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Miscellaneous USMLE Step 3 > Section 5: Pediatrics > Flashcards

Section 5: Pediatrics Flashcards

1
Q

Normal vital signs in the newborn

  • Respiratory rate (RR)
  • Heart rate (HR)
A
  • RR: 40 to 60 breaths per minute
  • HR: 120 to 160 beats per minute
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2
Q

A 28-year-old G1 P0 woman delivers a 3.9 kg male infant whose Apgar scores are 9 and 10 at 1 and 5 minutes respectively. The delivery was uncomplicated and both mother and child are in no acute distress. What is the most appropriate next step in management of this patient?

a. Intubate the child
b. Send cord blood for arterial blood gas (ABG)
c. Suction the mouth and nose
d. Nasogastric tube (NGT) placement
e. Give prophylactic antibiotics

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 403). Kaplan Medical Test Prep. Kindle Edition.

A

C. Once the child is delivered, the mouth and nose are suctioned, followed by clamping and cutting of the umbilical cord. The newborn is then dried, wrapped
in clean towels, and placed under a warmer as he has just descended from an environment of 98.6° F to approximately 65° F. Gentle rubbing or stimulating the heels of the newborn helps to stimulate crying and breathing. Intubation and ABG analysis of the
child are indicated only if the newborn is not breathing or is in respiratory distress. Nasogastric tube placement is indicated when GI decompression is needed. Antibiotics are indicated for sepsis.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 403). Kaplan Medical Test Prep. Kindle Edition.

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3
Q

Outline the Rx given at delivery of the newborn

A
  • 1% silver nitrate eye drops or 0.5% erythromycin ophthalmic ointment
  • 1mg of vitamin K IM to prevent vitamin K deficient bleeding (VKDB). VKDB used to be known as hemorrhagic disease of the newborn
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4
Q

List screening tests to do before discharge

A
  1. Hearing test to rule out sensorineural hearing loss
  2. Phenylketonuria
  3. Galactosemia
  4. Hypothyroidism
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5
Q

Apgar Score

The Apgar score delineates a quantifiable measurement for the need and effectiveness of resuscitation. The Apgar score does not predict mortality.

  • What does the one-minute Apgar score evaluate?
  • What does the five-minute Apgar score evaluate?

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 404). Kaplan Medical Test Prep. Kindle Edition.

A
  • One-minute score evaluates conditions during labor and delivery
  • Five-minute score evaluates the response to resuscitative efforts.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 404). Kaplan Medical Test Prep. Kindle Edition.

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6
Q

True or False:

A low score on the Apgar is associated with future cerebral palsy.

A

False

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 404). Kaplan Medical Test Prep. Kindle Edition.

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7
Q

A 3.9 kg male infant whose Apgar scores were 9 and 10 at 1 and 5 minutes, respectively, after delivery is brought in by his parents because his eyes are red.
The delivery was without any complications and both mother and child are in no acute distress. What is the most likely diagnosis at 1 day, at 2 to 7 days, and at >7 days?
a. Chemical irritation
b. Neisseria gonorrhoeae
c. Chlamydia trachomatis
d. Herpes simplex
e. All of the above

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 404). Kaplan Medical Test Prep. Kindle Edition.

A

E. To diagnose the cause of conjunctivitis in the newborn, you must consider when the redness and irritation begins.

  • At 1 day, the most likely cause of the conjunctivitis is chemical irritation
  • From days 2 to 7, the most likely cause is Neisseria gonorrhoeae
  • Conjunctivitis after more than 7 days post delivery is most likely due to Chlamydia trachomatis
  • Conjunctivitis after 3 weeks or more is most likely due to herpes infection.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 404). Kaplan Medical Test Prep. Kindle Edition.

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8
Q

List the criteria of the Apgar Score

A

Acronym used is APGAR

  1. Appearance = Skin color/complexion
    • Blue all over = 0
    • Normal except extremities = 1
    • Normal all over = 2
  2. Pulse = Pulse rate
    • < 60 bpm or asystole = 0
    • > 60 bpm but < 100 bpm = 1
    • > 100 bpm = 2
  3. Grimace = Reflex irritability
    • No response = 0
    • Grimace/feeble cry = 1
    • Sneeze/cough = 2
  4. Activity = Muscle tone
    • None = 0
    • Some flexion = 1
    • Active movement = 2
  5. Respiration = Breathing
    • Absent = 0
    • Weak or irregular = 1
    • Strong = 2

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 404). Kaplan Medical Test Prep. Kindle Edition.

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9
Q

List the lab abnormalities of infant of a diabetic mother (IODM)

A
  • Hypoglycemia
  • Hypocalcemia
  • Hypomagnesemia
  • Hyperbilirubinemia
  • Polycythemia
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10
Q

List the congenital abnormalities associated with IODM

A
  • Cardiac abnormalities (ASD, VSD, truncus arteriosus)
  • Small left colon syndrome
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11
Q

True or False:

IODM is associated with an increased risk of developing diabetes and childhood obesity

A

True

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12
Q

A 1-week-old newborn is brought to the ED after a home delivery. His parents state they do not believe in vaccinations nor did they seek any medical attention
after delivery. They state they have noticed bright red blood per rectum from the infant and he is very lethargic. On examination the infant has unequal pupils and his diaper has gross red blood. What is the most likely diagnosis?
a. Cerebrovascular accident
b. Meckel’s diverticulum
c. Vitamin K deficient bleeding
d. Crohn disease

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 405). Kaplan Medical Test Prep. Kindle Edition.

A

C. As this child received no routine newborn care, it is very likely he is suffering from a vitamin K deficiency. Newborns are at most risk as their immature livers do not utilize vitamin K to develop the appropriate clotting factors. Breast milk typically has very low levels of vitamin K. The child’s lethargy is likely from intracranial bleeding, and the bright red blood per rectum is mucosal bleeding. The child’s age precludes a diagnosis of CVA, Crohn disease, or a Meckel’s diverticulum.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 405). Kaplan Medical Test Prep. Kindle Edition.

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13
Q

Respiratory distress in the newborn

  1. Best initial test
  2. List the other diagnostic studies
  3. Best initial Rx
A
  1. Chest X-ray
  2. Other tests:
    • ABG
    • Blood cultures (R/O sepsis)
    • Blood glucose (R/O hypoglycemia)
    • CBC (R/O anemia or polycythemia)
    • Cranial ultrasound (R/O intracranial hemorrhage)
  3. Best initial Rx:
    • Oxygen: keep SaO2 > 95%
    • Give nasal CPAP if high O2 requirements to prevent barotrauma and bronchopulmonary dysplasia
    • Consider empiric antibiotics for suspected sepsis
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14
Q

Meconium aspiration 1:

List the diagnostic test and the findings

A

CXR. Findings are;

  • Patchy infiltrates
  • Increased AP diameter (barrel chest)
  • Flattening of the diaphragm
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15
Q

Rx of meconium aspiration

A
  • positive pressure ventillation
  • High-frequency ventillation
  • Nitric oxide therapy
  • Extracorporeal membrane oxygenation
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16
Q

How to prevent meconium aspiration?

A

endotracheal intubation and airway suction of depressed infants

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17
Q

Possible complications of meconium aspiration

A
  • Pulmonary artery HTN
  • Air leak (pneumothorax, pneumomediastinum)
  • Aspiration pneumonitis
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18
Q

Meconium plugs are seen in the lower colon. List the conditions associated with meconium plugs

A
  • Small left colon in IODM
  • Hirschsprung disease
  • Cystic fibrosis
  • Maternal drug abuse
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19
Q

Meconium ileus is seen in the lower ileum. List the condition in which it is associated with.

A

Cystic fibrosis

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20
Q

Best initial diagnostic test and Rx of meconium plug and ileus

A

Best initial test: Abdominal X-ray

Rx: Gastrografin enema

21
Q

List the components of the VACTERL syndrome

A
  • Vertebral defects
  • Anal atresia
  • Cardiac abnormalities
  • Tracheoesophageal fistula with esophageal atresia
  • Radial and Renal anomalies
  • Limb syndrome
22
Q

A premature infant is born by normal vaginal delivery without complication. There is no respiratory distress. Upon the first feed, she begins vomiting gastric and bilious material. CXR is shown. What is the most likely diagnosis?

A

Duodenal atresia. Half of infants with this condition are born prematurely, and the condition is associated with Down syndrome. Look for polyhydramnios in the prenatal exam. Treatment involves NG decompression and surgical correction. You must search for other abnormalities (VACTERL association) with X-ray of the spine, abdominal ultrasound, and echocardiogram

23
Q

List the differential diagnosis of double-bubble seen on abdominal X-ray of newborn infants

A
  • Duodenal atresia
  • Annular pancreas
  • Malroration
  • Volvulus
24
Q

When is hyperbilirubinemia considered pathological?

A
  • It appears on the first day of life
  • Bilirubin rises > 5mg/dL/day
  • Bilirubin > 12mg/dL in term infant
  • Direct bilirubin > 2mg/dL at any time
  • Hyperbilirubinemia is present after the 2nd week of life
25
Q

List the causes of direct bilirubinemia

A
  • Sepsis
  • TORCH infections
  • Total parenteral nutrition
  • Hypothyroid
  • Galactosemia
  • Tyrosinemia
  • Cystic fibrosis
  • Choledochal cyst
26
Q

List the causes of a Coombs positive indirect hyperbilirubinemia

A
  • Rh incompatibility
  • ABO incompatibility
  • Thalassemia minor
27
Q

List the causes of a Coombs negative indirect hyperbilirubinemia with high hgb

A
  • Polycythemia
  • Twin-twin transfusion
  • Maternal-fetal transfusion
  • Delayed cord
  • IURG
  • Infant of diabetic mother
28
Q

List the diagnostic work-up for jaundice presenting in the first 24 hours

A
  • Total and direct bilirubin
  • Blood type of infant and mother: Look for ABO or Rh incompatibility
  • Direct Coomb’s test
  • CBC, reticulocyte count, and smear: Assess for hemolysis
  • Urinalysis and culture if elevated direct bilirubin: Assess for sepsis
29
Q

List the common causes (organisms) of early onset neonatal sepsis

A

Group B Streptococcus

E. coli

Haemophilus influenzae

Listeria monocytogenes

30
Q

List the common causes of late onset neonatal sepsis

A

Staphylococcus aureus

E.coli

Klebsiella

Pseudomoans

31
Q

In the newborn intensive care unit, an infant is noted to be “jittery” and has repetitive sucking movements, tongue thrusting, and brief apneic spells. Blood counts and chemistries are within normal limits. What is the initial workup of this patient?

A

Seizures classically pesent with subtle repetitive movements, such as chewing, tongue thrusting, apnea, staring, blinking, or desaturations. Classic-tonic clonic movements are uncommon. Look for ocular deviation and failure of jitteriness to subside with stimulus (e.g., passive movement of a limb)

32
Q

List the diagnostic tests in neonatal seizures

A

EEG: may be normal

CBC, electrolytes, calcium, magnesium, phosphorous, glucose

Amino acid assay and urine organic acids

Total cord blood IgM for TORCH infection studies

Blood and urine cultures

LP if meningitis is suspected

Ultrasound of the head in preterms for intraventricular hemorrhage

33
Q

Best initial Rx of neonatal seizure

Rx if seizure persists

A

Phenobarbital

Phenytoin

34
Q

List the CF of neonatal withdrawal to substance abuse

A
  • Hyperactivity
  • Irritability
  • Fever
  • Diarrhea
  • Tremors/jitters
  • High-pitched crying
  • Sneezing
  • Restlessness
  • Vomiting
  • Nasal suffiness
  • Poor feeding
  • Seizures
  • Tachypnea
35
Q

If the infant presents with substance withdrawal symptoms within the first 48 hours, list the likely abused substances

A
  • Heroin
  • Cocaine
  • Amphetamine
  • Alcohol
36
Q

True or False:

  1. Methadone is associated with a higher risk of seizures
  2. Methadone withdrawal presents within the first 48 hours
  3. Methadone withdrawal may present up to 2 weeks
A
  1. True
  2. False. It is within the first 96 hours
  3. True
37
Q

List the complications of infants of addicted mothers are at higher risk of

A

Low birth weight

Intrauterine growth retardation (IURG)

Congenital anomalies (alcohol, cocaine)

Sudden infant death syndrome (SIDS)

38
Q

Best initial Rx for neonatal withdrawal to mother’s substance abuse

A

Opioids (especially if specific opioid use was known) and

Phenobarbital

39
Q

True or False:

Never give naloxone to an infant born from mother with known narcotics use. Why?

A

True. It may precipitate sudden withdrawal, including seizures

40
Q

A premature infant born at 28 weeks is in respiratory distress, with grunting, nasal flaring, and the use of accessory muscles. Bowel sounds are heard upon auscultation of the back and chest x-ray shows air fluid levels are seen in the chest. Which of the following is the most likely diagnosis?

a. Hydrocele
b. Gastroschisis
c. Diaphragmatic hernia
d. Hiatal hernia
e. Omphalocele

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 409). Kaplan Medical Test Prep. Kindle Edition.

A

C. A hernia in the diaphragm will allow for bowel contents to move into the chest and impair ventilation. Hydrocele is a urinary defect and is not seen on x-ray. It cannot be gastroschisis or omphalocele, as those are defined as an extrusion of abdominal contents outside of the body. Hiatal hernia is a benign finding most commonly seen in elderly or obese patients.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 409). Kaplan Medical Test Prep. Kindle Edition.

41
Q

Upon her first feeding, a 1-day-old child begins to choke and exhales milk bubbles from her nose, then appears to be in significant respiratory distress. CXR reveals
an air bubble in the upper esophagus and no gas pattern in the remainder of the GI tract. A coiled NGT is also seen. What is the most common complication of this condition?
a. Meningitis

b. Pneumonia
c. Dental caries
d. Dyspepsia
e. Belching

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 419). Kaplan Medical Test Prep. Kindle Edition.

A

B. The signs described both on physical exam and radiological exam point towards an esophageal atresia with a tracheoesophageal fistula. Aspiration pneumonia
is a severe and common complication of this condition as food contents are aspirated via the fistula in the respiratory system. Aspiration leads to abscess formation from anaerobic proliferation. Dental caries cannot form because the child is only 1 day old and therefore does not have teeth. Food cannot reach the stomach, so there is no possibility for either dyspepsia or belching.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 420). Kaplan Medical Test Prep. Kindle Edition.

42
Q

1-month-old child is fed, after which he has vomitus that is forceful and winds up across the nursery. The vomitus is nonbloody and nonbilious. Physical examination reveals a palpable mass in the abdomen. An upper GI series is ordered. Which of the following is the most likely finding on this radiologic exam?

a. String sign
b. Doughnut sign
c. Bird’s beak sign
d. Steeple sign
e. Murphy sign

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 420). Kaplan Medical Test Prep. Kindle Edition.

A

A. Projectile vomiting and palpable abdominal mass is characteristic of pyloric stenosis. String sign is seen on upper GI series (barium is swallowed and its passage is
watched under fluoroscopy). Doughnut sign is seen during intussusceptions. Bird’s beak is seen in achalasia, steeple sign is seen during croup, and the Murphy sign is not ever a radiological sign, but rather a physical exam sign with right upper quadrant tenderness that causes cessation of breathing.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 421). Kaplan Medical Test Prep. Kindle Edition.

43
Q

1-day-old child is given her first feeding, at which time she begins to have very dark green vomiting. On physical examination, the child has oblique eye fissures
with epicanthic skin folds and a single palmar crease. A holosystolic murmur is also heard. CXR reveals a double bubble sign. Which of the following is the most likely diagnosis?
a. Biliary atresia
b. Duodenal atresia
c. Volvulus
d. Intussusception
e. Pyloric stenosis

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 424). Kaplan Medical Test Prep. Kindle Edition.

A

B. The child’s bilious vomiting on the first day of life is the prototypic finding in children with this condition. Furthermore, the description of Down syndrome-like
characteristics such as eye shape, simian crease, and congenital murmur also points to duodenal atresia. Volvulus and intussusception would present with symptoms of obstruction such as distension and failure to pass flatus and stool, and do not have vomiting as a presenting symptom. Biliary atresia would not have any bilious

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 424). Kaplan Medical Test Prep. Kindle Edition.

44
Q

A 1-year-old child is having his diaper changed when his father notices the stool looks like a purple jelly. He quickly rushes to the ED and reports that the previous night, the child was very irritable, complained of pain, and had an episode of vomiting. On physical exam the child seems lethargic and a firm sausage-shaped
mass is palpated. Which of the following is the most likely diagnosis?
a. Biliary atresia
b. Duodenal atresia
c. Volvulus
d. Intussusception
e. Pyloric stenosis

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 425). Kaplan Medical Test Prep. Kindle Edition.

A

D. Intussusception presents with currant jelly stool, sausage-shaped mass, neurologic signs, and abdominal pains. The remaining choices do not fit this description.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 425). Kaplan Medical Test Prep. Kindle Edition.

45
Q

An 11-month-old girl is brought from daycare to the ED for severe diarrhea and a fever of 103°F. The parents are still not present, but the daycare provider states
that the girl has been lethargic, has not been eating, and has had several episodes of diarrhea. The last episode was bloody and contained mucus. Physical
exam reveals a child who is listless and drowsy. Her skin shows signs of tenting. Laboratory findings show marked leuokocytosis, elevated BUN and creatinine,
and markedly decreased bicarbonate and elevated hematocrit. Which of the following is the most appropriate next step in management of this patient?
a. CT of the abdomen and pelvis
b. Discharge home
c. Fluid resuscitation
d. Stool ova and parasite (O&P) analysis
e. Empiric antibiotic delivery

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 427). Kaplan Medical Test Prep. Kindle Edition.

A

C. The child is severely dehydrated as demonstrated by acute renal failure secondary to hypovolemia, skin tenting, and hemoconcentration The most appropriate
next step is aggressive IV fluid rehydration and electrolyte replenishment. At this time, no other test or therapy is important; this child is unstable and could be on the brink of hypovolemeic shock. Radiologic imaging delays the administration of fluids and discharging the child home could result in fatal consequences. Antibiotic coverage is not the most appropriate next step because antibiotics can take 12 to 24 hours to become effective. Antibiotics are needed, but fluids work faster and are needed more urgently at this time.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 427). Kaplan Medical Test Prep. Kindle Edition.

46
Q

A 3-day-old preterm female neonate is noted by the resident to have increased gastric residual volume and abdominal distension. On rectal exam the stool is
heme positive. Lactate is 2.9 mg/dL. A supine x-ray of the abdomen shows air in the bowel wall but no free air in the peritoneum. What is the best next step in management of this condition?
A. Call surgical consult
B. Start antibiotics
C. CT scan of the abdomen
D. 0.9% normal saline bolus
E. Ringer lactate maintenance fluids

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 428). Kaplan Medical Test Prep. Kindle Edition.

A

B. When there is confirmed evidence of necrotizing enterocolitis, start antibiotics; the antibiotics of choice are vancomycin, gentamicin, and metronidazole. This is
adjunct with serial abdominal x-rays to exclude perforation. Calling a consult is always the wrong answer on the USMLE, and a CT scan of the abdomen is not necessary, as x-ray can diagnose the findings. Although starting fluids is correct, it is not the best next step compared with initiating antimicrobial therapy.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 428). Kaplan Medical Test Prep. Kindle Edition.

47
Q

A 10.5-pound infant is born to a mother with Type I diabetes. Upon examination of the newborn, he is shaking and a holosystolic murmur is heard over the precordium. The baby’s right arm is adducted and internally rotated. His lab findings show elevated bilirubin. Which of the following is the most appropriate next step in management?

a. IV insulin
b. Blood sugar level
c. Serum calcium levels
d. Serums TSH
e. CT head and neck

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 429). Kaplan Medical Test Prep. Kindle Edition.

A

B. Infants of diabetic mothers (IDMs) are born macrosomic, with plethora, and can be very jittery. The newborn usually has dramatically high circulating levels
of glucose, but upon delivery, maternal glucose is no longer available. This child is still producing high levels of insulin, and thus his blood sugar levels have dropped. Cardiac anomalies are common, as in this child, who most likely has a VSD. When we think of diabetes, our first thought is insulin treatment. This is the most common wrong answer, since it would further exacerbate these newborns’ problems.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 429). Kaplan Medical Test Prep. Kindle Edition.

48
Q

A 6-month-old infant is brought in by his mother after what she describes as a seizure. The child has had a fever of 103°F for the last 3 days and has been very
irritable lately. He appears unresponsive but is breathing. Physical examination reveals a markedly delayed capillary refill and a blood pressure of 80/20.
What is the most likely diagnosis?
a. Febrile seizure
b. Absence seizure
c. Dog bite
d. Cocaine withdrawal
e. Epilepsy

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 433). Kaplan Medical Test Prep. Kindle Edition.

A

A. This child has febrile seizure secondary to sepsis. The real take-home message with this case is to evaluate the child for the underlying cause of the sepsis. Understanding he has had a febrile seizure is only the surface of the case. A full sepsis evaluation must be ordered, which includes CBC with differential blood and urine
cultures, urinalysis, chest x-ray, and lumbar puncture (if irritability or lethargy is mentioned = meningitis). Dog bites do not present with seizures. Cocaine withdrawal
does not have seizures.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 433). Kaplan Medical Test Prep. Kindle Edition.

49
Q

Neonatal Sepsis:

  1. Most common causes
  2. Most common organisms
  3. Diagnostic tests
  4. Rx
A
  1. Pneumonia; Meningitis
  2. Group B strep; E. coli; S. aureus; Listeria monocytogenes
  3. Blood cultures and urine cultures; CXRay
  4. Ampicillin and gentamicin

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 433). Kaplan Medical Test Prep. Kindle Edition.

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