Module 4

Question 1

A Hispanic woman brought her 5-year-old son to the clinic. The child had been suffering from gastrointestinal (GI) illness for the last three days, for which the mother gave him home remedies. At presentation, the child is lethargic and has lost his appetite. What should be the most concerning diagnosis for this patient?

1. Enteric fever
2. Meningitis
3. Lead poisoning
4. Rotavirus infection

Answer 1

3. Lead poisoning

POINTS
It is a tradition in Hispanic families to treat GI illnesses with homemade herbal medication.
The herbal powder which is used in this tea contains lead oxide.
This herbal tea can lead to lead toxicity.
The most concerning diagnosis would be lead toxicity.

Question 2

A 5-week-old female was brought to the clinic with the complaint of projectile vomiting after every feed. On examination, there was a small lump in her upper abdomen. What additional findings should the healthcare provider expect?

1. Rash around the umbilicus
2. Abdominal tenderness and guarding
3. Peristalsis across the abdomen
4. Neck stiffness

Answer 2

3. Peristalsis across the abdomen

POINTS

Pyloric stenosis is the condition in which the distal end of the stomach becomes narrow, which prevents the entry of food from the stomach to the small intestine.
It is diagnosed at 3 to 5 weeks of age.
The infant presents with projectile vomiting after every feed.
Examination shows an olive size mass in the upper abdomen and peristalsis across the abdomen.

Question 3

A 2-day-old male neonate is being evaluated for a new rash that appeared in the newborn nursery. The baby had no delivery or postnatal complications. The infant has been feeding well. Vital signs are within normal limits. Which of the following physical exam findings is most consistent with a benign condition in this patient?

1. Grouped vesicles over the scalp
2. Papules surrounded by an erythematous base
3. Erythematous hands and feets
4. Multiple large bumps around the diaper area

Answer 3

2. Papules surrounded by an erythematous base

POINTS

Papules surrounded by an erythematous base are consistent with erythema toxicum.
Erythema toxicum is a common condition that affects more than half of newborns.
Erythema toxicum is a benign condition that resolves spontaneously.
Grouped vesicles are concerning for herpes virus infection and require prompt investigation and treatment. Erythematous hands and feet can indicate congenital syphilis. Large pustules in the diaper area are suggestive of impetigo.

Question 4

A 5-year-old male is brought to the emergency department after having a seizure at home, which stopped on its own after 30 seconds. The mother states that the boy has been having trouble coloring and tying his shoes for the past month. He has been more irritable. On exam, the patient is ill-appearing and lethargic but moves all extremities and speaks in short sentences. Initial labs are significant for normocytic, hypochromic anemia, and pending interpretation of smear. Lead levels come back at 75 mcg/dL. What is the most appropriate management strategy for this patient?

1. Admit to the floor for inpatient parenteral chelation therapy
2. Admit to the intensive care unit for inpatient parenteral chelation therapy
3. Discharge home with a case management consultation
4. Discharge home with outpatient chelation therapy

Answer 4

2. Admit to the intensive care unit for inpatient parenteral chelation therapy

POINTS

• The child, in this case, has an elevated lead level and symptoms of acute lead toxicity/encephalopathy. Although there is no safe threshold for lead in the blood, the CDC considers 5 mcg/dL or more to be the level at which public health actions should be initiated.
• Any symptomatic child (at any blood lead level), such as the child in this case, or who has a blood lead level above 70 mcg/dL, should be hospitalized and undergo chelation therapy. However, the intensive care unit is most appropriate due to his altered mental status.
• Two oral chelation agents are available for the treatment of lead poisoning: succimer (dimercaptosuccinic acid or DMSA) and penicillamine. Succimer has received FDA approval for use in the lead-poisoned patient, but penicillamine has not. However, penicillamine is used in Europe to treat lead poisoning (mainly in adults). Different sources report different treatment regimens for children, including oral chelation with succimer or intravenous or intramuscular chelation with calcium disodium EDTA alone and British anti-Lewisite (BAL), also known as dimercaprol. Children with lead encephalopathy should be treated with combination therapy with calcium disodium EDTA and BAL. BAL should be administered before CaNa2EDTA to prevent increased CNS uptake.
• Discharge is not the correct option for this child: he is symptomatic, and any symptomatic child with an elevated blood lead level should be admitted for chelation therapy. Asymptomatic children with blood lead levels of 5 to 44 mcg/dL may be safely discharged with a case management consultation to assess the child’s environment for sources of lead. Asymptomatic children with blood lead levels of 45 to 69 mcg/dL may also be discharged home with oral outpatient chelation therapy with close follow-up and case management involvement.

Question 5

A 3-day-old neonate is brought by her parents for an initial visit. She was born via spontaneous vaginal delivery at 37 weeks gestation. The family recently moved to the area, and her mother did not receive any routine prenatal care. The family has a dog and a cat, both of whom live inside with the family. Physical exam reveals a continuous machine-like murmur best heard at the left sternal border, and the infant’s red reflex is absent bilaterally. For which of the following complications is the patient at greatest risk?

1. Sensorineural hearing loss
2. Notched teeth
3. Obstructive hydrocephalus
4. Chorioretinitis

Answer 5

1. Sensorineural hearing loss

POINTS

• Infants with congenital rubella often have cataracts and a patent ductus arteriosus (PDA), which can cause prolonged left to right shunting and congestive heart failure.
• PDA presents with a continuous machine-like murmur at the upper left sternal border.
• Sensorineural hearing loss is a sequela of congenital rubella, which can present as a failed hearing screen in a newborn or develop later in life.
• Notched teeth (i.e., Hutchinson’s teeth) are a late finding of untreated congenital syphilis. Congenital toxoplasmosis causes chorioretinitis as well as obstructive hydrocephalus and parenchymal calcifications.

Question 6

A 17-year-old male presents to the emergency department complaining of pain and swelling over the third metacarpophalangeal joint. He mentions that he was in a fight and hit his opponent, knocking out a couple of teeth. On examination, the injured area is swollen and red, with a decreased range of motion at the third metacarpophalangeal joint. Which of the following antibiotics is indicated in the management of this patient?

1. Amoxicillin-clavulanate
2. Tigecycline
3. Erythromycin
4. Metronidazole

Answer 6

1. Amoxicillin-clavulanate

POINTS

• Human bites represent about 3% of the total bite injuries seen in the emergency department and are most commonly closed-fist injuries.
• The physical trauma from a human bite is rarely spectacular, with relatively minor lacerations and occlusion bruising being the main initial findings. Human oral flora and contagious disease spread to account for the greater amount of morbidity with human bites. Eikenella corrodens, as well as more common aerobic and anaerobic bacteria, are normal human flora.
• All wounds should be extensively irrigated, and the patient’s tetanus status updated if necessary. Provide appropriate pain management before exploration, irrigation, or debridement of the wounds. All human bite wounds that pierce the skin should receive amoxicillin-clavulanate prophylaxis for a week, and the patient is given strict wound care precautions.
• If signs or symptoms of infection in a joint space or tendon sheath are present, orthopedics should be consulted for evaluation for surgical washout and inpatient treatment with IV antibiotics.

Question 7

A 17-year-old male is brought to the emergency department with complaints of headache and jerky movements of the left side of his body. The patient has ulcerative colitis and has been on oral azathioprine and corticosteroids for the last 3 years. He has been having severe right-sided headaches for the past 5 days. Today, he developed sudden onset jerky movement of his left side, which lasted for 5 minutes. The patient did not lose consciousness during the episode. His examination reveals a blood pressure of 120/70 mmHg, pulse of 115 beats per minute, a temperature of 99 F (37.2), and a respiratory rate of 22 breaths per minute. His neurological examination reveals power of 3/5 on the left upper and lower arm with diminished reflexes. The left plantar is absent. There is mild upper motor neuron type facial palsy on the left side of the face. His cardiovascular, respiratory, and gastrointestinal examination is unremarkable. The investigations reveal a WBC of 7,000 per microliter, hemoglobin of 11 gm/dl, platelets of 90,000 per microL, serum ALT 75 IU/l, serum AST 55 IU/l, serum LDH 620 IU/l, CRP 55 mg/l, and serum creatinine 1.1 mg/dl. CT brain reveals two hypodense lesions in the right frontal-parietal region, which demonstrate ring enhancement. CSF analysis reveals a protein count of 105 cells/microL, protein of 120 mg/dl, and glucose of 45 mg/dl. A Giemsa stain on the centrifuged specimen reveals crescent-shaped organisms with blue cytoplasm and red staining nucleus. The patient is started on carbamazepine for the seizures and appropriate treatment of the cerebral lesions. Which of the following side effects is this patient most likely to suffer due to the patient’s previous treatment regimen?

1. Heart block
2. Renal failure
3. Pulmonary fibrosis
4. Bone marrow suppression

Answer 7

4. Bone marrow suppression

POINTS

• This patient is on glucocorticoids due to a preexisting disease and had developed a new-onset headache and focal seizures. The CT scan and CSF findings are characteristic of toxoplasmosis. The treatment is with pyrimethamine, which poses a risk of bone marrow suppression. Bone marrow suppression can also be caused by carbamazepine and phenytoin, which are commonly used in these patients as well.
• Pyrimethamine inhibits dihydrofolate reductase and prevents the formation of tetrahydrofolate, thus inhibiting DNA synthesis, which leads to bone marrow suppression. When administered for treatment of toxoplasmosis, close monitoring of complete blood count is necessary.
• Folinic acid (leucovorin) is added to the regimen when treating patients with toxoplasmosis. Folic acid is not an appropriate replacement.
• Treatment of toxoplasma gondii is often prolonged; careful monitoring for potential drug interactions and toxicities is essential in reducing side effects.

Question 8

A female complains of several areas of isolated urticaria on her arms and legs. There are no signs of purulence or drainage. The patient denies fevers, chills, nausea, vomiting, neurologic changes. She notes she lives in a house with several other individuals with numerous outdoor cats and reports poor access to hygiene products. Which of the following is an appropriate treatment for her rash?

1. Vancomycin
2. Ice packs
3. Topical antihistamines
4. Selenium shampoo

Answer 8

3. Topical antihistamines

POINTS

• The patient in this question is presenting with flea bites.
• Flea bites result in papular urticaria that is treated symptomatically.
• Topical antihistamines are an appropriate treatment of choice.
• Antibiotics are not indicated here are there are no signs of infection at this time.

Question 9

A healthy 18-month-old boy is brought in with lower extremity burns. He is accompanied by his babysitter, who says he spilled boiling milk over himself. She washed it off of him as soon as she found him crying and brought him in immediately. She has babysat him since he was born. The patient does not take medications. He has no known drug allergies. Examination shows a fussy child with patches of blistered, red skin on the back, buttocks, and legs. Which of the following is an alarming sign of child abuse in this patient?

1. Patches of blisters
2. Uniform burn depth
3. Burns involving the flexure creases
4. Presence of splash marks

Answer 9

2. Uniform burn depth

POINTS

• The clinical vignette is consistent with an intentional scald injury. Burns due to deliberate immersion in a hot liquid usually involve the buttocks, back, and legs as the child is placed into a bathtub containing hot water.
• The sparing of flexural creases due to ankle, knee, and hip flexion at the time of forced immersion, the stocking burn distribution with a sharp line of demarcation, uniform burn depth, and the absence of burn in the distribution of splash marks indicate that the child was immersed in a hot liquid.
• A history that is inconsistent or does not correlate with the physical findings of the case or a delay in seeking treatment raises suspicion of abuse.
• Child abuse should be considered while dealing with scald injuries in the pediatric population.

Question 10

A 17-year-old female patient presents to the emergency department with her mother after a cat bit her in the park. Her wound was appropriately irrigated. She currently complains of immense pain in her right arm and is extremely irritable. Her past surgical history includes an appendectomy two years ago. On examination, a puncture wound can be seen on the anterior side of her right forearm. An x-ray is performed. What is the most appropriate initial treatment for this patient?

1. Ketorolac
2. Diazepam
3. Haloperidol
4. Amoxicillin and clavulanate

Answer 10

4. Amoxicillin and clavulanate

POINTS

• Cat bites often introduce polymicrobial infection, but Pasteurella multocida is the dominant organism.
• Anaerobic bacteria may also be present in a bite wound.
• This patient should be prescribed amoxicillin and clavulanate to prevent the development of localized cellulitis.
• A less-potent non-steroidal anti-inflammatory drug (NSAID) like ibuprofen may also be prescribed for the control of analgesia. More potent NSAIDs such as ketorolac are not usually needed.

Question 11

A 16-year-old patient presents to the clinic due to pruritus. He has no significant past medical history. Physical examination reveals inflammatory papules and burrows between the finger webs and on the buttocks. Which medication should be prescribed, and how should it be administered?

1. 5% permethrin cream applied twice each day for 3 weeks
2. 5% permethrin cream applied from the patient’s head to toes and washed off after 8 to 14 hours
3. 1% permethrin cream applied once each day for a week
4. 5% permethrin cream applied from the patient’s head to toes and washed off after 5 hours

Answer 11

2. 5% permethrin cream applied from the patient’s head to toes and washed off after 8 to 14 hours

POINTS

• This patient’s presentation is consistent with scabies.
• To treat scabies, 5% permethrin cream should be applied from the patient’s head to toes and washed off after 8 to 14 hours.
• Mucosal sites should be avoided when applying topical permethrin.
• Close contacts of patients with scabies should also be treated.

Question 12

A 2-month-old male is examined at a pediatric clinic following a forceps-assisted vaginal delivery at 38 weeks gestation to a 26-year-old G1P1 mother. The infant presents with the condition seen in the attached image. Which of the following pathologic mechanisms best describes his current presentation?

1. Genetic deletion at 22q11.2
2. Forceps-related birthing trauma
3. Failed fusion of the maxillary prominence and lateral nasal process
4. Failed fusion of the maxillary prominence and medial nasal process

Answer 12

4. Failed fusion of the maxillary prominence and medial nasal process

• Unilateral cleft lip is caused by a failure of the maxillary prominence to appropriately fuse with one of the medial nasal processes during embryogenesis. Bilateral cleft palate may occur secondary to failed fusion of the maxillary prominence with both the left and right medial nasal processes.
• Cleft lip may occur independently or with a concomitant cleft palate. Facial clefts occur at an incidence of 1/700 live births.
• Causes of facial clefts include genetic disorders, teratogen exposure, or a maternal viral infection.
• The primary treatment of cleft lip is surgical correction. The appropriate time for this surgery typically is guided by the rule of 10s: at least 10 weeks old, at least 10 pounds (4.5 kg) in weight, and hemoglobin of at least 10 grams/dL. The most common surgical correction performed for cleft lip is the Millard procedure.

Question 13

A previously healthy 4-year-old boy presents for evaluation after swallowing one or more unknown foreign bodies. Physical examination findings are normal. Two small metallic foreign bodies are seen in the mid-abdomen on X-rays. Which objects are most likely to cause subsequent bowel perforation?

1. Two coins
2. Two small magnets
3. Two button batteries
4. Pop-tops from two soda cans

Answer 13

2. Two small magnets

POINTS

• The vast majority of small, blunt objects, including button batteries that have passed the esophagus and stomach, will not cause complications.
• Small magnets in the intestines pose a high risk of injury and require emergent referral for endoscopic intervention.
• Small magnets in the intestines may strongly attract each other, causing necrosis and severe damage to any tissue interposed between the magnets, such as bowel perforation. The co-ingestion of a button battery and a magnet should also be concerning.
• Neglect and other psychosocial concerns should be considered in children who swallow multiple foreign bodies.

Question 14

A 1-year-old boy is brought to the emergency department by his mother with bruises. She leaves the child at home with her boyfriend, who has a history of alcohol use disorder. His vital signs are within normal limits. On physical examination, the child appears anxious and is crying inconsolably. He has multiple bruises on his limbs and head. Which of the following is the next best step in the management of this patient?

1. Lumbar puncture
2. Blood cultures
3. Call child protection services
4. Discharge with outpatient follow-up

Answer 14

3. Call child protection services

POINTS

• The patient most likely has abusive head trauma, given the risk factors and examination.
• A careful physical exam in some cases can uncover signs of abusive injury.
• Exam findings include bruising anywhere in an infant younger than four months old. Bruising on the ears, neck, or torso, especially in children younger than four years should be suspect. Bulging fontanel, cerebral atrophy, frenulum injuries, hydrocephalus, lack of external injury, ligature marks, retinal hemorrhages, and subdural hematomas all can be evidence of abuse. Common fractures are of long bones, metaphyseal, and rib.
• Child protection services should be involved as soon as possible.

Question 15

A 2-month-old boy is brought to the hospital by his father with listlessness. The boy lives with both parents but spends most of the time at home alone with his mother. The mother has postpartum depression and is still taking medication. His vital signs are within normal limits. Physical examination findings include listlessness, difficulty arousing the infant, and retinal hemorrhages on fundoscopy. He has multiple bruises on his limbs and head. What is the most likely diagnosis?

1. Cavernous sinus thrombosis
2. Meningitis
3. Shaken baby syndrome
4. Epidural hematoma

Answer 15

3. Shaken baby syndrome

POINTS

• Abusive head trauma with a pattern of injuries that may include retinal hemorrhages and regular patterns of brain injury. Rib fractures as well as fractures of the ends of long bones are also seen.
• “Shaken baby syndrome” is used to describe brain injury symptoms consistent with vigorously shaking an infant or small child.
• The injuries often include unilateral or bilateral subdural hemorrhage, bilateral retinal hemorrhages, and diffuse brain injury.
• While children can be injured by shaking alone, there is often evidence of blunt trauma, so a more inclusive term, “shaken impact syndrome” may be used.

Question 16

A 16-year-old male patient presents to the hospital after a trip and fall onto a tree branch while walking. On physical examination, there are superficial abrasions over the right knee. The patient can ambulate, bear weight, has a full range of motion of the injured knee, and is neurologically intact. No other areas of injury are noted. He had his tetanus vaccination a year ago. After the robust irrigation of the wound with normal saline and removal of all the visible debris, what would be the next best step in this patient’s care?

1. Apply sterile gauze and bacitracin over the area of injury, and discharge
2. Prescribe a 7-day course of oral cephalosporin and discharge
3. Obtain an x-ray of the knee and continue to monitor
4. Apply sterile gauze and discharge

Answer 16

1. Apply sterile gauze and bacitracin over the area of injury, and discharge

POINTS

• Bacitracin is a topical antibiotic ointment widely used by both medical professionals and the general public to treat minor skin injuries including cuts, scrapes, and burns.
• Many gram-positive bacteria including Staphylococci, Streptococci, Corynebacterium, Clostridium, and Actinomyces are susceptible to bacitracin. Some gram-negative organisms, such as Gonococci and Meningococci also exhibit susceptibility; however, most gram-negative organisms are resistant.

= Bacitracin readily absorbs through denuded, burned, or granulated skin and works to prevent the transfer of mucopeptides into the cell wall of various microorganisms. This subsequently inhibits bacterial cell wall synthesis and ultimately, bacterial replication. Bacitracin also acts as an inhibitor of proteases and other enzymes involved in altering bacterial cell membrane function.

• Its most common use a topical agent that is administered directly onto the wound or infected area. It can also be administered as a topical ophthalmic ointment to treat superficial ocular infections involving the conjunctiva and cornea.

Question 17

A 2-year-old girl has an umbilical hernia. The hernia measures 2 x 2 cm, and the abdominal exam is unremarkable. Which of the following is most appropriate for the treatment of this patient?

1. Surgery as soon as possible
2. Surgery within the next 6 months
3. Surgery only if the hernia becomes incarcerated
4. Surgery before school age if still present

Answer 17

4. Surgery before school age if still present

POINTS

• The umbilical hernia protrudes through a fibromuscular ring and usually closes without intervention.
• The hernias are usually a congenital defect. They are surgically closed at age 5.
• They are more common in African Americans.
• They may require surgery sooner than that if they become strangulated.

Question 18

A 6-month-old African American girl presents with a bulge in her belly button. The bulge enlarges when she cries, coughs, or strains. A physical exam reveals a globular abdomen, normoactive bowel sounds, and a 1 cm defect in her umbilical area. Which of the following pathology is associated with this condition?

1. Persistent omphalomesenteric duct
2. Persistent urachus
3. Failed obliteration of the umbilical ring
4. Omphalocele

Answer 18

3. Failed obliteration of the umbilical ring

POINTS

• During fetal development, the primitive umbilical ring appears as early as 4th week of gestation on the ventral surface of the body. It contains umbilical vessels (one vein and two arteries), allantois, vitelline duct, vitelline vessels and loop of midgut. As the herniated midgut reduces, the definitive umbilical cord will develop containing the umbilical vessels surrounded by Wharton’s jelly.
• The umbilical vessels obliterate after birth and will be replaced by a ligamentous structure. Congenital disorders of the umbilicus include umbilical hernia, patent urachus, omphalomesenteric fistula, and umbilical polyp. It is important to recognize these defects as early as possible is essential to prevent complications.
• A persistent omphalomesenteric duct is associated with an umbilical fistula, sinus, or polyp. Omphalocele is a central abdominal wall defect with an absent umbilicus. A persistent urachus is associated with an umbilical fistula, sinus, or polyp.
• Failure of obliteration of the umbilical ring after separation of the umbilical cord predisposes to the development of an umbilical hernia. The umbilicus also represents a relatively weak point in the abdominal wall that is prone to herniation as a result of increased intra-abdominal pressure.

Question 19

An 8-year-old girl is helping her mother in the kitchen when she cuts her thumb with a knife. The wound is linear and superficial, and bleeding stops within a few seconds. Her mother immediately takes her to the pediatrician’s office for evaluation and recommendations. The mother reports that she received her last vaccination when she was five years old. The provider irrigates and washes the wound, but no stitches were used. What tetanus prophylaxis should the child receive?

1. Human tetanus immunoglobulin
2. None
3. Tetanus toxoid
4. Horse tetanus antiserum

Answer 19

2. None

POINTS

• If the patient with a clean non-tetanus-prone wound has a complete vaccination history and is less than 10 years since the last dose, no prophylaxis should be given.
• If the patient with a tetanus-prone wound has a complete vaccination history, but it is more than 5 years since the last dose, tetanus toxoid should be given.
• Tetanus vaccination, in addition to wound cleaning, is used to prevent tetanus.
• Tetanospasmin toxin prevents neurotransmitter release in the central nervous system, which leads to muscle spasms and unopposed muscle contraction.

Question 20

A 12-hour-old female is being evaluated for a rash. The pregnancy was uncomplicated; however, the mother did not receive much prenatal care and was temporarily homeless at the beginning of this pregnancy. The newborn has been feeding well since birth and has had no other issues. On exam, she has a rash on her nose consisting of small pinpoint papules, with firm consistency and dome shape appearance. The lesions do not appear pruritic or painful. Which of the following best describes the most likely expected prognosis of this condition?

1. No systemic complications
2. Dissemination of papules to the rest of the body
3. Persistence of the lesions without treatment
4. Hyperpigmentation after healing

Answer 20

1. No systemic complications

POINTS

• Milia are benign and asymptomatic lesions.
• Practitioners should educate and inform caregivers about the benign course of congenital milia and the proneness to resolve without scarring spontaneously.
• Primary congenital milia tend to resolve spontaneously without scarring within a couple of weeks, though they may persist for several months, usually disappearing during the first month of life.
• Secondarily acquired milia may continue without treatment.