Day 27 Flashcards
Q1-A 4-month-old girl presents with several weeks of chronic wheeze and apneic episodes 20–30 minutes after feeds. She has been spitting up after feeds since birth. The infant has presented to the office on several occasions with the same complaint despite adjustments in feed technique and formula consistency. She is at the 5th percentile for weight. Which of the following is the most appropriate intervention?
A-Erythromycin B-Fundoplication C-Metoclopramide D-Ranitidine E-Omeprazole
Ans: D. GERD results from incompetent esophageal sphincter tone early in life. Symptoms typically resolve by 12–24 months. Diagnosis is clinical. However, the best initial test is esophageal pH monitoring. Endoscopy is used to evaluate for erosive gastritis or other complications. The best initial management is a change in feeding technique and thickened feeds. H2-receptors are considered first line in children because of the safety profile. However, proton pump inhibitors tend to be more effective in suppressing gastric acid production.
Q2-A 4-week-old boy presents with recurrent vomiting after feeds. Vomitus is nonbilious in nature. Laboratory findings include chloride 88 mEq, potassium 3.1 mEq, sodium 146 mEq, and pH 7.48. What is the best initial test in the workup of this infant?
A-Abdominal x-ray B-Barium enema C-CT scan of the abdomen D-Ultrasound E-Esophageal pH monitoring
Ans: D. The case will describe a first-born European-Caucasian male with nonbilious projectile vomiting typically in first 6 weeks of life. There is hypochloremic and metabolic alkalosis, and a firm, mobile, 1-inch mass is often palpated in the epigastrium. The best initial test is ultrasound of the abdomen. Treatment is pyloromyotomy. Abdominal x-ray is less useful in identifying pyloric stenosis and is not the test of choice in cases where clinical suspicion is high. CT scan is not indicated to prevent exposure to radiation when a more appropriate test is available.
Q3-A 2-year-old boy is brought to the office because his mother has noticed bleeding in his diaper for 1 week. The child has had no complaints. Physical examination is unremarkable. Which of the following is the best initial test?
A-Guaiac exam B-Push enteroscopy C-Red blood cell tagged scan D-Tc-99m pertechnetate scan E-Upper endoscopy
Ans: D. The Tc-99m pertechnetate scan is also known as the Meckel radionuclide scan, the diagnostic exam for Meckel diverticulum. Intermittent, painless rectal bleeding is the classic presentation due to acid-related bleeding of aberrant mucosa (remnant of embryonic yolk sac). May present with intussusception (remnant may become a lead point) or diverticulitis or look like acute appendicitis.
Q4-A 16-month-old child is seen for cramping and colicky abdominal pain for the past 12 hours. He has a 1-week history of diarrhea but developed episodes of vomiting and passed black-bloody stool today. Physical examination is remarkable for a lethargic child; abdomen is tender to palpation. Temperature is 101.3°F. White blood count is 18,000. Which of the following is the most important next step in management?
A-Antibiotic prophylaxis B-Bowel resection C-Electrolyte replacement D-Reduction of bowel E-Embolectomy
Ans: D. Reduction of telescoped bowel is the priority of management in patients presenting intussusception.
Q5-A 2-year-old girl presents with a urinary tract infection. She has had multiple urinary tract infections since birth but has never had any follow-up studies to evaluate these infections. Physical examination is remarkable for an ill-appearing child who has a temperature of 40°C (104°F) and is vomiting. Voiding cystourethrogram reveals abnormal urinary backflow from the bladder. Which of the following is the most important step to prevent permanent damage?
A-ACE inhibitors B-Trimethoprim-sulfamethoxazole C-NSAIDs D-Regular creatinine measurement E-Surgical reconstruction
Ans: B. Antibiotic prophylaxis (trimethoprim-sulfamethoxazole or nitrofurantoin) is used for the 1st year following diagnosis for any grade of VUR, particularly in younger infants, to prevent kidney scarring from recurrent infections.
Q6-A 10-year-old boy presents with lower extremity swelling. He has had a sore throat for 2 weeks and fever. His mother has noticed very dark, brownish-red urine over the past couple of days. He has no known allergies. On physical examination, his blood pressure is 185/100 mm Hg. Which of the following is indicated for management?
A-ACE inhibitors B-Diuretics C-Erythromycin D-Penicillin E-Oral prednisone
Ans: D. The most appropriate therapy for APGN is antibiotics to eradicate the underlying infection. Penicillin is the drug of choice. Erythromycin is used on patients who are penicillin-allergic.
Q7-A 3-year-old child presents to the physician with puffy eyes. The mother reports diarrhea 2 weeks ago. On physical examination, there is no erythema or evidence of trauma, insect bite, cellulitis conjunctival injection, or discharge. Urinalysis reveals 3+ proteinuria. Laboratory profile is significant for albumin 2.1 mg/dL creatinine is 0.9; and C3 and C4 are normal. Which of the following is the next step in management?
A-Outpatient prednisone B-Hospitalize and observe C-Heparin D-High-dose methylprednisone E-Intravenous antibiotics
Ans: A. Outpatient prednisone is the first step in management of patients presenting with mild cases of minimal change disease. Prednisone is continued daily for 4–6 weeks, and then tapered to alternate days for 2–3 months without initial biopsy.
Q8-An 18-month-old presents with a fever for 1 week and a rash on his hands with desquamation that developed today. On examination, he is noted to have conjunctival injection, erythematous tongue, cracked lips, and edema of the hands. He has palpable and painful lymph nodes in the neck. What is the next step in management?
A-Anticoagulation B-Echocardiogram C-IVIG D-Methylprednisolone E-Prednisone
Ans: C. Kawasaki disease is an acute vasculitis of medium-sized arteries and the leading cause of acquired heart disease in the United States and Japan. IVIG and highdose aspirin should be started immediately to prevent coronary artery involvement (reduces risk from 25 percent to < 5 percent). Echocardiogram should be performed at diagnosis for baseline measurement; however, coronary artery abnormalities occur in the 2nd to 3rd week.
Q9- A 28 y/o female is naked wandering in the street. When she is caught and questioned by the police, she replies, “I heard a voice from the sky telling me to do so to attract people.” When she talks, she frequently changes topics, with euphoric and labile affect. She denies having similar history in the past. What’s the most likely diagnosis?
A-Schizophrenia B-Schizophreniform disorder C-Delusional disorder D-Schizoaffective disorder E-Brief psychotic disorder
Ans: D.Schizoaffective disorder = Illogical thinking and association + labile affect, but not consistent with the criteria of schizophrenia.
Q10-A 6-year-old girl presents with her 3rd episode of pallor and mildly icteric sclera associated with symptoms of mild upper RTI. On examination, she has an easily tipped spleen. Which one of following investigations is most likely to confirm her diagnosis?
A-Coombs test B-Reticulocyte count C-Eosin-5-maleimide (E5M) staining test D-Hb electrophoresis E-Howell-jolly bodies in a RBC smear
Ans: D - Case of sickle cell disease
• Infection (autosplenectomy by age 5) leads to increased susceptibility to infection, particularly with encapsulated bacteria (S. pneumococcus, H. influenzae, and N. meningitidis).
• Acute chest syndrome (this and sepsis are most common causes of mortality).
• Acute splenic sequestration (peak incidence from 6 months to 3 years of age).
Q11-A 4-year-old child is brought in by her mother because of red “spots and rashes” on her lower extremities. Today she fell from her bicycle and was bleeding for 30 minutes. She has no known medical problems, and the only significant history is a recent upper respiratory viral illness. Examination reveals petechiae in lower extremities and purpura on her buttocks. There are no signs of active bleeding.PT, PTT, and bleeding time is within normal limits. Platelet count is 32,000. Hemoglobin is 12 mg/dL. What is the next step in the workup?
A-Bone marrow biopsy B-Factor levels C-Mixing study D-Peripheral smear E-Ristocetin assay
Ans: D. This case is a classic presentation of immune thrombocytopenic purpura (ITP) in childhood. The most common age of onset is 1–4 years, usually after a nonspecific viral infection. The defect is autoantibodies against the platelet surfaces. Diagnosis is by exclusion. Always get a peripheral smear to rule out TTP and HUS.
Q12-You are asked to see a previously well 13-month-old boy who is brought in after a generalized tonic-clonic seizure 1 hour ago. The seizure lasted 6minutes. The mother remembers that a similar episode occurred when she was a child. On examination vitals are BP 100/52, HR 110, Temp 101.4°F, RR 32. She wishes to know if her child has epilepsy. What is the most appropriate response to the parents?
A-Reassure mother that there is no risk of epilepsy
B-There is a slightly increased risk of epilepsy
C-There is a high risk of epilepsy developing in the next year
D-The patient has epilepsy but medications will be withheld until second episode of seizure.
E-The patient has epilepsy and will require anti-seizure medications
Ans: A. This patient presents with simple febrile seizure-generalized tonic-clonic seizure < 10 min duration occurring with rapid onset high fever (when > 39°C [102°F]) in child 9 months to 5 years of age. There is usually positive family history. There is no risk of epilepsy. Management includes evaluation for meningitis and controlling fever. DO NOT order EEG or neuroimaging.
Q13-A 5-month-old child presents with lethargy, poor feeding, and irritability. He has been vomiting for 2 days and has had a temperature of 101.3°F. On exam, the fontanelles are noted to be bulging, and there is paralysis of the lateral gaze on the left side. The mother reports that he is up-to-date on all vaccinations. Which of the following is the next step in management?
A-CT scan of the head B-Empiric antibiotics C-Lumbar puncture D-Steroids E-Urine culture
Ans: B. This history is highly suggestive of meningitis. However, the patient is also exhibiting signs of increased intracranial pressure, a contraindication to lumbar puncture
(Workup of meningitis includes blood culture and lumbar puncture, unless there are signs of ICP). CT scan is not sensitive in diagnosing increased ICP or meningitis. It is not required for the initiation of antibiotics when clinical suspicion is high. The most important next step in management is to begin empiric antibiotics based on clinical suspicion. Intravenous dexamethasone has been shown to be of value in management of meningitis due to HiB. However, HiB is uncommon in the United States with the advent of vaccines, which protect infants against HiB infections.
Q14-A 22-year-old woman comes to the physician because of a missed menstrual period. She has a complex past medical history. She has hypothyroidism, for which she takes thyroxine, she has an artificial heart valve, for which she takes warfarin, and she recently started tetracyclinefor acne. She does not think that she is pregnant because she is currently on the oral contraceptive pill, but, if pregnant, she would keep the pregnancy. Physical examination, including pelvic examination, is unremarkable. Urine human chorionic gonadotropin (hCG) is positive. Which of the following medications should the patient continue to take during the pregnancy?
A-Warfarin B-Oral contraceptive pill (OCP) C-Tetracycline D-Thyroxine E-Discontinue all medications
Ans: D. Hypothyroidism is associated with several complications regarding fertility and pregnancy. Women with overt hypothyroidism have increased rates of infertility. Women with uncorrected hypothyroidism that do become pregnant are at increased risk of having stillborn and low-birth-weight infants. Various studies have also shown that rates of preeclampsia, placental abruption, and heart failure may be increased in pregnant patients with hypothyroidism. Pregnancy often leads to an increased requirement for thyroid hormone replacement (thyroxine) as the pregnancy
Progresses. Pregnant women with hypothyroidism on thyroxine should have their thyroid stimulating hormone (TSH) level checked periodically to determine if the drug dosage is adequate. This patient, with her history of hypothyroidism, should continue her thyroxine during the pregnancy.
Warfarin (choice A) is contraindicated during pregnancy, as it is a known cause of birth defects. This patient needs anticoagulation, however, and should be placed on heparin, which does not cross the placenta.
It is possible to become pregnant while taking the oral contraceptive pill (choice B), as the pill has a small rate of failure. There is no known association between first trimester exposure and birth defects. Now that the patient has become pregnant, however, she should stop taking the OCP.
Tetracycline (choice C) is used to treat some forms of acne and, therefore, some
Women will become pregnant while on the medication. Its use is contraindicated during pregnancy, however, because it is associated with fetal teeth and bone malformations. To state that the patient should discontinue all medications (choice E) is absolutely incorrect. While some medications are contraindicated during pregnancy.
Q15-A 23-year-old woman (G3 P1 Abortion 1) is seen at 18 weeks gestation. She recently underwent a triple marker screen with the maternal serum alpha fetoprotein (normal< 2.2 MoM). Her test showed an elevation in maternal serum alpha fetoprotein. On examination, her uterus is at the umbilicus. What is the next step in management?
A-Amniocentesis B-Chorionic villus sampling C-Inhibin A D-Ultrasound E-Recommendation of termination of pregnancy
Ans: D. The most common cause of an abnormal maternal serum alpha fetoprotein (MS-AFP) is gestational dating error. The first step in evaluating any pregnancy with an abnormal MS-AFP is to get an obstetric ultrasound to confirm the gestational date.
