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PREP+PREPTEST Flashcards
MC ligament sprains in ankle
anterior talofibular and calcaneofibular ligaments
Classification sprain
Grade 1 when the ligament is stretched.
Grade 2: A partial ligament tear
Grade 3: complete tear of the ligament.
Mild ankle sprain management. Patient able to walk , edema, bears weight
begin range-of-motion exercises and wear a stirrup ankle brace
When do you indicate Complete immobilization with a cast or removable boot in a sprain
patients who have difficulty bearing weight because of pain.
Ottawa Ankle rules
An ankle X-Ray series is only required if there is any pain in the malleolar zone and…
Bone tenderness at the posterior edge or tip of the lateral malleolus (A)
OR
Bone tenderness at the posterior edge or tip of the medial malleolus (B)
OR
An inability to bear weight both immediately and in the emergency department for four steps
An ankle X-Ray series is only required if there is any pain in the malleolar zone and…
Bone tenderness at the posterior edge or tip of the lateral malleolus (A)
OR
Bone tenderness at the posterior edge or tip of the medial malleolus (B)
OR
An inability to bear weight both immediately and in the emergency department for four steps
A foot X-Ray series is only required if there is any pain the midfoot zone and…
Bone tenderness at the base of the fifth metatarsal (C)
OR
Bone tenderness at the navicular (D)
OR
And inability to bear weight both immediately and in the emergency department for four steps
Ottawa rules
Ankle support braces worn during sports can prevent ankle sprains
True
facial palsy with hx of viral infection 2 weeks ago
Bell’s palsy
Cause of bell’s palsy
Idiopathic
reactivation of herpes simplex, varicella-zoster
demyelination through autoimmune or allergic inflammation
OMA
Lyme ( Bilateral)
Varicella
Coxsackie
HSV
Treatment and prognosis of Bells’ palsy
artificialtears, no tears - prevent keratitis
prednisone 2 mg/kg daily up to 60-80 mg/daily x daily 5 days
Severe: Prednisone + Valacyclovir 20 mg/kg TID for 7 days
Px: 85% complete spontaneous resolution
10% mild residual disease
5% dont resolve
Causes of Congenital Facial palsy
traumatic( >3.5kg, forceps delivery, prematurity)
Moebius syndrome( Uni/Bil, abducens)
Myotonic dystrophy
Hereditary congenital facial paresis
Presentation of infant botulism in children and infants
CN findings: diplopia, blurred vision, dry mouth,
descending weakness and paralysis
In infants of 2-4 months: constipation, poor gag reflex, and then descending weakness and paralysis.
Typical RF for slipped capital femoral epiphysis
Obesity
Males > F
Males not reached Tanner 4
Females not reached menarche
Atypical RF of Slipped Capital Femoral Epiphysis
Renal failure
Hx of radiation therapy
Endocrine Abnormality ( Hypothyroidism, GH deficiency)
Down Sx
Others:
<10 years
> 16 years
W < 50th percentile
H < 10th percentile
What is Slipped Capital Femoral Epiphysis and how does it present
Displacement of the capital femoral epiphysis from the femoral neck through the growth plate
MC hip pain
15% isolated hip or knee pain
Increased pain with physical activity, can be acute, chronic, intermittent
Severity of Slipped Capital Femoral Epiphysis
There are several classifications, but here is one of them:
MILD < 1/3 . displacement
Moderate >1/3 but <1/2
Severe >1/2
Can Slipped Capital Femoral Epiphysis be bilateral?
yes
20-40% are bilateral
In children who present with unilateral disease, the contralateral hip slips at a later time in an additional 30-60%
Dx and tto of Slipped Capital Femoral Epiphysis
DX: AP and lateral Rx of BOTH HIPS
Management:operative stabilization , non weightbearing.
Some patients are admitted to the hospital: if acute ( severe SCFE), bilateral
Complications of Slipped Capital Femoral Epiphysis
Osteonecrosis
Chondrolysis: narrowing of the joint space
Femoroacetabular impingement: abnormal contact between the proximal femoral metaphysis and acetabulum.
Cause of transient synovitis
Is in theory unknown BUT in 32-50% cases there have been previous URI
Management of Transient Synovitis
Rule out osteomyelitis and septic hip
Conservative: NSAIDs and return to activity
Labs in Transient synovitis
Patient can or not have high ESR and WBC
Oligo vs Polyarticular JIA
Oligoarticular: < 5 joints, 2-3 years of age and as age increases less likely, can have normal labs. UVEITIS
Polyarticular >=5 joints, in < 10 years, increased ESR, Anemia, hypergammaglobulinemia
2 yo walking funny in the mornings but after a while improves, no complaints of pain, but knee swollen and tender. No erythema. What is the dx?
Oligoarticular JIA
Classification of Oligoarticular JIA
Persistent: no additional involvement of joints after 6 months ( has better chance of remission)
Extended: additional involvement after 6 months of illness.
Management of Oligoarticular JIA
Intra-articular glucocorticoids,
methotrexate if > 5 joint involvement
If uveitis: topical methotrexate + slit lamp periodic assessments. other: TNF alpha monoclonal abs.
Does Oligoarticular JIA has ANA +?
Yes can have and is associated with increased risk of uveitis.
Osgood Schlatter disease
overuse injury causing microfracture of the tibial tubercle at the insertion of the patellar tendon.
What is Ritter disease
staphylococcal scalded skin disease
How many big boxes in 1 second of EKG
5
1mV is ______ big boxes?
2, or 10 little boxes
The pause required for blood to be pumped from the atrium to the ventricles occurs at eh AV node and is manifested on an EKG by the …
The last portion of the ventricle to be depolarized is the….
epicardium
Depolarization of the ventricle has positive charges moving ______________.
inside out - endocardium, meso to epicardium
how many seconds in one large box in the ecg
0.2 sec= 200 msec
how many seconds in one small box of the ecg
0.04 sec or 40 msec.
large box in ecg is __mm x ___mm
5mm x 5 mm
small box in ecg is __mm x ___mm
1mmx 1mm
speed of ecg paper
25 mm/sec
The reason why conduction slows down at the AV node is because the ion used there is _______.
Ca
A long QT interval typically predisposes a patient to what?
arrhythmias
The general rule of thumb is that the QT interval should be less than …
50% of the R-R interval
The U-wave is associated with a depletion of what ion?
K
What is the cut off for abnormal length of the QRS complex?
120msec=0.12
normal PR segment
=<0.2sec
normal QRS
=<0.12 OR 120 MSEC
Normal QT
=< 0.440sec
What is the receptor in the heart that is activated by epinephrine?
B1
An R - R interval is just under 3 boxes long. The rate is closest to ________.
100
radiographs of the ankle sprain are indicated for:
individuals unable to bear weight on the affected ankle or those with tenderness involving the tip or posterior aspect of the ankle malleoli.
Clindamycin provides coverage against group A Streptococcus
TRUE however, it is typically reserved for patients who have had anaphylactic reactions to penicillin
FIRST LINE CHOICE PENICILLIN V oral for 10 days
Why does physiological anemia occurs in neonates, what is the value and when does it present?
The concentration of fetal erythropoietin is highest in the third trimester and rapidly drops with the sudden increase in blood oxygen levels at birth
Low erythropoietin levels in the neonate result in a slow decrease in the hemoglobin level over the first 8 to 12 weeks after birth known as the physiologic nadir ( 11g/dL)
If temper tantrum in a well child visit where vaccine needs to be given?
Rescheduling the vaccine is not clinically indicated and would delay protection from influenza and may be inconvenient for the family.
Children are screened for Autism at
18 months
Up to 20% of typically developing children will bang their heads while having a tantrum.
TRUE,
head banging associated with a tantrum in isolation is not enough to raise clinical suspicion of a developmental problem such autism
onset of tantrums and when do they decrease
often beginning after 1 year of age.
These decrease after the child turns 3 years of age when language development allows for more functional expression of the child’s frustration.
human metapneumovirus (hMPV) infection presentation
bronchiolitis ( is the second MCC after RSV),
presents all year round but more commonly late winter and spring
high fever, cough, wheezing, tachypnea, and hypoxia.
ALSO will have OMA- viral inflammation of Eustachian tubes allows bacteria to easily infect!
Parainfluenza virus presentation
Parainfluenza type I and II: Croup and stridor
Parainfluenza type III: can cause bronchiolitis but is not as common as RSV, human metapneumovirus
16 month old with abdominal distention and vomiting. Suprapubic mass and labs consistent with renal failure.
Bladder obstruction –> postrenal acute kindey failure
Emergency is to have catheterization.
in children is most often soft tissue sarcomas or posterior urethral valves
posterior urethral valves presentation
urinary tract infection
failure to thrive
abdominal distension (from an enlarged bladder)
and a poor urinary stream or voiding dysfunction (urinary frequency, daytime and nocturnal enuresis, and poor urinary stream).
Differential of urinary tract obstruction
- Soft tissue sarcomas : a. Rhabdomyoscarcoma-MC in children)
b. botryoid variant (sarcoma botryoides), arising within the wall of the bladder or vagina, is seen almost exclusively in infants. - Posterior urethral valves
amniotic band syndrome (ABS).
sequence of events leading to an interruption of normal development of the limb tissue
theories:vascular insult, hypoxia, or uterine trauma., or band of amnion interrupt normal progression
(77%) from ABS are identified in the arms and fingers.
Amniotic band syndrome is associated with gestational diabetes.
FALSE
Otitis media with effusion vs AOM
Otitis media with effusion : the presence of fluid in the middle ear without signs or symptoms of middle-ear inflammation.
acute otitis media : acute onset of middle-ear effusion with middle-ear inflammation.
Otitis media with effusion may occur spontaneously as the result of AOM or associated with other conditions, including allergic rhinitis, adenoidal hypertrophy, eustachian tube abnormalities, or craniofacial anomalies.
Management of OME
First Q –> RF for speech or language delay ? (include children with developmental delays, hearing loss independent of OME, syndromes associated with language delay, cleft palate, craniofacial anomalies, or visual impairment)
Yes: Immediate visit to Audiology and Speech evaluation
No: watchful waiting and reevaluation in 3 months because the most OMEs resolve spontaneously
If persists > 3 months or speech delay-> Audiology eval
Conditions associated with OME
allergic rhinitis, adenoidal hypertrophy, eustachian tube abnormalities, and craniofacial anomalies.
A 16-year-old female presents with her parents who express concern about their daughter’s weight loss. Reportedly she “eats next to nothing most of the time” and has lost nearly 30 pounds over a 6-month period. She appears angry and withdrawn, wearing multiple layers of baggy clothes. Her heart rate is 52 beats/minute and blood pressure is 90/65.
Which of the following clinical findings is most suggestive that she has purging behaviors in addition to restrictive eating?
- Facial lanugo hair
- Yellowish-orange discoloration of the palms
- A systolic murmur associated with a midsystolic click
- Parotid gland enlargement
- Acrocyanosis associated with dependent edema
D – Parotid gland enlargement
- The history of weight loss associated with bradycardia and hypotension, in addition to her physical appearance and dress, is highly suggestive of anorexia nervosa.
- There are two types of anorexia nervosa – restricting and binge eating/purging.
- Parotid gland hypertrophy is associated with recurrent vomiting and elevation in amylase levels.
After failing to improve with outpatient therapy for anorexia nervosa, a 16-year-old girl is admitted to an inpatient unit. Her temperature is 97.9 F (36.6 C), blood pressure is 95/55 mmHg, and heart rate is 55 beats per minute. Physical findings include cachexia, thinning scalp hair, acrocyanosis, and atrophic breast tissue.
Which of the following best describes auscultatory findings associated with a common cardiac complication in patients with anorexia nervosa?
- A late systolic murmur at the apex preceded by a click
- A high-pitched, early diastolic murmur beginning with the aortic component of the 2nd heart sound
- A holosystolic, apical, high-pitched, blowing murmur radiating to the left axilla and back
- A crescendo-decrescendo systolic ejection murmur heard best at the left upper sternal border associated with a widely split and fixed S2
- A continuous murmur in the left and right 2nd intercostal spaces that disappears when supine
A – A late systolic murmur at the apex preceded by a click
· A late systolic murmur at the apex preceded by a click is consistent with mitral valve prolapse, a common cardiac complication among patients with anorexia nervosa.
· Additional cardiac complications may include syncope, prolonged QT interval, dysrhythmias, and pericardial effusion. Most patients are bradycardic with orthostatic changes in blood pressure.
· During refeeding, heart failure may develop without careful attention to gradual reintroduction of foods and monitoring of serum electrolytes and minerals.
On the 5th day of hospitalization for treatment of severe anorexia nervosa associated with a 21% weight loss over an 11-month period of time, a 16-year-old girl complains of difficulty breathing. Although her physician initially thought that she was simply attempting to manipulate the staff to remove her feeding tube, her physical exam reveals a new gallop rhythm associated with bibasilar rales and a respiratory rate of 44 breaths/minute.
Which of the following laboratory findings is the most likely cause of this patient’s cardiopulmonary symptoms and findings?
- Hypermagnesemia
- Hyponatremia
- Hyperkalemia
- Hypophosphatemia
- Hypercalcemia
D - Hypophosphatemia
- Hypophosphatemia may impair myocardial contractility and also lead to respiratory compromise due to weakness of the diaphragm.
- Severely malnourished patients often have depleted intracellular phosphate stores. With refeeding, cells increase uptake of phosphorus, leading to hypophosphatemia.
- Hypophosphatemia usually occurs during the first 5-7 days of refeeding and can be prevented by a more gradual increase in nutrition with careful attention to phosphorus supplementation and monitoring of phosphorus levels.
Other common electrolyte abnormalities during refeeding are hypokalemia and hypomagnesemia.
A 30-month-old girl with a history of recurrent otitis media, ear drainage for the previous 3 weeks, and the recent onset of hearing loss is discovered to have a spherical, discrete, opaque mass in the superior portion of the right tympanic membrane. She is otherwise well. At 14 months of age, she underwent tympanostomy tube placement.
Which of the following is the most appropriate next step in her treatment?
- Surgical removal of the lesion.
- Ciprofloxacin/hydrocortisone otic drops.
- Amoxicillin/clavulanate.
- Recheck in 3 months or earlier if symptoms of otalgia or language delay occur.
- Ofloxacin otic drops.
: A – Surgical removal of the lesion
· This patient has findings consistent with a cholesteatoma, which is a lesion consisting of desquamated squamous epithelium and keratin trapped within the temporal bone, middle ear, or mastoid bone.
· Surgery is recommended to eliminate risk of recurrent infection and prevent invasion into adjacent structures.
· Clinically presents with painless otorrhea; may complicate chronic otitis media or develop after extrusion of a tympanostomy tube.
· If untreated, complications include hearing loss, cranial nerve palsies, vertigo, and infection.
· Recurrence within 5 years of surgery is noted in >50% of patients.
An 8-year-old girl presents with a history of intermittent headaches. Her headaches are described as pounding, moderate in intensity, and located in the bilateral frontal area. She has no aura and frequently experiences nausea and vomiting. There is associated photophobia and phonophobia.
Which of the patient’s symptoms is more frequently seen in children who suffer from migraine headaches, as compared to adult sufferers?
- Presence of an aura
- Osmophobia
- Photophobia
- Bilateral pain
- Phonophobia
D – Bilateral pain
· Pediatric migraine headaches are more likely to be bilateral, rather than unilateral, as is usually seen in adults.
· Other common associated symptoms include dizziness, pallor, nausea, vomiting, and sensitivity to external stimuli such as light and sound.
· The most common type is migraine without aura.
· Cyclic vomiting syndrome and benign paroxysmal vertigo of childhood are thought to be precursors to migraines.
A 3-year-old boy is transported to the emergency department following an accidental ingestion at his grandparent’s home. Upon arrival, stabilization of his airway, breathing, and circulation is promptly completed. There is no clinical evidence of associated trauma or illness.
For which of the following substances is activated charcoal likely to be most effective in the treatment of a poisoning?
- Carbamazepine
- Potassium chloride
- Lithium
- Iron
- Aromatic hydrocarbons
Carbamazepine
- Activated charcoal is often the preferred method of GI decontamination in a patient anticipated to have good airway protection.
- Most effective when administered with <1 hour of ingestion.
- Activated charcoal is NOT of benefit following certain ingestions, including heavy metals and inorganic ions, alcohols, caustics, hydrocarbons, cyanide, and essential oils.
Activated charcoal is contraindicated following ingestion of low-viscosity hydrocarbons and in patients who may require endoscopy, as it will obscure the evaluation.
A pregnant lupus patient at 35 weeks of gestation presents to the hospital following premature rupture of membranes. The neonate is delivered vaginally but is transported to the neonatal ICU because of persistent bradycardia. An ECG in the neonate demonstrates a 2nd degree heart block, Mobitz Type II. Additional laboratory findings include mild anemia, thrombocytopenia, neutropenia, and elevated serum transaminase levels.
Which of the following is the next best step in the evaluation of the neonate?
- Echocardiogram
- Chest x-ray
- Urinalysis
- Head CT scan
- Liver biopsy
A – echocardiogram
· This neonate has ECG findings consistent with congenital heart block secondary to neonatal lupus .
· An echocardiogram is needed to look for structural defects that may be associated with neonatal lupus syndrome.
· Most congenital heart block and infants is due to maternal lupus anti-Ro (anti-SSA) and anti-La (anti-SSB) antibodies.
· With the exception of heart block, symptoms of neonatal lupus, which are caused by transplacental passage of maternal antibodies, resolved within the 1st few months of life.
An 18-year-old male who was diagnosed last month with erythema nodosum is found to have multiple oral aphthous ulcerations, which he describes as very painful. He reports that during the past year he has experienced 3 or 4 similar outbreaks of oral ulcerations, each of which took up to 2 weeks to heal. He is now experiencing new symptoms associated with painful ulcerative lesions on the scrotum and painful red eyes with blurred vision.
Which of the following complications is most likely to occur in this patient?
- Blindness, central nervous system disease, and large aneurysmal vasculitis
- Tinnitus, vomiting, and vertigo
- Recurrent and progressively severe proximal muscle weakness
- Recurrent episodes of jaundice
- Progressive dysphagia, first with solids, then with liquids
A – blindness, central nervous system disease, and large aneurysmal vasculitis
· The patient has findings consistent with Behcet disease, a condition characterized by oral ulcerations occurring at least 3 times per year. Genital ulcers are common on the scrotum or vulva.
· Associated cutaneous lesions include erythema nodosum, acneiform lesions, erythema multiforme-like lesions, and pustular eruptions.
· A positive pathergy test (a papule greater than 2 mm develops within 48 hours after insertion of a 20-25 gauge needle) is characteristic.
· More tele is most commonly attributed to CNS complications (stroke, meningoencephalitis, seizures), blindness, and large vessel aneurysms or thrombosis.
A 16-year-old boy presents for the third time in the last 8 months with right knee pain and swelling. He is a stand out player on his high school soccer team but does not recall a specific injury. Both previous episodes of knee pain were thought to be related to physical activity and responded to rest and physical therapy. He denies any history of rash, malaise, photosensitivity, or eye pain. On physical examination, the right knee is swollen. There is no associated warmth. Tenderness over areas of ligamentous insertion is noted not only on the involved knee, but in the contralateral knee and left ankle. Results of laboratory evaluation include a positive HLA-B27.
Which of the following is likely to be identified during additional evaluation of this patient?
- Limited anterior forward flexion of the lumbosacral spine
- Fusion of hypoplastic cervical vertebra on plain radiograph
- Erosive symmetrical polyarthritis
- Bilateral fragment a shin, loss of height, and angular deformity of the medial portion of the proximal tibia on plain film
- Syndactyly
: A – limited anterior forward flexion of the lumbosacral spine
- The patient has findings consistent with juvenile idiopathic arthritis (JIA), subtype enthesis-related arthropathy, such as ankylosing spondylitis.
- Patients typically complain of progressive stiffness of the spine, first with morning stiffness which is followed by chronic lower back pain.
Oligoarthritis, not polyarthritis, is most common in the hips, knees, and ankles.
A 5-year-old girl presents with dysuria, fever, vomiting, and flank pain. Urinalysis demonstrates marked neutrophils and trace blood. The patient is admitted for IV antibiotic therapy and the urine is sent for culture. The patient demonstrates minimal improvement, and 24-hour cultures are reported positive for Enterococcus faecalis.
Pending susceptibility studies, which of the following would be the best antibiotic choice?
- IV ampicillin
- IV ceftazidime
- IV gentamicin
- PO vancomycin
- IV TMP/SMX
: A – IV ampicillin
· The child is likely not getting better because empiric antibiotic therapy is typically a cephalosporin, which has no activity against Enterococci.
· Ampicillin generally provides good coverage for Enterococci.
· The combination of ampicillin and gentamicin can provide a synergistic effect and is often used in severe infections such as sepsis, meningitis, and endocarditis.
A 4-year-old boy is brought to the clinic by his mother with complaints of incontinence. His mother states that he was toilet-trained for urine when he was 24 months old and for bowel movements when he was 27 months old. He has done well, with very few “accidents” until 2 weeks ago. Since then he has had multiple episodes of urinary incontinence.
Which of the following factors would be the most likely to require a prompt evaluation?
- A family history of nocturnal enuresis
- Rotavirus infection requiring hospitalization of his 2-month-old sister
- Recent diagnosis of renal carcinoma in a grandmother who lives in the family
- Frequent nocturnal enuresis
- Difficulty getting to the toilet in time and crying even when he urinates in the toilet
E – Difficulty getting to the toilet in time and crying even when he urinates in the toilet
· Incontinence associated with dysuria should prompt further investigation to rule out an infectious etiology.
· Difficulty getting to the toilet in time could indicate urinary urgency, while crying during urination could indicate dysuria in a young child.
· Incontinence is a frequent complaint in preschoolers, and commonly also occurs without significant underlying pathology.
An 8-year-old girl has advanced chronic kidney disease due to grade 5 vesicoureteral reflux. She continues to have recurrent infections and was hospitalized last month with an E. coli pyelonephritis. Her parents have refused corrective surgery. She takes a daily dose of TMP/SMX as urinary tract infection prophylaxis. Her family history is notable for several paternal relatives with colon cancer, and her mother has diabetes mellitus Type 2. On physical exam, you note mild hypertension for age, and height and weight at approximately the 5th percentile for age. Her nephrologist, who saw her last week, has not referred her for transplantation but feels she will need dialysis in <6 months.
Which of the following would explain a delay in transplantation in this child?
- She must grow a bit larger before she can be technically transplanted.
- She has recurrent infections.
- She must not be on TMP/SMX within 12 months of a transplant.
- Her family history must be corrected.
- She must be on dialysis before getting a transplant.
B – She has recurrent infections.
- Active and recurrent infections, uncontrolled malignancy, and ABO incompatibility are the major reasons for delay in transplantation.
TMP/SMX is not contraindicated and is used after transplant for Pneumocystis prophylaxis.
A 4-year-old girl, hospitalized 6 weeks earlier with Kawasaki disease and coronary artery ectasia continues her recommended treatment to reduce the risk of coronary artery aneurysm.
This patient is at increased risk for which of the following complications if she becomes infected with an influenza virus?
- Toxic epidermal necrolysis
- Autoimmune hepatitis
- Reye syndrome
- Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome
- Pseudotumor cerebri
: C – Reye syndrome
· The risk of coronary artery aneurysm is approximately 20-25% in Kawasaki disease; this is reduced to approximately 5% in children treated with IVIG and aspirin within 10 days of onset of illness.
· Salicylates are a precipitating factor for Reye syndrome, a rapidly progressive encephalopathy associated with hepatic dysfunction.
· Often occurs in the setting of recovery from viral infections, especially varicella and influenza.
An irritable and febrile 3-year-old boy with a morbilliform-like rash and bulbar conjunctival injection is hospitalized and subsequently found by echo to have a proximal left coronary artery aneurysm.
Which of the following is most likely to be identified during additional evaluation of this patient?
- Acute distention of the gallbladder identified on abdominal ultrasound
- Dilation of the aortic root identified on echocardiogram
- A renal artery thrombosis identified on Doppler ultrasound
- An intramural duodenal hematoma identified on abdominal ultrasound
- Multiple dilated loops of large bowel with bubbly linear gas collections within the bowel wall
A – Acute distention of the gallbladder identified on abdominal ultrasound
· This patient has signs and symptoms consistent with Kawasaki disease.
· Gallbladder hydrops may occur in the first 2 weeks of illness and is typically self-limited.
· It may present as a right upper quadrant mass on physical examination and appears markedly enlarged and balloon-shaped on abdominal ultrasound.
A 12-month-old boy presents for a follow up visit 2 weeks after discharge from the hospital following treatment for Kawasaki disease with intravenous immunoglobulin (IVIG) and aspirin. He continues to take aspirin daily and is scheduled for an echocardiogram in several weeks to evaluate for coronary artery aneurysm. He is currently not up to date on his immunizations and is due for several vaccinations.
Which of the following vaccines should be withheld at this time?
- Haemophilus influenza Type b conjugate vaccine
- Measles, mumps, rubella
- Pneumococcal conjugate vaccine
- Hepatitis A
- Diphtheria-tetanus-acellular pertussis
B – Measles, mumps, rubella
- Measles/varicella –containing vaccines should be deferred for 11 months after receipt of high-dose IVIG because of possible diminished immunogenicity and interference with immune response.
- If a child is at high risk of exposure, the child should be immunized and then reimmunized >11 months after administration of IVIG.
Administration of IVIG does not inhibit the immune responses to inactivated vaccines (e.g., DtaP, HepA, PCV13, Hib) or toxoids and the schedule for these does not need to be altered.
A 15-year-old girl presents with a 24 hour history of increasingly severe lower abdominal and back pain and progressive weakness of both lower extremities, which she states are “tingly and numb.” She also reports that she had a bad cold several weeks earlier. On physical exam, the muscles of the legs are noted to be weak and flaccid, with decreased sensation documented below the umbilicus.
Which of the following is most likely to be identified upon further evaluation of this patient?
- Inflammation and edema of the spinal cord at T10 documented on MRI
- Disc space narrowing at C2 and C3 and irregularity of the adjacent vertebral endplates documented on a plain radiograph
- Decreased levels of glucose in the CSF
- Decreased levels of protein in the CSF
- A stress fracture of the pars interarticularis associated with forward slippage of L5 on S1 documented on a bone scan
A – Inflammation and edema of the spinal cord at T10 documented on MRI
· The patient has findings consistent with transverse myelitis: abrupt onset of progressive weakness and sensory abnormalities in the lower extremities. A sensory level is characteristic.
· Transverse myelitis can be seen following an infectious process but can also be the presenting symptom of multiple sclerosis and neuromyelitis optica.
· Most patients experience at least partial recovery but persistent disability may occur in up to 40% of patients.
A 15-year-old female presents to the ED complaining of weakness in both legs over the last couple of days, with recent difficulty walking. She also states she is unable to urinate and has decreased sensation in her legs. On exam, a midthoracic sensory level is present. MRI reveals patchy hyperintensity (T2-weighted images) and swelling at the level of T6-T8 spinal cord.
Which of the following is most likely to be noted on exam of the CSF in this patient?
- Mild lymphocyte pleocytosis
- Decreased protein levels
- Marked polymorphonuclear neutrophil pleocytosis
- Decreased glucose levels
- Acid-fast organisms on smear
A – Mild lymphocyte pleocytosis
· The patient has findings consistent with transverse myelitis. Implicated common infectious etiologies include EBV, rubella, mumps, varicella, influenza, Mycoplasma pneumoniae, and Borrelia burgdorferi.
· CSF findings include mild lymphocyte pleocytosis and normal or slightly elevated levels of protein.
· Corticosteroid therapy is effective in some patients, especially when administered early.
A 17-year-old girl presents with leg weakness and muscle cramping associated with tingling and difficulty walking. Symptoms started 2 days ago and are progressively getting worse. She is afebrile, her heart rate is 58 bpm, and her blood pressure fluctuates between 105/65 and 90/55. Funduscopic and cranial nerve examinations are normal. She describes a tingling sensation in the lower extremities that is more pronounced distally; weakness and absent reflexes are also noted in the lower extremities. Following a lumbar puncture, CSF testing reveals a protein level of 105 mg/dL, glucose level of 78 mg/dL, and WBC count of 2 cells/microliter.
Which of the following is the most likely diagnosis?
- Guillain-Barre syndrome
- Transverse myelitis
- Epidural hematoma
- Epidural abscess
Botulism
A – Guillain-Barre syndrome
- The patient has clinical and CSF findings consistent with GBS. GBS is often preceded by a viral upper respiratory illness or gastrointestinal illness secondary to Campylobacter jejuni.
- GBS affects peripheral nerves, causing demyelination and a symmetric, ascending, flaccid paralysis. Areflexia is typical.
- CSF commonly shows elevated protein with normal glucose and WBC count.
Recall that botulism causes symmetric descending paralysis.
During a health maintenance examination, a 9-month-old boy with a history of bacterial meningitis at 5 months of age is carefully evaluated for evidence of delayed development and abnormalities on neurologic exam.
Which of the following is the most appropriate method to evaluate this patient’s balance and equilibrium reactions?
A. Observe the patient’s response as you allow the patient to free fall while held in ventral suspension.
B. Observe the patient’s degree of mobility while on the hands and knees.
C. Observe the patient’s ability to “commando crawl.”
D. Observe the patient’s ability to anticipate the direction of movement during the pull-to-sit maneuver.
E. Look for the absence of spontaneous extension of the arm and leg on the same side that the head is directed to while the patient is lying on his back.
A – Observe the patient’s response as you allow the patient to free fall while held in ventral suspension.
· The free fall technique describes the “parachute response,” characterized by symmetrical extension of the extremities when the examiner allows the child to free fall while held in ventral position.
· This response usually develops at 8-9 months of age.
· The parachute reflex is the last of the postural reflexes to develop.
A mother brings her 18-month-old in for his well-child exam. This is her first child, and she is very concerned about his development and is always comparing him to other children. You ask her several questions and assure her that he is doing just fine.
Which of the following should he be able to do?
A. Use 3-word sentences
B. Dress himself
C. Identify 1 or more body parts
D. Participate in cooperative play
E. Go up and down stairs (2 feet each step)
C – Identify 1 or more body parts.
· By 18 months, a child can identify 1 or more body parts, build a tower of 4 cubes, use a cup well, and speak 10-25 words.
· A 3-year-old can use 3-word phrases and most can dress themselves.
· Cooperative play is typical around 3-4 years of age.
· A 2-year-old can go up and down stairs with 2 feet on each step.
The parents of a 2-month-old girl are concerned that their child may be at risk for autism because her 18-month-old cousin was recently diagnosed with autism.
Which of the following most accurately describes an early sign of autism?
- Not using single words by 10 months of age
- Not using 2-word phrases by 18 months of age
- Lack of make-believe play by 12 months of age
- Absence of babbling and pointing by 9 months of age
Absence of social smile by 6 months of age
: E – Absence of social smile by 6 months of age
- Absence of social smile and/or limited eye contact by 6 months of age may be an early sign of autism.
- The AAP recommends a standardized autism-specific screening tool at 18 and 24 months of age, and whenever parents express concern about their child’s development.
Most commonly used screening tools are the Modified Checklist for Autism in Toddlers (M-CHAT) and the Modified Checklist for Autism in Toddlers Revised for Follow Up (M-CHAT-R/F).
During nursery rounds with a rotating medical student, a newborn is noted to have clinically apparent jaundice. You measure a serum bilirubin in the patient, which is 6 mg/dL. You conclude the patient has physiologic hyperbilirubinemia and determine the patient is at low risk for severe hyperbilirubinemia. The medical student asks if there are other causes of newborn jaundice you would consider.
Which of the following causes of hyperbilirubinemia would most likely have an elevated level of unconjugated bilirubin?
A. Crigler-Najjar syndrome
B. Cystic fibrosis
C. Dubin-Johnson syndrome
D. Biliary atresia
E. Rotor syndrome
A – Crigler-Najjar syndrome
· Crigler-Najjar syndrome and Gilbert syndrome are caused by lower levels of activity of the UGT1A1 conjugating enzyme in hepatocytes.
· In Crigler-Najjar there is complete (Type I) or near complete (Type II) absence of the enzyme.
· Patients with this syndrome are at risk for kernicterus and most need 24-hour phototherapy +/- liver transplant.
· Gilbert syndrome results from lower levels of UGT1A1 but not enough to cause problems.
· Dubin-Johnson and Rotor syndrome are genetic defects that prevent the exportation of bilirubin from the hepatocytes into bile leading to conjugated hyperbilirubinemia.
An 18-year-old female presents for physical examination prior to leaving for college. She reports the recent onset of sexual activity with her boyfriend and that they “sometimes” use condoms. She is asymptomatic. Physical examination is normal and a urine pregnancy test is negative. Urine nucleic acid amplification testing (NAAT) results are positive for Chlamydia and negative for gonorrhea.
What is the most appropriate next step in the treatment of this patient?
A. Ceftriaxone 250 mg IM; retest for chlamydial infection in 3 weeks
B. Cefixime 400 mg PO; retest for chlamydial infection in 3 weeks
C. Azithromycin 1 g PO; retest for chlamydial infection in 3 weeks
D. Azithromycin 1 g PO; retest for chlamydial infection in 3 months
Azithromycin 1 g PO plus ceftriaxone 250 mg IM; retest for chlamydial infection in 3 months
Azithromycin 1 g PO; retest for chlamydial infection in 3 months.
· Test-of-cure is not necessary because cure rates for patients compliant with azithromycin or doxy are >95%.
· Retest for chlamydia in 3 months not as a “test-of-cure” but to assess for reinfection from an untreated partner.
· Due to emerging antibiotic resistance, ceftriaxone as a single agent for treatment of gonorrhea is no longer recommended.
An 18 yo female complains of vaginal discharge associated with a burning sensation, pruritus, and dysuria. On physical exam, a greenish-yellow, frothy vaginal discharge is evident, as well as erythema of the vaginal mucosa and cervical punctate hemorrhages.
Which of the following is the most appropriate treatment in this patient?
- Metronidazole
- Azithromycin
- Ceftriaxone
- Acyclovir
Levofloxacin
– Metronidazole
- This patient has clinical signs and symptoms of trichomoniasis caused by a flagellated protozoan that is sexually transmitted.
- While some adolescent females may be asymptomatic carriers, others may have discharge noted within the vagina and on the cervix, which may be covered by numerous punctate hemorrhages (“strawberry cervix”).
- Findings on wet prep include motile trichomonads, an elevated pH >4.5, and numerous PMN’s.
Metronidazole is the recommended treatment. Patients should be counseled not to drink alcohol for 24 hours after treatment because of the possibility of a disulfiram-like reaction.
The mother of a 3-year-old female presents to the clinic with concerns that her child has a large lump in her neck; the lump has been present for the last 7-10 days. The mother is unaware of any preceding illness, though her daughter has had a mild decrease in oral intake. Physical examination shows lymphadenopathy.
Which of the following characteristics would be the most concerning for a neoplastic condition upon evaluation of the lymphadenopathy?
A. Supraclavicular location
B. Tenderness of a swollen node
C. Single prominent lymph node <1 cm in size
D. A completely mobile node
E. Warmth of a swollen node
A – Supraclavicular location
· Persistently enlarged lymph nodes without regional infection are concerning.
· Can occur in inflammatory conditions (e.g. SLE), infectious, or neoplastic processes.
· Nodes concerning for a neoplastic process are more often multiple, nontender, and fixed.
· Nodes that are warm to the touch usually indicate an infectious process.
An 18-year-old male has right inguinal lymphadenopathy, which he states is extremely painful to palpation. He reports that he noticed a “bump” on his penis several weeks ago that “never hurt and went away by itself.” Additional findings on physical exam include tender right femoral lymphadenopathy that is clearly distinct and separate from the inguinal nodes.
Which of the following is the most likely cause of this patient’s clinical findings?
A. Chlamydia trachomatis
B. Klebsiella granulomatis
C. Haemophilus ducreyi
D. Treponema pallidum
E. Human papillomavirus
Chlamydia trachomatis
- This patient’s clinical findings are consistent with lymphogranuloma venereum caused by Chlamydia trachomatis.
- The patient has the characteristic “groove sign” – femoral lymphadenopathy clearly separated from inguinal lymphadenopathy formed by lymph nodes above and below the Poupart ligament.
- Primary lesion consists of a small, painless papule or pustule that may erode into a painless ulceration.
- Painful inguinal and femoral lymphadenopathy develops 2-6 weeks afterward, usually unilateral.
- Preferred treatment is doxycycline 100 mg PO twice daily for 3 weeks.
A 15-year-old boy complains of increased temperature, headache, chills, and generalized malaise. On physical examination, an ulcerated lesion is noted on the left leg associated with 3 tender, distinct, 2 x 4-cm left inguinal lymph nodes. Upon further history, it is learned that the patient removed several ticks from his legs during a recent camping trip.
Which of the following is the most likely etiology of this patient’s clinical signs and symptoms?
- Francisella tularensis
- Rickettsia rickettsii
- Bartonella henselae
- Borrelia burgdorferi
Ehrlichia chaffeensis
: A – Francisella tularensis
- This patient has clinical signs and symptoms of tularemia – abrupt onset of fever, chills, headache, myalgia, and generalized malaise following an incubation period of 3-5 days.
- Most common presentation is ulceroglandular syndrome. It is characterized by a maculopapular lesion at the site of the tick bite which ulcerates and heals slowly, in addition to painful, acutely inflamed regional lymph nodes.
- Ticks and rabbits are major sources of human infection.
Treatment options include gentamicin, amikacin, or streptomycin. For individuals with milder illness, ciprofloxacin or doxycycline can be used.
You are evaluating a 10-year-old female soccer player with a complaint of exercise-related dyspnea. She has no history of asthma, wheezing, or recurrent respiratory infections. Her medical history is unremarkable. The girl states that within 3 to 5 minutes of maximal exertion, she feels a shortness of breath with a choking sensation. Her mother reports that this is accompanied by noisy breathing, which on questioning, appears consistent with inspiratory stridor and expiratory wheezing. The girl’s coach has noted that the girl develops a “squeaky” voice during these episodes of exercise intolerance. There is no history of cyanosis, chest pain, or loss of consciousness. On physical examination, the girl is well appearing. Her respiratory rate is 14 breaths/min and unlabored, heart rate is 66 beats/min and regular, and 3 extremity blood pressures are normal. There is no cardiac murmur. Her lungs are clear with good aeration throughout. There is no wheezing, stridor, or other adventitious sound. Her extremities are well perfused with brisk capillary refill.
Of the following, the girl’s MOST likely diagnosis is:
A. Extrinsic asthma
B. Hypertrophic cardiomyopathy
C. Laryngomalacia
D. Paradoxical vocal fold dysfunction
E. Vocal cord paralysis
Paradoxical vocal fold dysfunction
- Paradoxical vocal fold dysfunction is defined by adduction of the vocal cords during inspiration, or during inspiration and expiration, with preservation of a posterior region of glottic opening known as a “posterior glottic chink.” For diagnostic confirmation, provocation of symptoms and direct visualization of paradoxical vocal cord movement are required.
- Patients with paradoxical vocal fold dysfunction (PVFD) experience episodes of dyspnea, wheezing, stridor, and/or throat tightness; these symptoms mimic those of asthma, but typically respond poorly to asthma therapies.
- Symptoms that may help differentiate PVFD from asthma include stridor as opposed to wheezing, difficulty in inspiration as opposed to expiration, throat tightness as opposed to chest tightness, and onset of symptoms early during physical activity as opposed to late or after completion.
- Unlike PVFD, unilateral vocal cord paralysis often presents with a weakened voice or chronic stridor. Bilateral vocal cord paralysis is associated with harsh stridor that is persistent and is associated with significant respiratory distress.
A 12-year-old boy with moderate persistent asthma presents to the pediatric clinic for wheezing in September. He has had 3 days of rhinorrhea and cough. This morning, he developed shortness of breath and has had increased use of his rescue inhaler. Vital signs show a temperature of 37.7°C, respiratory rate of 30 breaths/min, heart rate of 110 beats/min, and blood pressure of 100/55 mm Hg. On physical examination, he is in mild distress, and auscultation reveals diffuse wheezing and a prolonged expiratory phase.
Of the following, the MOST likely etiology for the illness in this patient is
A. Adenovirus
B. Coronavirus
C. Parainfluenza
D. Respiratory syncytial virus
E. Rhinovirus
E - Rhinovirus
- Rhinoviruses are the principal cause of the common cold, accounting for one-half to two-thirds of all colds.
- Compared to adults, young children have more episodes of the common cold annually, have longer duration of symptoms, and shed the virus longer.
- Rhinoviruses are associated with approximately two-thirds of all asthma exacerbations.
A 10-year-old boy has a chronic cough. His mother notes that he coughs at night several times each week, enough to wake her but it does not seem to bother him. He has trouble keeping up with peers in sports activities and gym class; he says he runs out of breath easily and has to stop and rest. There is a family history of asthma in a paternal uncle, cystic fibrosis in a maternal cousin, and seasonal allergies in both parents. Physical examination findings are normal, including growth parameters and vital signs.
Of the following, the BEST next step in his evaluation is to perform
- Chest radiography
- Methacholine inhalation
- Spirometry
Sweat chloride testing
C - Spirometry
- Asthma is one of the most misdiagnosed conditions in pediatric medicine, both by underdiagnosis and overdiagnosis. The most appropriate initial diagnostic test for asthma in patients of school age or older is spirometry.
- If there is sign of obstruction on PFT’s, repeating spirometry 15 to 20 minutes after administration of inhaled bronchodilator could establish reversible airflow obstruction.
Methacholine challenge is rarely needed in children. Most often, children with persistent cough or significant daily symptoms will show obstruction on spirometry with demonstration of reversibility; in that case, there is no need for methacholine challenge as a diagnostic tool. In the presence of cough without wheeze and normal spirometry, it might be appropriate to do a methacholine challenge if no other etiology can be found for the cough.
