental caries occur when the tooth's surface is susceptible to injury, bacteria are present, and there is a food source from which the bacteria can live and reproduce. The primary bacteria is S. mutans, which can manufacture lactic acid, damaging the tooth's protective covering. Excessive and repeated consumption of dietary carbohydrates places the patient at risk for the development of dental caries. Symptoms may include sensitivity to hot and cold fluids or foods, persistent pain, or visible caries formation. Diagnosis is usually made by probing the dental pits with a sharp dental instrument and detecting softened enamel. Radiographs may also show radiolucent areas. Treatment involves removal of the damaged enamel and replacement with restorative material. Prophylaxis involves proper brushing and flossing technique two times per day, combined with the use of fluoride and regular dental checkups to remove plaque buildup.
Douglass JM, AB Douglass. A guide to infant oral health. Am Fam Physician. 2004;70:2113–2120, 2121–2122.
165. A 1 week old is diagnosed with breast milk jaundice. You should instruct the mother to
A) maintain breast pumping and switch the child to formula and monitor bilirubin levels
B) stop breast-feeding and start phototherapy
C) continue breast-feeding and start phototherapy
D) schedule an exchange transfusion
E) avoid any future breast-feeding and switch to formula-feeding
View Answer
Answer and Discussion
The answer is A. Breast milk jaundice usually peaks in the 6th to 14th days of life. This late-onset jaundice may develop in up to one-third of healthy breastfed infants. Total serum bilirubin levels vary from 12 to 20 mg/dL (340 µmol/L) and are not considered patho-logic. The underlying cause of breast milk jaundice is not entirely known. Substances in maternal milk, such as β-glucuronidases, and nonesterified fatty acids may inhibit normal bilirubin metabolism. The bilirubin level usually decreases continually after the infant is 2 weeks old, but it may remain persistently elevated for 1 to 3 months. If the diagnosis of breast milk jaundice is in doubt or the total serum bilirubin level becomes markedly elevated, breastfeeding may be temporarily interrupted, although the mother should continue to express breast milk to maintain production. With formula substitution, the total serum bilirubin level should decline rapidly over 48 hours [at a rate of 3 mg/dL (51 µmol/L)/day], confirming the diagnosis. Breast-feeding may then be resumed.
Dennery PA, Seidman DS, Stevenson DK. Neonatal hyperbilirubinemia. N Engl J Med. 2001;344:581–590.
Gartner LM, Herschel M. Jaundice and breastfeeding. Pediatr Clin North Am. 2001;48:389–399.
166. A 15-year-old female dancer presents with pain, swelling, and a “give away� sensation in her knee. The patient reports that going up and down stairs aggravates the pain. Physical examination shows an increased Q angle. The most likely diagnosis is
A) anterior cruciate ligament rupture
B) Osgood-Schlatter disease
C) patellofemoral syndrome
D) tibial plateau fracture
E) iliotibial band syndrome
View Answer
Answer and Discussion
The answer is C. Patellofemoral syndrome is a common overuse injury associated with the anterior knee. It commonly affects young women. In most cases, the syndrome is associated with poor conditioning and the initiation of a new activity, particularly running, but also other activities including dancing, gymnastics, and figure skating. Symptoms include pain, swelling, and a “give way� sensation associated with the knee. Ascending or descending hills or stairs and repeated squatting or weight bearing on a semiflexed knee tend to aggravate symptoms. The contributing factor is weakness of the quadriceps muscles and particularly the vastus medialis. The condition is also associated with an increased Q angle (the angle formed from a line down the femur and a line formed by the patellar tendon) and a high-riding patella (patella alta). Radiographs (sunrise view) of the knees may show patellofemoral malalignment but are not necessary for the diagnosis. Treatment involves rest, ice, nonsteroidal anti-inflammatory agents, and quadriceps-strengthening exercises. Elastic neoprene knee sleeves worn during activities can help keep the patella in proper alignment and help prevent symptoms.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2311.
167. Of the following, the drug of choice for a pertussis infection is
A) penicillin
B) tetracycline
C) ciprofloxacin
D) chloramphenicol
E) erythromycin
View Answer
Answer and Discussion
The answer is E. Pertussis is a potentially serious illness in children younger than 2 years. Mortality is about 1% to 2% in children younger than 1 year of age (highest in the first month of life). Most deaths are caused by bronchopneumonia and cerebral complications. Pertussis is troublesome but rarely serious in older children and adults, except in the elderly. Patients should be quarantined, particularly from susceptible infants, for at least 1 month from disease onset or until symptoms have subsided. Hospitalization is recommended for seriously ill infants to assess progression of disease and prevent and treat complications. Antibiotics given in the catarrhal stage may ameliorate the disease. After paroxysms are established, antibiotics usually have no discernible effect but are recommended to limit spread. The drug of choice is a macrolide antibiotic (e.g., erythromycin or azithromycin). Antibiotics should also be used for any bacterial complications such as bronchopneumonia and otitis media.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1465–1466.
168. Which of the following statements about isotretinoin (Accutane) is true?
A) It is recommended in the treatment of mild to moderate acne.
B) It has potential detrimental effects on the kidney.
C) It has beneficial effects on cholesterol levels.
D) Documentation of a negative pregnancy test is mandatory before its use in women.
E) A common side effect is tinnitus.
View Answer
Answer and Discussion
The answer is D. Isotretinoin (Accutane) is used for moderate to severe nodulocystic acne unresponsive to conventional therapy. Therapy usually lasts 16 to 20 weeks followed by an 8-week drug vacation before the administration of the next course. It is absolutely contraindicated in pregnancy, and 2 to 3 contraceptive methods should be instituted before its administration. In addition, female patients should have a documented negative pregnancy test before isotretinoin (Accutane) administration. Side effects include xerosis, cheilitis, epistaxis, myalgias, and arthralgias. The effects of the drug may also alter the liver function test, blood counts, blood glucose, uric acid, and cholesterol and triglyceride levels, all of which may require frequent monitoring. There has been an association with pseudotumor cerebri development in patients who use isotretinoin. The administration is required to be monitored by certified provider.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2311.
The effects of isotretinoin (Accutane) may also alter the liver function test, blood counts, blood glucose, uric acid, and cholesterol and triglyceride levels, all of which may require frequent monitoring.
169. Which of the following anti-seizure medications is associated with weight loss?
A) Felbamate (Felbatol)
B) Gabapentin (Neurontin)
C) Lamotrigine (Lamictal)
D) Topiramate (Topamax)
E) Levetiracetam (Keppra)
View Answer
Answer and Discussion
The answer is D. Several new medications for the treatment of epilepsy have become available in the recent past. The new drugs include: felbamate (Felbatol), gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax), tiagabine (Gabitril), levetiracetam (Keppra), and zonisamide (Zonegran). Comparisons among these new drugs are difficult to make. In general, they are similar to each other in terms of efficacy. Therefore, the choice of a specific agent is often based on other factors, including side effect profile. All anti-epilepsy drugs are central nervous system depressants and are associated with sedation, dizziness, ataxia, cognitive and visual disturbances, and gastrointestinal symptoms. These side effects are predictable, benign, and dose- or rate-dependent. In most instances, the new anti-epileptic drugs are better tolerated than the older medications. However, significant differences exist among the drugs with regard to side effects, potential toxicity, and pharmacokinetics. Felbamate has a broad spectrum of activity in both partial and generalized seizures, but rare reports of fatal aplastic anemia and hepatic failure limit its use to patients for whom no other treatment alternative exists. Gabapentin is characterized by excellent tolerability. It is not protein bound, has no appreciable hepatic metabolism, and is excreted by the kidneys. Thus, gabapentin is appropriate for use in patients who require relatively quick titration, who have multiple drug intolerances, or who are taking multiple drugs with the potential for interaction, including the elderly. Lamotrigine has a broad spectrum of activity against multiple seizure types. Sedation is notably rare in monotherapy, and it even has an “alerting� response in some patients. One idiosyncratic side effect of lamotrigine, which is similar to effects of older antiepileptic drugs, is a rash. Infrequently the rash can be serious and may progress to Stevens-Johnson syndrome, which can be life-threatening. Rashes are more common in children when lamotrigine is taken in association with valproate sodium (Depakote) and with rapid dose adjustment. Topiramate also has a broad spectrum of activity. Weight loss has been noted, which can be a desirable side effect. The development of nephrolithiasis, which is rare, and paresthesias, which is common, likely reflects carbonic anhydrase inhibition. Tiagabine has no significant systemic or serious idiosyncratic adverse side effects, but it does have a relatively narrow spectrum of activity and must be adjusted slowly. One limitation of lamotrigine, topiramate, and tiagabine is that they need to be initiated at a low dosage and slowly increased in dosage over several weeks. Levetiracetam is unique among the new antiepileptic drugs because it is effective starting with the initial dose. It also has a mechanism of action that appears to be different from that of other antiepileptic drugs and, like gabapentin, its tolerability and pharmacokinetics are very acceptable. Levetiracetam is not metabolized by the liver (more than 60% is renally excreted unchanged), and <10% is protein bound. As a result, drug interactions are minimal.
Benbadis SR, Tatum WO IV. Advances in the treatment of epilepsy. Am Fam Physician. 2001;64:91–98, 105–106.
170. Which of the following statements about enuresis in children is true?
A) Primary enuresis is defined as the onset of bedwetting after a 6-month period of dryness.
B) Bed-wetting usually occurs in stage 1 of NREM sleep.
C) Most outgrow the condition before 12 years of age.
D) There is no approved treatment for enuresis.
E) Diagnosis should consist of cystoscopy to rule out structural causes.
View Answer
Answer and Discussion
The answer is C. Nocturnal enuresis beyond 5 years of age in girls and 6 years of age in boys is a relatively common problem. Primary enuresis is defined as a patient who has never had an extended period of dryness since birth. Secondary enuresis is the onset of bed-wetting after 6 months of dryness. The condition is more common in young boys and firstborn children, and there is usually a positive family history. Bed-wetting usually occurs during the first REM sleep cycle, when sleep is relatively light. It may also occur in other stages, except for stage 1. The family and patient should be reassured that this is a common problem and is not associated with any underlying disorder. Diagnostic tests are usually limited to urinalysis to rule out infection. The bladder is usually a normal structural size but is functionally small. The physician should keep in mind that primary nocturnal enuresis is a diagnosis of exclusion, and all other causes of bed-wetting must be ruled out. Causes of secondary enuresis include neurogenic bladder and associated spinal cord abnormalities, urinary tract infections, and the presence of posterior urethral valves in boys or an ectopic ureter in girls. Posterior urethral valves cause significant voiding symptoms such as straining to void and diminished urinary stream. An ectopic ureter causes constant wetting. Treatment consists of observation. In older children, imipramine (Tofranil), oxybutynin (Ditropan), or nasal desmopressin (DDAVP) can be used. Other forms of treatment for older children include bell-and-pad conditioning. Most patients outgrow the condition before 12 years of age. Daytime enuresis may indicate underlying pathology or voiding dysfunction and requires further evaluation.
Thiedke CC. Nocturnal enuresis. Am Fam Physician. 2003;67:1499–1506, 1509–1510.
171. The majority of cases of occult bacteremia are caused by
A) Streptococcus pneumoniae
B) Neisseria meningitides
C) Staphylococcus aureus
D) Haemophilus influenzae type b (Hib)
E) Salmonella
View Answer
Answer and Discussion
The answer is A. Occult bacteremia is caused by Streptococcus pneumoniae in 65% to 75% of cases, and the remainder by other bacteria, including Neisseria meningitidis, Salmonella spp., and Staphylococcus aureus. The incidence of bacteremia due to Haemophilus influenzae type b (Hib) has decreased substantially where Hib conjugate vaccine is part of routine childhood immunization. Occult bacteremia is detected in about 4% to 17% of febrile infants between 1 and 24 months of age. The majority of cases occur in infants between 6 and 24 months of age. Children who look well enough to be managed as outpatients but who later are found to be bacteremic usually are younger than 24 months of age. Incidence does not vary with sex or race.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1392–1393.
172. Substances that are contraindicated during breast-feeding include all of the following except
A) alcohol
B) tetracycline
C) penicillin
D) ciprofloxacin
E) bromocriptine
View Answer
Answer and Discussion
The answer is C. Certain medications are contraindicated during breast-feeding, including quinolone antibiotics, tetracycline, chloramphenicol, bromocriptine, cyclosporine, cyclophosphamide, doxorubicin, methotrexate, lithium, and ergotamine. Other drugs that have relative contraindications include metronidazole, sulfonamides, salicylates, phenobarbital, other psychotropic medication, and antihistamines. Caffeine in large amounts should also be avoided. In addition, recreational drugs (e.g., alcohol, cocaine, marijuana) should be avoided.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2297.
173. Which of the following is not usually associated with autism?
A) Normal intelligence quotients (IQs)
B) Echolalia
C) Repetitive movements
D) Self-injury behaviors
E) Seizures
View Answer
Answer and Discussion
The answer is A. The impairments noted in autistic persons are varied and result in good skills in some areas and poor skills in others. Echolalia, the involuntary repetition of a word or a sentence just spoken by another person, is a common feature of language impairment that, when present, may cause language skills to appear better than they really are. There may also be deficiencies in symbolic thinking, stereotypic behaviors (e.g., repetitive nonproductive movements of hands and fingers, rocking, meaningless vocalizations), self-stimulation, self-injury behaviors, and seizures. Mental retardation is not a diagnostic criterion, but it is frequently present in the moderate to severe range.
Prater CD, Zylstra RG. Autism: a medical primer. Am Fam Physician. 2002;66:1667–1674, 1680.
174. Which of the following statements about otitis media is true?
A) The most common organisms causing otitis media in newborns are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
B) Ten percent of otitis media cases with H. influenzae as the causative organism are resistant to amoxicillin.
C) Close to 100% of otitis media cases with M. catarrhalis as the causative organism are resistant to amoxicillin.
D) The treatment of otitis media should include the use of antibiotics and an antihistamine/decongestant preparation.
E) Analgesic pain medication is rarely needed in the treatment of otitis media.
View Answer
Answer and Discussion
The answer is C. Otitis media is one of the most frequent reasons parents bring their children to the physician. The condition occurs more frequently in the winter months and affects bottle-fed infants (especially those put to bed with bottles) more frequently than other infants; it also affects boys more often than girls, as well as premature infants or those enrolled in daycare more often than other infants. Infants with cleft palate or Down syndrome are also at increased risk. The most common etiologic agents for otitis media are as follows:
· Streptococcus pneumoniae
· 2. Moraxella (Branhamella) catarrhalis
· Non-typeable H. influenzae
Newborns are more likely to be affected with E. coli and S. aureus. Children older than 5 years are less frequently affected by Klebsiella pneumoniae and Bacteroides rarely cause otitis media. Viruses, including RSV, rhinovirus, and adenovirus, can also cause otitis media and are often complicated with secondary bacterial organisms.
The major factor that contributes to otitis media is eustachian tube dysfunction and anatomic immaturity, which allows fluid and bacteria to reflux into the middle ear. Symptoms of otitis media include pain, fever, and occasionally purulent drainage if the tympanic membrane has ruptured. Younger children may be fussy, irritable, and show decreased appetite or sleep disturbances. Pulling at the ears may also be a sign of otitis media. Physical examination usually shows a bulging erythematous tympanic membrane with a loss of tympanic landmarks and lack of mobility with pneumatoscopy. Treatment involves the use of analgesics and first-line antibiotics, including amoxicillin, trimethoprim–sulfamethoxazole, and erythromycin. Amoxicillin remains the antibiotic of first choice, although a higher dosage (80 mg/kg/day) may be indicated to ensure eradication of resistant S. pneumoniae. Oral cefuroxime or amoxicillin-clavulanate and intramuscular ceftriaxone are suggested second-line choices for treatment failure.
Thirty percent to 60% of S. pneumoniae and close to 100% of M. catarrhalis strains are β-lactamase producers and are resistant to amoxicillin. Resistance may vary according to locality. If β-lactamase–producing infections are suspected, amoxicillin–clavulanate, erythromycin, trimethoprim–sulfamethoxazole, or cephalosporins are recommended. The use of antihistamines and decongestants has little or no benefit in the treatment of otitis media.
Pichichero ME. Acute otitis media: Part II. Treatment in an era of increasing antibiotic resistance. Am Fam Physician 2000;61:2410–2416.
175. According to the American Academy of Pediatrics, at what age should a child begin formal swimming lessons?
A) After 1 year of age
B) After 2 years of age
C) After 3 years of age
D) After 4 years of age
E) After 5 years of age
View Answer
Answer and Discussion
The answer is D. Children who are near water are at higher risk of drowning. The American Academy of Pediatrics (AAP) has updated its policy about swimming programs for infants and toddlers. While some aquatic programs may include water safety instructions for parents and children, these programs are clearly not designed to teach children how to swim. In fact, swimming skills are not the same as water safety skills, and parents should be clear about what is developmentally possible in different age groups. Rudimentary swimming movements (e.g., the dog paddle) are possible in a 1-year-old child, but traditional swimming strokes do not occur until a child is about 5 years of age. Children who have not yet reached their fourth birthday will not have the neuromuscular capability to adequately learn swimming skills. Taking swimming lessons at an earlier age does not mean that the child will master water skills earlier or be more proficient than children who take such lessons later. Training programs have been shown to improve water survival skills, but safety training has not been shown to decrease the risk of drowning. In fact, programs that emphasize making the child stop fearing water may, in fact, encourage children to enter the water without supervision. Therefore, the AAP recommends that children do not begin formal swimming lessons until after they are 4 years of age. Parents should not be encouraged to believe that a child's participation in an aquatic program will decrease the risk of drowning, and they should remain within arm's reach or able to touch the swimmer at all times (also known as touch supervision).
American Academy of Pediatrics Committee on Sports Medicine and Fitness and Committee on Injury and Poison Prevention. Swimming programs for infants and toddlers. Pediatrics. 2000;105:868–870.
176. The most common cause of septic joint in an immigrant 3-year-old boy with no prior immunizations is
A) Neisseria gonorrhea
B) Pasteurella multocida
C) Mycoplasma pneumoniae
D) Streptococcus pneumoniae
E) Haemophilus influenzae
View Answer
Answer and Discussion
The answer is E. Bacterial infections are usually responsible for septic joints. In children (between 2 and 5 years of age), the most common pathogen associated with osteomyelitis is Staphylococcus aureus; other causes include Staphylococcus, Streptococcus, and gram-negative bacteria. In sexually active teenagers and young adults Neisseria gonorrhea is a common cause. Additionally, Staphylococcus, group A streptococcus, and Streptococcus pneumoniae are causes. Other agents include viruses, mycobacteria, or fungi. H. influenzae type B was most common before universal vaccination and may affect unimmunized immigrants. Salmonella and S. aureus are the two most common causes of osteomyelitis in children with sickle cell anemia. Patients with rheumatoid arthritis are at particular risk for septic joints. In adults, the most common joint affected is the knee, whereas, in children, the hip and knee are the most commonly affected. Typically, the child with a septic joint will have pain with any range of motion of the joint, whereas patients with trauma or toxic synovitis will allow some range of motion of the joint. Laboratory tests show an elevated white blood cell count and elevated sedimentation rate. Culture and Gram's stain of the joint fluid should be performed. Blood cultures are positive in 30% to 40%. Treatment involves surgical débridement as soon as possible if a bacterial source is suspected.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2298.
In sexually active teenagers and young adults Neiserria gonorrhea is a common cause of septic joints.
177. Which of the following sounds is associated with a positive Ortolani sign when assessing for developmental dysplasia of the hip (DDH)?
A) “Click�
B) “Clunk�
C) “Pop�
D) “Grinding�
View Answer
Answer and Discussion
The answer is B. The American Academy of Pediatrics (AAP) has issued a clinical practice guideline about early detection of developmental dysplasia of the hip (DDH). It is important to remember that no physical examination finding is pathognomonic for DDH. The neonate should have a normal range of motion of abduction to 75 degrees and adduction to 30 degrees. A physical assessment should include evaluation for asymmetry as well as assessing Ortolani and Barlow signs. The Ortolani maneuver is performed with the infant supine and the hip flexed to 90 degrees. The leg is held in neutral rotation with the physician's index and middle finger along the greater trochanter and the thumb along the inner thigh. The hip is abducted as the leg is lifted anteriorly. A “clunk� (not a high-pitched click) indicates a positive Ortolani sign and occurs as the dislocated femoral head is reduced into the acetabulum. A positive Barlow sign occurs when there is a palpable “clunk� (or movement) of the femoral head being dislocated. Again, the infant has the hip flexed to 90 degrees; the leg is adducted while posterior pressure on the knee is applied to detect an unstable hip dislocating. High-pitched clicks are common with extension and flexion and are insignificant. With the infant prone, the physician should check for limb length discrepancy or asymmetric gluteal or thigh folds. In an older infant (about 3 months of age), limited abduction of the hip is a reliable sign of DDH. Again, asymmetry should be sought. Physical examination screening for DDH should occur at 2 to 4 days and at each well-child visit (1, 2, 4, 6, 9, and 12 months) until the child is 1 year old or is reliably able to walk.
Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics. 2000;105:896–905.
178. Erythema infectiosum (fifth disease) is caused by
A) parvovirus
B) adenovirus
C) rhinovirus
D) paramyxovirus
E) herpes virus
View Answer
Answer and Discussion
The answer is A. Parvovirus B19 is the causative agent responsible for erythema infectiosum, or fifth disease. The incubation period is 6 to 14 days. Outbreaks frequently occur at day schools, elementary schools, or junior high schools, and they frequently occur in the spring. Symptoms include a distinctive facial rash that has a “slapped-cheek� appearance, fever, arthralgias, and fatigue. Within 2 days, the facial rash gives rise to a generalized lace-like macular rash that involves the trunk. It has become increasingly clear over the past several years that parvovirus B19 causes arthritis and arthralgias in adults and children. Although parvovirus infections in adults are most commonly asymptomatic, an estimated 50% to 60% of women with symptomatic disease manifest arthropathy. Men appear to be affected much less frequently. Blood cell counts during the illness show leukopenia, lymphopenia, and thrombocytopenia with decreased reticulocytes. Because parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production, patients who have underlying hematologic abnormalities (and thus depend on a high rate of erythropoiesis) are prone to cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis, which may occur in persons with chronic hemolytic anemia and conditions of bone marrow stress. Thus, patients with sickle cell anemia, thalassemia, acute hemorrhage, and iron deficiency anemia are at risk. The diagnosis of erythema infectiosum is made clinically, and laboratory studies are not needed under normal circumstances. Serologic tests are usually relied on for the diagnosis of parvovirus B19 infection in patients with transient aplastic crisis or arthropathy; a positive parvovirus B19–specific IgM antibody or a significant rise in parvovirus B19–specific IgG titer is indicative of an acute or recent infection. Exposure during pregnancy can lead to fetal hydrops, spontaneous abortion, and fetal death. Supportive care during an attack of fifth disease is usually adequate, and the illness is self-limited. The risk of respiratory transmission is decreased significantly when the rash starts to fade. Children with erythema infectiosum are not infectious and can attend school and daycare.
Young NS, Brown KE. Parvovirus B19. N Engl J Med. 2004;350:586–597.
179. When administering varicella vaccine, it is important to note that simultaneous administration of what other vaccine can diminish the effectiveness of the varicella vaccine?
A) Measles, mumps, rubella (MMR) vaccine
B) Hepatitis B vaccine
C) Haemophilus influenzae vaccine
D) Pneumococcal vaccine
E) Influenza vaccine
View Answer
Answer and Discussion
The answer is A. Varicella is a highly contagious illness manifested by fever and a 3- to 5-day rash. Experts recommend live attenuated varicella zoster vaccine for healthy susceptible children (12 months and older), adolescents, and adults because of its high efficacy rate. Widespread use of the varicella vaccine has substantially decreased the rates of chickenpox and vaccine-related complications. Vaccinated persons develop milder symptoms with fewer skin lesions, which are more likely to be macular than vesicular. Residual scarring also is less common. However, atypical cases are making the diagnosis of varicella more difficult. Recent varicella exposure is the most useful clinical diagnostic hint because demonstration of viral antigen in skin scrapings or vesicular fluid is rarely available to the physician. It also is important to exclude similarly presenting conditions and to note that breakthrough varicella infection can be communicated to susceptible persons. Vaccination may be less effective in children younger than 15 months. However, because children 12 to 15 months of age are at risk and may not return at a later age for vaccination, the present recommendation remains to vaccinate at 12 months of age. Studies have found that children given a varicella vaccine within 30 days or less of receiving an MMR vaccine are at an increased risk of developing breakthrough varicella infection. Therefore, guidelines suggest separating the MMR and varicella zoster vaccines by 28 days if not given simultaneously.
Vãzquez M. Varicella infections and varicella vaccine in the 21st century. Pediatr Infect Dis J. 2004;23:871–872.
180. Transposition of the great vessels is associated with which of the following?
A) An aorta that arises from the left atrium
B) Cyanosis at birth with an intact ventricular septum
C) A pulmonary vein that empties into the right ventricle
D) A pulmonary artery that arises from the right ventricle
E) A superior vena cava that empties directly into the pulmonary circulation
View Answer
Answer and Discussion
The answer is B. Transposition of the great vessels is a cause of cyanotic heart disease. Male term infants are more commonly affected than are females, as are infants of diabetic mothers. The condition is associated with an aorta that arises from the right ventricle and a pulmonary artery that arises from the left ventricle. There are basically two types:
· Transposition with an intact septum
· Transposition with a ventricular septal defect
Because the systemic blood must mix with the pulmonary circulation, an intact ventricular septum leads to immediate cyanosis and death if not treated. In many cases, the ductus arteriosus remains open for several days, and cyanosis does not develop until it has fully closed. In most cases, congestive heart failure develops and can lead to death. Retardation of growth and development is common. Many (but not all) children will have an associated systolic murmur, and some show significant cyanosis at the time of birth. Chest radiographs may be normal but can show mild cardiomegaly with an egg-shaped heart with a narrow superior mediastinum and increased pulmonary vascular markings (“egg on a string�). Cardiac catheterization is used for the diagnosis, and surgery is performed to return the normal anatomic circulation or to place an intra-atrial shunt to redirect blood flow to the appropriate circulation.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1535–1538.
181. The most common organism isolated in periorbital cellulitis in vaccinated children in the absence of trauma is
A) Haemophilus influenzae
B) Streptococcus pneumoniae
C) Moraxella catarrhalis
D) Staphylococcus aureus
E) Pseudomonas aeruginosa
View Answer
Answer and Discussion
The answer is B. Periorbital and orbital cellulitis may be caused by trauma (e.g., a wound, an insect bite), an associated infection (e.g., sinusitis), or seeding from bacteremia. Before widespread immunization, Haemophilus influenzae type b was the most common cause secondary to bacteremia (about 80% of cases) and remains so in nonimmunized populations. Streptococcus pneumoniae accounted for most of the remaining 20%. S. pneumoniae is the most likely agent in Haemophilus influenzae type b-vaccinated patients when sinusitis is present. The most common pathogens associated with external foci (trauma) are Staphylococcus aureus and Streptococcus pyogenes, but these are seldom isolated from the blood. In general, a bacterial pathogen is isolated from the blood in <33% of patients with periorbital cellulitis.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:926–927.
182. A 4-year-old boy is noted to have impaired language development, compulsive repetitive behavior, impaired intelligence, and a preoccupation with inanimate objects. The most likely diagnosis is
A) conductive hearing loss
B) attention-deficit disorder
C) autism
D) manic–depressive disorder
E) dyslexia
View Answer
Answer and Discussion
The answer is C. Autism is a condition that is associated with abnormal social relationships, impaired language development and understanding, compulsive repetitive behavior with a resistance to change, and impaired intelligence; most affected individuals are in the mentally retarded range. The condition affects boys more frequently than girls and, in most cases, manifests itself before 1 year of age. Symptoms include a lack of attachment; preoccupation with inanimate objects; avoidance of eye contact; resistance to change; outbursts of temper; repetitive, often self-destructive acts; delayed speech development or total muteness; and seizures in severely impaired children. Neurologic examination fails to show focal findings. CT scans of the head may show enlargement of the ventricles, and EEG studies are usually unremarkable. Most children are brought to their doctors because of poor speech development. Treatment involves psychotherapy; however, results have been limited with regard to improving the child's deficiencies and behavior. Most children require special schooling. Mainstream treatment consists of early, intensive education for parents, focusing on behavior and communication disorders. A highly structured environment with intensive individual instruction should be encouraged. Laboratory, metabolic, or genetic tests and diagnostic imaging provide little useful information, although an EEG is indicated in children in whom epilepsy is suspected. No specific pharmacologic therapies are available, but many patients do not require medication. When needed, medication is generally used for a particular manifestation or constellation of symptoms. Families may benefit from ongoing counseling and support, and specific instructions for dealing with tantrums and destructive behavior. Parents should be cautioned about costly and often questionable dietary, medical, and other unconventional therapies.
Prater CD, Zylstra RG. Autism: a medical primer. Am Fam Physician. 2002;66:1667–1674, 1680.
183. An 18-year-old woman presents with swelling, warmth, and spreading redness at the upper part of her ear, where she recently underwent an ear piercing. Appropriate antibiotic coverage includes
A) cephalexin
B) ciprofloxacin
C) azithromycin
D) penicillin
E) tetracycline
View Answer
Answer and Discussion
The answer is B. The popularity of body piercing at sites other than the earlobe has grown since the mid-1990s. The tongue, lips, nose, eyebrows, nipples, navel, and genitals are frequent areas used for piercing. Complications include local and systemic infections, poor cosmetic results, and foreign body rejection. Swelling and damage to the dentition are common problems after tongue piercing. Minor infections, allergic contact dermatitis, keloid formation, and traumatic tearing may occur after piercing of the earlobe. “High� ear piercing through the ear cartilage is associated with more serious infections and disfigurement. Fluoroquinolone antibiotics are advised for treatment of auricular perichondritis because of their antipseudomonal activity. Navel, nipple, and genital piercings often have prolonged healing times.
Meltzer DI. Complications of body piercing. Am Fam Physician. 2005;72:2029–2034, 2035–2036.
184. Which of the following is NOT a contraindication for diphtheria-pertussis-tetanus (DPT) immunization?
A) Fever of 105°F (40.4°C) or higher within 48 hours after previous DPT dose
B) Current mild viral infection
C) Continuous crying for more than 3 hours after previous DPT dose
D) Convulsions within 3 days of a previous DPT dose
E) Progressive neurologic disorder that is not diagnosed
View Answer
Answer and Discussion
The answer is B. Several conditions are a contraindication to the DTaP immunization:
· Fever of 105°F (40.4°C) or higher within 48 hours after previous dose
· Previous anaphylaxis to the vaccine
· Moderate to severe current illness; febrile illness
· Encephalopathy within 7 days after a previous DTaP dose
· Progressive neurologic disorder that is not diagnosed
· Continuous crying for more than 3 hours within 48 hours after a previous DTaP dose
· Convulsions occurring within 3 days after a previous DTaP dose
Abate M, Bates D, Berga SL, Ladenson PW. PDR monthly prescribing guide. Montvale NJ: Thompson PDR. 2006;5:290.
185. Which of the following medications has been shown to shorten hospital stays in children with croup?
A) Epinephrine
B) Dexamethasone
C) Albuterol
D) Antiviral medication
E) Ipratropium bromide
View Answer
Answer and Discussion
The answer is B. Viral croup is the most common form of airway obstruction in children 6 months to 6 years of age. For children with mild croup, symptomatic care and mist therapy may be all that is necessary. Epinephrine has been used in the past to treat more severe cases of croup, but recent meta-analyses have found that glucocorticoid use is associated with shorter hospital stays, improvement in croup scores, and less use of epinephrine. Studies have shown that treatment with oral dexamethasone is as effective as intramuscular dexamethasone or nebulized budesonide. While more studies are needed to establish guidelines, oral dexamethasone can be used to treat mild to moderate croup with close follow-up and instructions for further care, if needed.
Knutson D, Aring A. Viral croup. Am Fam Physician. 2004;69:535–540, 541–542.
Glucocorticoid use in children with croup is associated with shorter hospital stays, improvement in croup scores, and less use of epinephrine.
186. A 3-month-old girl is brought into your office. The parent reports that she has been having excessive nonpurulent tearing from the left eye for the past 4 weeks. The most likely diagnosis is
A) congenital cataracts
B) Chlamydia trachomatis infection
C) dacryostenosis
D) glaucoma
E) viral conjunctivitis
View Answer
Answer and Discussion
The answer is C. Congenital stenosis of the nasolacrimal duct is associated with excessive tearing of usually one eye. The condition is rather common and usually affects children between 2 and 12 weeks of age. In most cases, the condition resolves by 6 months of age. Parents should be instructed to massage the duct 2 to 3 times daily. If no relief occurs by 12 months of age, the duct may need to be probed with the aid of anesthesia. Topical antibiotics should be administered if purulent discharge or conjunctivitis develops.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2099.
187. Which of the following (otherwise healthy) age groups is considered a priority group when administering influenza vaccine?
A) Birth to 6 months
B) 6 months to 23 months
C) 2 years to 5 years
D) Children under 7
E) Children in elementary school
View Answer
Answer and Discussion
The answer is B. Given the uncertainties in doses and distribution, the AAFP and the CDC recommend that the following priority groups receive trivalent inactivated influenza vaccine (TIV):
· Persons age >65 years with comorbid conditions
· Residents of long-term care facilities
· Persons ages 2 to 64 years with comorbid conditions
· Persons ages > 65 years without cormorbid conditions
· Children ages 6 to 23 months
· Pregnant women
· Health-care personnel who provide direct patient care
· Household contacts and out-of-home caregivers of children ages <6 months
CDC Update: Influenza vaccine supply and recommendations for prioritization during the 2005–2006 influenza season. MMWR. 2005;54(34):850.
188. Which of the following statements about transient cortical blindness is true?
A) It usually lasts 3 to 5 days.
B) It can be associated with head trauma.
C) It is associated with cerebral edema seen on computed tomography (CT) scans.
D) It is associated with permanent slowing seen on EEG.
E) It is commonly associated with other neurologic findings.
View Answer
Answer and Discussion
The answer is B. Transient cortical blindness is blindness without other focal neurologic signs that resolves in 24 hours; it is usually caused by mild head trauma. Head CT scans are unremarkable, and there is no evidence of skull fractures. EEG results initially show some slowing, which resolves spontaneously as the blindness dissipates.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2087–2089.
189. Which of the following medications is not approved for the treatment of influenza A in a 15-year-old adolescent?
A) Amantadine (Symmetrel)
B) Rimantadine (Flumadine)
C) Zanamivir (Relenza)
D) Oseltamivir (Tamiflu)
View Answer
Answer and Discussion
The answer is B. Four influenza antiviral agents are available in the United States: amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), and oseltamivir (Tamiflu). Amantadine and rimantadine are chemically related antiviral drugs known as adamantanes with activity against influenza A viruses, but not influenza B viruses. Amantadine was approved in 1966 for chemoprophylaxis of influenza type A virus infections among adults and children 1 year old or older. Rimantadine was approved in 1993 for treatment and chemoprophylaxis of influenza A inflection among adults and prophylaxis among children. Although rimantadine is approved only for chemoprophylaxis of influenza A infection among children, rimantadine treatment for influenza A among children can be beneficial. Zanamivir and oseltamivir are chemically related antiviral drugs known as neuraminidase inhibitors that have activity against both influenza A and B viruses. Both zanamivir and oseltamivir were approved in 1999 for treating uncomplicated influenza infections. Zanamivir is approved for treating persons 7 years or older, and oseltamivir is approved for treatment of persons 1 year or older. In 2000, oseltamivir was approved for chemoprophylaxis of influenza among persons 13 years or older.
CDC. Prevention and control of influenza. Recommendations of the Advisory committee on Immunization Practices (ACIP). MMWR. 2005;54(No. RR-8):1–40.
190. A painless, cystic structure in the scrotum that transilluminates but is not associated with the presence of sperm is most likely a
A) spermatocele
B) hydrocele
C) varicocele
D) epididymis
E) testicular tumor (Leydig cell)
View Answer
Answer and Discussion
The answer is B. Hydrocele is a common condition in which a collection of fluid forms between the tunica vaginalis and the tunica albuginea surrounding the testicle. It usually is noted as a painless, enlarging, cystic structure that transilluminates. It is usually an idiopathic congenital finding but can be associated with injury, infection, and, rarely, tumor. Most cases require no further treatment unless the patient is symptomatic or a hernia occurs; surgical consultation is then recommended. Ultrasound examination is usually not necessary, unless there is a question about the diagnosis or the mass does not transilluminate; in these cases, other conditions such as testicular tumors should be ruled out. In some cases, a communicating hydrocele may start out small in the early morning and enlarge throughout the day, or it may enlarge with Valsalva-type maneuvers (e.g., coughing, crying, changing position). Most hydroceles seen in newborns resolve during the first year, and parents need only to be reassured about the condition.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1820.
191. Which of the following statements regarding inhalant abuse is true?
A) Approximately 5% of children in middle school and high school have experimented with inhaled substances.
B) No associated fetal abnormalities have been associated with inhalant abuse during pregnancy.
C) Drug testing can help aid in the diagnosis of inhalant abuse.
D) Inhalant abuse can become addictive.
E) Reversal of inhalant effects can be achieved with the administration of naloxone (Narcan).
View Answer
Answer and Discussion
The answer is D. Inhalant abuse is a prevalent and common form of substance abuse in teenagers. Study results consistently show that nearly 20% of children in middle school and high school have experimented with inhaled substances. The method of delivery is inhalation of a solvent from its container, a soaked rag, or a bag. Solvents include almost any household cleaning agent or propellant, paint thinner, glue, or lighter fluid. Inhalant abuse typically can cause a euphoric feeling and can become addictive. Acute effects include sudden sniffing death syndrome, asphyxia, and serious injuries (e.g., falls, burns, frostbite). Chronic inhalant abuse can damage cardiac, renal, hepatic, and neurologic systems. Inhalant abuse during pregnancy can cause fetal abnormalities. Diagnosis of inhalant abuse is difficult and relies almost entirely on a thorough history and a high index of suspicion. No specific laboratory tests confirm solvent inhalation. Treatment is generally supportive, because there are no reversal agents for inhalant intoxication. Education of young persons and their parents is essential to decrease experimentation with inhalants.
Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician. 2003;68:869–874, 876.
192. Tick paralysis is associated with all of the following except
A) the bite of the Dermacentor or Amblyomma species of tick
B) muscle weakness, anorexia, lack of coordination, ascending flaccid paralysis
C) a bacteria harbored by the tick that serves as its vector
D) a neurotoxin produced by the tick's salivary gland
E) rapid recovery once the tick is removed
View Answer
Answer and Discussion
The answer is C. Ticks are capable of carrying many diseases. The Dermacentor and Amblyomma species of ticks found in North America have been linked to a condition called tick paralysis. Children, especially those with long hair that can hide ticks, are usually those affected. Manifestations include muscle weakness, anorexia, lack of coordination, lethargy, nystagmus, and an ascending flaccid paralysis. Sensory examinations and lumbar punctures are normal. In severe cases, respiratory and bulbar paralysis can occur. The paralysis is thought to be caused by inoculation of a neurotoxin that is found in the tick's salivary gland; it is not thought to represent a disease carried by the tick. Therefore, antibiotics are not indicated for affected patients; removal of the tick usually starts the recovery. Treatment of tick paralysis is symptomatic. In severe cases, mechanical ventilation may be necessary if respiratory paralysis occurs. Mortality rates can be as high as 10% for those with severe cases that go untreated. Removal of the tick usually results in improvement within a few hours and total recovery in a few days.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2074–2075.
193. Which of the following is true regarding Neisseria meningitides?
A) Serogroup B that accounts for the highest incidence of disease in young infants is prevented with administration of the vaccine.
B) Young adults affected with Neisseria meningitis typically have better outcomes than other age groups.
C) Eleven- to twelve-year-old adolescents should be vaccinated against Neisseria meningitides.
D) Antibiotic prophylaxis is only recommended for household contacts.
E) Even high-risk adults should not receive Neisseria meningitides vaccination because of potential side effects.
View Answer
Answer and Discussion
The answer is C. Neisseria meningitidis has an average annual incidence of one case per 100,000 in the United States. The disease can cause rapid death or result in severe neurologic and vascular damage despite antibiotic therapy. Antibiotic chemoprophylaxis with rifampin, ciprofloxacin, or ceftriaxone is recommended for household and other close contacts. The majority of cases of meningococcal disease are sporadic, but outbreaks can occur, and vaccination of the affected population often is required. Serogroup B accounts for the highest incidence of disease in young infants but is not included in any vaccine licensed in the United States. Adolescents and young adults 15 to 24 years of age have a higher incidence of disease and a higher fatality rate than other populations. Because 70% to 80% of these infections in the United States are caused by meningococcal serogroups C, Y, and W-135, which are contained in the tetravalent meningococcal vaccines, they can be prevented. The U.S. Food and Drug Administration recently approved a meningococcal conjugate vaccine containing serogroups A, C, Y, and W-135. The Advisory Committee on Immunization Practices recommends that this vaccine be given to 11- and 12-year-old adolescents, to adolescents entering high school, and to college freshmen living in dormitories. The vaccine also may be given to persons 11 to 55 years of age who belong to certain high-risk groups.
Kimmel SR. Prevention of meningococcal disease. Am Fam Physician. 2005;72:2049–2056.
194. Syringomyelia may expand during adolescent years. Typically, the first neurologic deficit is with
A) coordination
B) motor function
C) pain and temperature sensation
D) lower-extremity reflexes
E) mentation
View Answer
Answer and Discussion
The answer is C. A syringomyelia is a fluid accumulation that involves the spinal canal and is usually associated with the cervical area; however, it may extend to involve the entire spinal cord. The lesion may expand during adolescent years and can give rise to symptoms, including loss of sensation involving the distal extremities, upper shoulders, and back; spasticity; asymmetric or absent reflexes; and weakness with muscle wasting. Pain and temperature sensation are usually lost first. A rapidly progressing scoliosis may be the initial manifestation of syryngomyelia. The congenital abnormality is associated with an Arnold-Chiari malformation, with cerebellar tissue extending into the spinal canal. Diagnosis involves the use of CT scans, magnetic resonance imaging (the test of choice), and myelography. Treatment involves surgery to remove the pocket of fluid.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:2051.
195. Which of the following conditions is associated with meconium ileus?
A) Pyloric stenosis
B) Malrotation
C) Cystic fibrosis
D) Duodenal atresia
E) Hirshsprung's disease
View Answer
Answer and Discussion
The answer is C. Meconium ileus is almost always an early sign of cystic fibrosis. The thick meconium in meconium ileus is easily differentiated from the rubbery meconium plug of meconium plug syndrome. In meconium ileus the meconium adheres to the bowel mucosa and causes obstruction at the level of the terminal ileum. Distal to the obstruction, the colon is narrow in diameter and contains dry meconium pellets. The relatively empty colon of small caliber is termed a microcolon. Loops of distended small bowel can sometimes be palpated through the abdominal wall.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2309.
Meconium ileus is almost always an early sign of cystic fibrosis.
196. Which of the following statements about immunoglobulin A (IgA) deficiency is true?
A) It is the most common immunodeficiency.
B) It is associated with influenza vaccination administration.
C) Symptoms include night blindness, skin necrosis, and joint pain.
D) Treatment involves (scheduled) monthly antibiotic administration.
E) Most individuals affected die before age 20 years.
View Answer
Answer and Discussion
The answer is A. IgA deficiency is the most common immunodeficiency and results in a lack of IgA in secretions. It is the mildest form of immunodeficiency and affects 1 in 600 individuals. The condition has been associated with phenytoin administration, congenital intrauterine infections, and abnormalities of chromosome 18. Most affected individuals are asymptomatic. However, some affected individuals may have decreased immune status resulting in frequent respiratory infections, allergies, recurrent diarrhea, and various autoimmune disorders (e.g., lupus erythematosus, rheumatoid arthritis). In most cases, treatment is unnecessary. However, patients with recurrent respiratory infections may use antibiotics frequently. In some cases, the patient may experience spontaneous remission. Some patients may have antibody development to IgA, which can lead to anaphylactic reactions during blood transfusion.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:691.
197. When do symptoms of pyloric stenosis usually become noticeable?
A) After the first few feedings
B) Within the first week
C) At 4 to 6 weeks after birth
D) At 3 to 4 months of age
E) Pyloric stenosis does not typically cause symptoms
View Answer
Answer and Discussion
The answer is C. Pyloric stenosis may cause almost complete gastric outlet obstruction. Hypertrophy is rare at birth but develops over the initial 4 to 6 weeks of life, when signs of upper intestinal obstruction usually first appear. Males are affected more than females (4:1). Forceful projectile vomiting of feedings without bile usually begins late in the first month of life. Delayed diagnosis may lead to repeated vomiting, dehydration, failure to gain weight, and hypochloremic metabolic alkalosis (from losses of hydrochloric acid). Diagnosis is suspected by palpation of a discrete, 2- to 3-cm, firm, movable pyloric “olive-like mass� deep in the right side of the epigastrum and confirmed by identification of the hypertrophied pyloric muscle by abdominal ultrasonography. If the diagnosis is uncertain, a barium swallow will show delayed gastric emptying and the typical “string sign� of a markedly narrowed, elongated pyloric lumen. The treatment of choice is a longitudinal pyloromyotomy, which leaves the mucosa intact and separates the incised muscle fibers. Postoperatively, the infant usually tolerates feedings within a few days.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2284.
198. The most important recommendation a family physician can make regarding reducing the risk of death while riding a bicycle is
A) always wear shoes while riding
B) look both ways before crossing an intersection
C) use proper hand signals
D) make sure the bike is properly fitted
E) wear a helmet while riding
View Answer
Answer and Discussion
The answer is E. The peak incidence of bicycle-related injuries and fatalities is in the 9- to 15-year age group with a male-to-female ratio of 2 to 3:1. Important risk factors for bicycle-related injuries include not wearing a helmet, crashes involving motor vehicles, an unsafe riding environment, and male gender. In adolescents and young adults, alcohol and substance abuse can be associated with bicycle injury. Most injuries occur in boys and are associated with riding at high speed; most serious injuries and fatalities result from collisions with motor vehicles. Although superficial soft tissue injuries and musculoskeletal trauma are the most common injuries, head injuries are responsible for most fatalities and long-term disabilities. Overuse injuries may contribute to a variety of musculoskeletal complaints, compression neuropathies, perineal complaints, and genital complaints. Physicians treating such patients should consider medical factors, as well as suggest adjusting various components of the bicycle, such as the seat height and handlebars. Encouraging bicycle riders to wear helmets is key to preventing injuries; protective clothing and equipment and general safety advice also may offer some protection.
Thompson MJ, Rivara FP. Bicycle related injuries. Am Fam Physician. 2001;63:2007–2014, 2017–2018.
199. Which of the following is true regarding lice infestations?
A) They are obligate human parasites.
B) They frequently jump onto new hosts.
C) Person-to-person contact is not necessary for transmission.
D) Head and pubic lice may cause systemic disease.
E) The incidence of head lice is decreasing.
View Answer
Answer and Discussion
The answer is A. The three lice species that infest humans are Pediculus humanus capitis (the head louse), Phthirus pubis (the crab or pubic louse), and Pediculus humanus corpus (the body louse). All three species are obligate human parasites. Contrary to popular belief, these insects do not hop, jump, or fly. Instead, they are transmitted by person-to-person contact. Despite the introduction of new treatments, the frequency of lice infestation may be increasing. One explanation may be the development of resistance to current treatments. Fortunately, head and pubic lice do not transmit systemic disease. Hence, treatment is directed at relieving symptoms and preventing reinfestation and transmission.
Flinders DC, De Schweinitz P. Pediculosis and scabies. Am Fam Physician. 2004;69:341–348, 349–350.
200. Which of the following is the antibiotic of choice for treating infected dog bites?
A) Amoxicillin
B) Cephalexin
C) Azithromycin
D) Penicillin
E) Amoxicillin–clavulanate
View Answer
Answer and Discussion
The answer is E. Almost one-half of all dog bites involve an animal owned by the victim's family or neighbors. A large percentage of dog bite victims are children. Although some breeds of dogs have been identified as being more aggressive than other breeds, any dog may attack when threatened. All dog bites carry a risk of infection, but immediate copious irrigation can significantly decrease that risk. Only 15% to 20% of dog bite wounds become infected. Crush injuries, puncture wounds, and hand wounds are more likely to become infected than scratches or tears. Most infected dog bite wounds yield polymicrobial organisms. P. multocida and S. aureus are the most common aerobic organisms. Amoxicillin–clavulanate potassium (Augmentin) is the antibiotic of choice for an infected dog bite. For patients who are allergic to penicillin, doxycycline (Vibramycin) is an acceptable alternative, except for children younger than 8 years and pregnant women. Erythromycin can also be used, but the risk of treatment failure is greater because of antimicrobial resistance. Assessment for the risk of tetanus and rabies virus infection should be made. The dog bite injury should be documented with photographs and diagrams when appropriate. Patients who have been bitten by a dog should be instructed to elevate and immobilize the involved area. Most bite wounds should be reexamined in 24 to 48 hours, especially bites to the hands. Family physicians should educate parents and children on ways to prevent dog bites.
Presutti RJ. Prevention and treatment of dog bites. Am Fam Physician. 2001;63:1567–1572, 1573–1574.
201. A 7 year old with a history of mild asthma presents to your office complaining of wheezing and shortness of breath that have developed over the last 24 hours. She has not used any medication. Which of the following medications would be initially indicated?
A) Albuterol
B) Salmeterol
C) Cromolyn sodium
D) Inhaled corticosteroids
E) Theophylline
View Answer
Answer and Discussion
The answer is A. The prevalence of asthma in children has increased 160% since 1980, and the disease currently affects nearly 5 million children in the United States. Asthma triggers include allergens from dust mites or mold spores, animal dander, cockroaches, pollen, indoor and outdoor pollutants, irritants (e.g., tobacco smoke, smoke from wood-burning stoves or fireplaces, perfumes, cleaning agents), pharmacologic triggers (e.g., aspirin or other nonsteroidal anti-inflammatory drugs, β-blockers, sulfites), physical triggers (e.g., exercise, hyperventilation, cold air), and physiologic factors [e.g., stress, gastroesophageal reflux, respiratory infection (viral, bacterial), rhinitis]. The National Asthma Education and Prevention Program provides guidelines for improved asthma care. The four components of asthma management include regular assessment and monitoring, control of factors that contribute to or aggravate symptoms, pharmacologic therapy, and education of children and their caregivers. The guidelines recommend a stepwise approach to pharmacologic treatment, starting with aggressive therapy to achieve control and followed by a “step down� to the minimal therapy that maintains control. Quick relief of symptoms can be achieved preferentially by the use of short-acting β2 agonists. Medications for long-term control should be considered for use in children with persistent symptoms. Inhaled corticosteroids are the most potent long-term anti-inflammatory medications. Other options include long-acting β2 agonists (usually reserved for patients when other treatments have failed), cromolyn sodium and nedocromil, antileukotriene agents, and theophylline. All have advantages and disadvantages in individual situations. Poor compliance is a major problem in pediatric asthma management, and several factors play a role in this. These include the route of administration (oral therapy is preferred to inhaled medication), frequency of dosing (once- or twice-daily regimens are preferred), medication effects (a slow onset of action and long duration on discontinuance have poor adherence rates), and the risk or concern of side effects. The goals of pharmacologic therapy are to minimize daytime and nocturnal symptoms, the number of asthma episodes, and the use of short-acting β agonists to improve peak exploratory flow to 80% or more of personal best and to allow the child to maintain normal activities without producing adverse medication side effects.
Kemp JP, Kemp JA. Management of asthma in children. Am Fam Physician. 2001;63:1341–1348, 1353–1354.
202. Which of the following statements is true regarding sexual abuse in children?
A) Less than 10% of girls at age 18 years have been sexually abused.
B) Sexual acting out is a normal child activity and represents little concern.
C) Secondary enuresis can be a symptom of sexual abuse.
D) Physicians should make a careful decision if there is enough evidence to report parents suspected of sexual abuse.
E) A person who reports sexual abuse may be held liable if no abuse is found.
View Answer
Answer and Discussion
The answer is C. It is estimated that by the age of 18 years, 12% to 25% of girls and 8% to 10% of boys have been victims of sexual abuse. With this high prevalence, it is likely that primary care physicians will encounter child victims of abuse in their practice. Suspicion of sexual abuse should be raised when children exhibit behavioral changes or have anogenital or other medical problems. Behavioral changes include sexual acting out, aggression, problems in school, regression (e.g., return to thumb sucking, use of a security blanket), sleep disturbances, depression, and eating disturbances. Sexual acting-out behavior is the most specific indicator of possible sexual abuse. Medical problems include anogenital trauma, bleeding, irritation or discharge, dysuria, frequent urinary tract infections, encopresis, enuresis (especially after continence has been achieved), pregnancy, diagnosis of a STD, and oral trauma. Children may present with somatic complaints such as recurrent abdominal pain or frequent headaches resulting from the psychologic stress. Physicians are mandated to report suspected cases of child sexual abuse to the local child protective services agency. When sexual abuse is suspected or when a child discloses a sexual abuse event, a report should be made. In most states, the person who reports the suspected abuse case will not be held liable if the report is made in “good faith.
Lahoti SL, McClain N, Girardet R, et al. Evaluating a child for sexual abuse. Am Fam Physician. 2001;63:883–892.
203. Which of the following statements regarding colic in infants is true?
A) Newborns are usually noted to be colicky before discharge from the hospital.
B) Inadequate parenting is a common cause of colic.
C) Treatment consists of swaddling the infant firmly in a blanket.
D) Infants rarely respond to being held, rocked, or being patted.
E) Colic rarely occurs at predictable times of day.
View Answer
Answer and Discussion
The answer is C. The term infant colic is referred to as a symptom constellation that consists of paroxysms of crying, apparent abdominal pain, and irritability. Colic can begin shortly after a baby comes home from the hospital but more often begins some weeks later and may persist until age 3 or 4 months. Typically, the colicky infant eats and gains weight well. He or she may seem excessively hungry and often sucks vigorously on almost anything available. However, bouts of crying may represent significant stress to the family and parents. Colic often occurs at a predictable time of day or night, but a few infants cry almost incessantly. Excessive crying causes aerophagia, which results in flatulence and abdominal distention. The diagnosis of colic is a diagnosis of exclusion. Identifiable conditions must be ruled out by physical examination, blood count, urinalysis, or other studies as needed. In most cases no testing is necessary. Parents should be reassured that the baby's irritability is not due to poor parenting. The infant may respond to being held, rocked, or patted gently. An infant with a strong sucking urge who fusses soon after a feeding may need to suck more. A pacifier also may quiet the infant. A very active, restless infant may respond to being swaddled firmly with a small blanket. A milk-substitute formula may be tried briefly to ascertain whether milk intolerance exists. Parents should be assured that the colicky infant is healthy, that this behavior will cease in a few weeks, and that too much crying is not harmful.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2236.
204. An 18 month old is brought into your emergency room after being involved in a motor vehicle accident. The child's blood pressure is low and he is tachycardic and lethargic. His capillary refill is delayed and his mucous membranes are dry. Appropriate management consists of
A) oral rehydration
B) intravenous lactated Ringer's, 20 mL/kg given over 30 to 60 minutes
C) intravenous 0.45 normal saline, 20 mL/kg given over 30 to 60 minutes
D) intravenous D5 with normal saline, 20 mL/kg given over 30 to 60 minutes
E) intravenous D5 W, 20 mL/kg given over 30 to 60 minutes
View Answer
Answer and Discussion
The answer is B. Emergent resuscitation of infants and children typically involves fluid replacement. Fluid deficits can result from a host of conditions including infection, trauma, or dehydration. A short-term weight loss >1% body weight/day is presumed to represent a fluid deficit. The rate at which the deficit is replaced depends on the severity of dehydration and the rate of fluid loss. In general, when signs of circulatory compromise exist, 20 mL/kg of lactated Ringer's solution or 0.9% sodium chloride solution is rapidly infused intravenously to restore adequate perfusion. If circulation does not improve satisfactorily, more fluid is infused. Children in severe hypovolemic shock may require and tolerate fluid boluses totaling 60 to 80 mL/kg within the first 1 to 2 hours of presentation. The need for additional fluid should alert the physician to anticipate complications of acute shock. The remainder of the deficit can be replaced over 8 to 48 hours, depending on clinical need.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:299.
205. Pseudostrabismus is best diagnosed using a
A) Snellen's eye chart
B) funduscopic examination
C) cover/uncover test
D) corneal light reflex test
E) slit-lamp examination
View Answer
Answer and Discussion
The answer is D. Visual acuity improves as children become older. All children older than 8 years should be able to achieve 20/20 visual acuity using eyeglass correction. Younger children should be referred to an ophthalmologist if there is a difference between the right and left eyes of two or more lines on a Snellen's chart visual evaluation. Strabismus is the most common cause of amblyopia (decreased visual acuity). All infants should have consistent, synchronized eye movement by 5 to 6 months of age. Strabismus most often results from an altered reflex arc in the central nervous system. It can also result from cranial nerve palsies, neuromuscular disorders, or structural abnormalities. Amblyopia is not necessarily related to the degree of strabismus. Small deviations can result in significant vision loss. Strabismus is categorized as medial deviation (esotropia), lateral deviation (exotropia), or vertical deviation (hypertropia). Vertical deviation is the least common type. Deviations that are always manifested are called tropias, whereas those that are only elicited by provocative testing are called phorias. Intermittent strabismus occurs when there is inconsistent alignment. Usually, the angle between the normal eye and the strabismic eye stays constant through all directions of eye movement and is not influenced by the eye used for fixation. This is termed concomitant strabismus. When the eye divergence worsens in some gaze directions, the strabismus is nonconcomitant. This is characteristic of restrictive or paralytic etiologies. In the majority of cases, strabismus develops between 18 months and 6 years of age. Pseudostrabismus is an apparent esotropia that occurs when a child has a wide nasal bridge and prominent epicanthal folds. The corneal light reflex is symmetric with pseudostrabismus. No treatment is needed. Amblyopia is treated by forcing the use of the suppressed eye with a patch over the preferred eye. A schedule whereby the patch is removed for 1 to 2 waking hours each day reduces the risk of a deprivation amblyopia in the good eye. Once the visual goal is achieved, part-time patching is needed to prevent relapse and is often continued for many months to years. The shorter the time that amblyopia is present and the later the age at which it began, the better the prognosis.
Broderick P. Pediatric vision screening for the family physician. Am Fam Physician. 1998;58:691.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:1975–1976, 2084–2085.
Strabismus is the most common cause of amblyopia (decreased visual acuity).
206. Which of the following is recommended in pediatric adolescent screening?
A) Lipid profiles for all teenagers before age 18 years.
B) Blood chemistries to include electrolytes and complete blood cell count determination.
C) Routine screening for sexually transmitted diseases (STDs) in sexually active teens.
D) Tuberculosis screening for all teens.
E) Urinalysis for all girls over the age of 18 years.
View Answer
Answer and Discussion
The answer is C. Goals for Adolescent Pediatric Screening (GAPS) consists of 24 recommendations that encompass health care delivery, health guidance, screening, and immunizations. The objective of GAPS is to improve health-care delivery to adolescents using primary and secondary interventions to prevent and reduce adolescent morbidity and mortality. Following are the 24 recommendations made:
· From ages 11 to 21 years, all adolescents should have an annual routine health visit.
· Preventive service should be age and developmentally appropriate and should be sensitive to individual and sociocultural differences.
· Physicians should establish office policies regarding confidential care for adolescents.
· Parents or other adult caregivers of adolescents should receive health guidance at least once during early adolescence, once during middle adolescence, and, preferably, once during late adolescence.
· All adolescents should receive general health guidance annually.
· All adolescents should receive guidance annually to promote the reduction of injuries.
· All adolescents should receive guidance annually about dietary habits.
· All adolescents should receive guidance annually about the benefits of exercise and should be encouraged to engage in safe exercise on a regular basis.
· All adolescents should receive guidance annually regarding responsible sexual behaviors, including abstinence. Latex condoms to prevent STDs (including HIV infection) and appropriate methods of birth control should be made available with instructions on ways to use them effectively.
· All adolescents should receive guidance annually to promote avoidance of tobacco, alcohol and other abusable substances, and anabolic steroids.
· All adolescents should be screened annually for hypertension according to the protocol developed by the National Heart, Lung, and Blood Institute's Task Force on Blood Pressure Control in Children.
· Selected adolescents should be screened to determine their risk of developing hyperlipidemia and adult coronary heart disease, following the protocol developed by the Expert Panel on Blood Cholesterol Levels in Children and Adolescents.
· All adolescents should be screened annually for eating disorders and obesity.
· All adolescents should be asked annually about their use of tobacco products, including cigarettes and smokeless tobacco.
· All adolescents should be asked annually about their use of alcohol and other abusable substances, and about their use of over-the-counter or prescription drugs, including anabolic steroids, for nonmedical purposes.
· All adolescents should be asked annually about involvement in sexual behaviors that may result in unintended pregnancy and STDs, including HIV infection.
· Sexually active adolescents should be screened for STDs.
· Adolescents at risk for HIV infection should be offered confidential HIV screening. (Newer guidelines recommend longer screening intervals.)
· Female adolescents who are sexually active and women 18 years or older should be screened annually for cervical cancer by use of a Papanicolaou test.
· All adolescents should be asked annually about behaviors or emotions that indicate recurrent or severe depression or risk of suicide.
· All adolescents should be asked annually about a history of emotional, physical, or sexual abuse.
· All adolescents should be asked annually about learning or school problems.
· Adolescents should receive a tuberculin skin test if they have HIV, have been exposed to active tuberculosis, have lived in a homeless shelter, have been incarcerated, have lived in or come from an area with a high prevalence of tuberculosis, or currently work in a health care setting.
· All adolescents should receive prophylactic immunizations according to the guidelines established by the federally convened Advisory Committee on Immunization Practices.
Elster AB, Kuzsets NJ, eds. AMA guidelines for adolescent preventive services (GAPS). Recommendations and rationale. Arch Pediatr Adolesc Med. 1997 Sept;151(a):958–959.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:643–646.
207. The major difference between stuttering and developmental dysfluency is
A) stuttering involves repetition of word parts and prolongation of sounds
B) stuttering involves repetition of whole words and phrases
C) stutterers tend to speak more slowly than those with developmental dysfluency
D) those affected with developmental dysfluency are more easily frustrated
E) those with developmental dysfluency may display inappropriate articulating postures
View Answer
Answer and Discussion
The answer is A. The etiology of stuttering is controversial. Today, the prevailing theory is that stutterers have subtle neurophysical dysfunctions that disrupt the precise timing required to produce speech. Stutterers also have difficulty coordinating airflow, articulation, and resonance. In addition, small asynchronies have also been found in the fluent speech of stutterers. Stuttering is a common disorder that usually resolves by adulthood. Boys are more frequently affected, and there appears to be an increased genetic risk. Generally, there is cause for concern if a patient's speech has five or more breaks per 100 words. Almost 80% of children who stutter recover fluency by the age of 16 years. 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. Differentiating between normal developmental dysfluency and stuttering is important. In general, developmental dysfluency involves the repetition of whole words and phrases, whereas stuttering involves the repetition of word parts and the prolongation of sounds. In addition, stutterers frequently speak at a faster tempo, display silent pauses, have inappropriate articulating postures, become more dysfluent in response to stress, and are more easily frustrated.
Lawrence M, Barclay DM. Stuttering: a brief review. Am Fam Physician. 1998;57:2175.
Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:102.
208. Which of the following is an acceptable criterion for discharging a premature infant from the neonatal unit?
A) Body temperature is maintained in an open crib.
B) The child is maintaining its birth weight.
C) The child is gaining weight of 5 g/day.
D) The child can tolerate tube feeds.
E) The child can react to external stimuli.
View Answer
Answer and Discussion
The answer is A. Because of the increased survival rate and because many neonatal intensive care units now allow early discharge, family physicians are increasingly likely to provide care to small, premature infants after discharge from the hospital. Most neonatal units have no minimum weight requirement for discharge (although most are at least 1,800 to 2,100 g). Medical guidelines for discharge are as follows:
· Body temperature is maintained while the infant is in an open crib, usually at 34 weeks of gestational age or at 2,000 g (4 lb, 6 oz) of weight
· The infant feeds by mouth well enough to have a weight gain of 10 to 30 g/day
· The infant is not receiving medications that require hospital management
· No recent major changes in medications or oxygen administration have occurred
· No recent episodes of apnea or bradycardia
During the first 2 years of life, growth is plotted using age corrected for prematurity. Growth charts for the “average� premature infant have been designed for this purpose. After the infant reaches 2 years of age, a standard growth chart for chronologic age may be used. The infant's development during the first 2 years should be plotted from the infant's estimated due date rather than the infant's birth date. The Denver Prescreening Developmental Questionnaire, the Denver Developmental Screening Test, and the Gesell Screening Inventory are all accepted tests. Using a standardized developmental test is more important than the choice of test. The timing of immunizations in the physician's office should be based on the infant's chronologic age, not the gestational age. The only exception is hepatitis B vaccination. The American Academy of Pediatrics Committee on Infectious Diseases has issued a statement indicating that it may be advisable to delay administration of hepatitis B vaccine until the infant weighs 2,000 g (4 lbs, 6 oz). The full dose of all immunizations should be given. As with term infants, premature infants should be given the acellular pertussis vaccine when it is available. Influenza vaccine should be given to infants older than 6 months with chronic medical problems, especially lung disease. With all premature infants, consideration should also be given to administering influenza vaccine before the influenza season to parents and other frequent visitors in the home. Administration of the pneumococcal vaccine at 2 years of age may be beneficial in infants with chronic problems such as lung disease; more recently, the heptavalent vaccine (Prevnar) has been given.