Quiz 18

Question 1

Posterior or posteromedial rib fractures

Answer 1

child abuse until proven otherwise

Question 2

Osteogenesis imperfecta

Answer 2

continuous beading of the ribs and crumpled long

bones such as accordina femora, and is often associated with blue sclerae, skin fragility, or brittle teeth.

Question 3

Rickets

Answer 3

Rickets usually is associated with long bone bowing deformities.
In the chest it can cause prominence of the costochondral junctions (rachitic rosary) and indentation of the
lower ribs where the diaphragm attaches (Harrison’s grooves)

Question 4

39 weeks gestation

management of hypertension in pregnancy

Answer 4

The 2013 ACOG guideline recommends induction of labor for gestational hypertension after 37 weeks.

Twice-weekly
office visits with assessment of blood pressure and the other tests mentioned may be appropriate for
patients at less than 37 weeks gestation

Question 5

A 40-year-old obese African-American male presents with a history of excessive daytime
drowsiness. At home he falls asleep shortly after starting to read or watch television. He admits
to nearly crashing his car twice in the past month because he briefly fell asleep behind the wheel.
Most frightening to the patient have been episodes characterized by sudden loss of muscle tone,
lasting about 1 minute, associated with laughing. An overnight sleep study shows decreased
sleep latency and no evidence of obstructive sleep apnea.

Appropriate treatment includes

Answer 5

Methylphenidate (Ritalin)

narcolepsy

In
addition to the sleepiness, the patient also has cataplexy, which is manifested in this case by episodes of
sudden weakness when laughing and is almost pathognomonic for narcolepsy. Some patients may also have
vivid hallucinations when falling asleep or waking up. Treatment involves improving both the quantity and
quality of sleep during the night, which can be accomplished with sodium oxybate. This improves daytime
alertness and cataplexy. Scheduling naps is the second important aspect of managing narcolepsy. The third
important step is the use of stimulants such as methylphenidate to improve function during the day.

Question 6

Diffuse parenchymal lung disease

Common offenders that can help cause it?

Answer 6

amiodarone and nitrofurantoin,
which can induce a pneumonitis. In this patient, lisinopril might explain the cough but not the dyspnea,
crackles, or abnormal spirometry.

Question 7

Gestational age of 14. What should be tested?

Answer 7

All pregnant women should be screened for asymptomatic bacteriuria between 11 and 16 weeks gestation
and should be appropriately treated if the urine culture is positive. Asymptomatic bacteriuria is a known
contributor to recurrent urinary tract infections, pyelonephritis, and preterm labor. TSH levels should be
checked in patients with a history of thyroid disease or symptoms of disease, but universal testing is not
recommended. Although treatment of bacterial vaginosis decreases the risk of low birth weight and
premature rupture of membranes, universal screening is not recommended. This patient should be screened
for both group B Streptococcus (GBS) and diabetes mellitus, but not at this point in her pregnancy. GBS
screening should be done between 35 and 37 weeks gestation, and diabetes screening should be performed
with a 50-g glucose load between 24 and 28 weeks gestation.

Question 8

Autism

Answer 8

Pediatrics recommends screening with a validated autism-specific tool such as the MCHAT at 18 and 24
months (SOR C). Delayed social development is typically the first sign of autism. Language delay can be
another finding, but it is less specific. Of the behaviors listed, only abnormal sensitivity to sound is
consistent with autism. Gesturing, pretend play, mimicking, and attempting to attract caregiver attention
all suggest other diagnoses.

Question 9

A 28-year-old male has had bright red blood in his semen with his last three ejaculations. He is
sexually active. He considers himself in good health, takes no medications, has no other
symptoms to suggest a coagulopathy, and has no other genitourinary symptoms. Examination
of the testes shows no masses or tenderness. Findings on a digital rectal examination are normal.
What do you do?

Answer 9

A urine probe for Neisseria gonorrhoeae and Chlamydia trachomatis

In males younger than 40, hematospermia is usually benign and self-limited. Examination of the testes and
prostate is warranted but findings are usually normal. If the patient is sexually active a screen for STDs
is reasonable. Imaging of the genitourinary tract, a serum PSA level, and urology referral are unnecessary
in this age group unless the history or physical examination suggests an unusual cause.