Pediatric Quiz Flashcards
You are giving a lecture on poisoning in children to a group of medical students. One student asks you the best way to prevent poisoning. You explain the preventive measures that should be taken and that anticipatory guidance counseling should be provided during health supervision visits.
Of the following, the health supervision visit at which it is MOST appropriate to begin discussing poisoning prevention strategies with parents is:
Choices: 2mo, 6mo, 9mo, 12mo, or 2 wks?
B. 6 months
Because many children will begin to explore their environment by either crawling or creeping before 9 months, childproofing the home by safely storing poisonous substances and medications should be discussed at the 6-month visit. Waiting until the 9- or 12-month visit may be too late
A 10-year-old boy presents to your office with the complaint of cola-colored urine. He had been well until 2 days ago, when he developed symptoms of rhinorrhea and mild cough. His sister had cold symptoms approximately 1 week ago. His review of systems is notable for a mild sore throat without fever. Family history is notable for an uncle who is on hemodialysis. On physical examination, the boy has a temperature of 37.3°C, a heart rate of 84 beats/min, a respiratory rate of 20 breaths/min, blood pressure of 106/62 mm Hg, and normal growth parameters. Laboratory evaluation reveals the following:
• Electrolytes, normal
• Blood urea nitrogen, 24 mg/dL (8.6 mmol/L)
• Creatinine, 0.9 mg/dL (80 mmol/L)
• Albumin, 3.4 gm/dL (34 g/L)
• Complement component 3 (C3), 128 mg/dL; normal, 80 to 200 mg/dL
• Complement component 4 (C4), 27 mg/dL; normal, 16 to 40 mg/dL
• Antinuclear antibody, negative
Urinalysis:
• Specific gravity, 1.015
• pH, 6.5
• 3+ blood
• 2+ protein
• Leukocyte esterase, negative
• Nitrite, negative
Of the following, the study MOST likely to result in a diagnosis is:
A. antistreptolysin O titer
B. hearing screen
C. noncontrast computed tomography scan of the abdomen
D. immunoglobulin A level
E. creatine phosphokinase level
B. Hearing Screen
The differential diagnosis in this clinical setting includes IgA GN, membranoproliferative glomerulonephritis (MPGN), and Alport syndrome. Although IgA GN and MPGN are more common, a genetic syndrome is suggested in light of the uncle on hemodialysis. The most appropriate course of action is to screen this patient for Alport syndrome with a hearing screen to look for bilateral high frequency hearing loss. pproximately 80% of cases of Alport syndrome are X-linked inherited. Types of familial nephritis include Alport syndrome and thin glomerular basement membrane disease.
A full-term male newborn is admitted to the regular nursery after an uneventful delivery. Apgar scores are 8 at 1 minute and 9 at 5 minutes. He feeds well initially, but 32 hours after birth you are called by the nurse because he is feeding poorly and seems “lethargic.” You arrange for transfer of the newborn to the intensive care nursery, where the resident on duty obtains a blood culture and provides appropriate antibiotic coverage.Of the following, if sepsis is ruled out, the test MOST likely to be diagnostic in this newborn is
A. electroencephalogram
B. head ultrasonography
C. liver function tests
D. serum ammonia and urine organic acids
E. a complete blood cell count with differential
D. serum ammonia and urine organic acids
The child in this vignette is a healthy, full-term newborn who has developed mental status changes within 48 hours after birth. Although sepsis is the most likely diagnosis in this scenario, the newborn’s presentation is also typical of an inborn error of metabolism, such as a urea cycle defect or organic acidemia. Therefore, serum ammonia and urine organic acid testing should be considered and done in parallel with blood cultures and antibiotic administration.
A 10-year-old girl is brought to your office after falling off her bicycle 4 hours ago. She did not lose consciousness after the fall but appeared confused and had 2 episodes of vomiting. These symptoms resolved in 30 minutes and she is now acting normally. She has had no further episodes of emesis and denies headache. On physical examination, she is awake, alert, and her Glasgow Coma Scale score is 15. Her vital signs are within reference range. She has abrasions on her forearms and her forehead. Her neurologic examination results are normal.Of the following, the MOST appropriate next step is
A. computed tomography of the brain without intravenous contrast
B. computed tomography of the brain with intravenous contrast
C. reassurance
D. skull radiographs
E. magnetic resonance imaging of the brain
C. reassurance
Observation is recommended for patients with isolated, nonprogressive, nonpersistent signs because they have significantly less than a 1% likelihood of clinically important intracranial injury (CIICI). Observing patients in this subgroup led to a lower CT scanning rate without an increase in morbidity.
Child in the vignette has an isolated, nonpersistent risk factor (history of vomiting). Four hours of observation have elapsed since the injury occurred, during which her symptom resolved. Her risk of CIICI is substantially less than 1%. Parents can be reassured, and the child can be safely discharged.
A 10-year-old girl presents with a 6-week history of double vision and droopy eyelids. Symptoms fluctuate and tend to worsen with fatigue. She has no difficulty walking up stairs or lifting her arms, and she has no complaints of pain. Physical examination reveals a healthy-appearing girl with normal vital signs. General physical examination findings are normal, as are mentation and language. She tips her head back to look under her drooping eyelids and has limited abduction and adduction of both eyes. She has weakness of eye closure. Her limb strength, tone, bulk, reflexes, and gait are normal.
Of the following, the MOST likely diagnosis is A. dermatomyositis B. Guillain-Barré syndrome C. myasthenia gravis D. pseudotumor cerebri E. tick paralysis
C. myasthenia gravis
vignette has an acquired, fluctuating, bilateral muscle weakness that affects face muscles and eye movements but not thinking or language. The prominent ptosis and fluctuation of symptoms that worsen with fatigue are consistent with myasthenia gravis.
Neuromuscular junction diseases affect the acetylcholine transmission signal between the nerve terminal and the muscle. The most common is myasthenia gravis, which is caused by autoantibodies directed against the acetylcholine receptor in the muscle. The presence of these antibodies variably blocks the nerve signal to the muscle, causing weakness.
A 10-year-old boy presents to the emergency department for fever. His mother states that he had a splenectomy 2 years ago for severe hereditary spherocytosis. He has an oral temperature of 39.5°C, pulse rate of 110 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 125/80 mm Hg. On examination, he is in no distress and his lungs are clear to auscultation bilaterally. The remainder of his examination is unremarkable. Results of a chest radiograph are normal with no consolidation. A blood culture is drawn and sent to the laboratory. The following are the results of the boy’s complete blood cell count:
- White blood cell count, 15,000/µL (15 × 109/L), with 45% polymorphonuclear leukocytes, 10% band neutrophils, 36% lymphocytes, 6% monocytes, and 3% eosinophils
- Hemoglobin, 12.3 g/dL (123 g/L)
- Platelet count, 625 × 103/µL (625 × 109/L)
Of the following, the MOST appropriate next step would be to administer A. oral penicillin B. aspirin C. conjugate pneumococcal vaccine D. intravenous ceftriaxone E. oral azithromycin
D. intravenous ceftriaxone
Patients with asplenia from a congenital, functional, or postsurgical state are at increased risk for bacteremia that often leads to sepsis. Because of the high incidence of sepsis among asplenic patients, fever in these patients should be treated immediately with empiric, broad-spectrum parenteral antibiotics such as ceftriaxone. Oral antibiotics are not sufficient treatment for presumed bacteremia. Vaccination against encapsulated organisms would not be indicated to treat the acute infection.
You are evaluating a newborn in the nursery who was delivered at term following an uneventful pregnancy to a 25-year-old gravida 1, para 0 woman by normal spontaneous vaginal delivery. The newborn’s birth weight was 3.2 kg and she is breastfeeding well. On examination, you note redundant skin on the nape of her neck and puffiness of the dorsum of her hands and feet (Item Q62).Of the following, the test MOST likely to provide a diagnosis for this newborn is
A. renal ultrasonography B. liver function tests C. a cytogenetic analysis D. serum electrolytes E. .an echocardiogram
C. A cytogenic analysis
The newborn described in this vignette has findings suggestive of Turner syndrome (TS), so the diagnostic test of choice would be a cytogenetic analysis. About half of affected girls having 45,XO karyotype. The remainder of girls with TS have sex chromosome mosaicism
TS –> redundant skin on the nape of the neck as well as hand and foot edema are very suggestive of this condition.
You are seeing a 16-year-old girl because she has not had a menstrual period in 6 months. She had menarche at 12 years of age and her periods had become progressively more irregular before completely stopping 6 months ago. Her past medical history is unremarkable and she is currently asymptomatic. She is on the cross country running team and is planning on running a marathon in the next year. She denies being sexually active or having any body image issues. Her vital signs are normal, her body mass index is 19.5, and her sexual maturity rating is stage 5. Results of the remainder of her physical examination are unremarkable. The pregnancy test result is negative. Additional tests, including a complete blood cell count, electrolytes, thyroxine, thyroid-stimulating hormone, luteinizing hormone, and follicle-stimulating hormone concentrations, yield normal results.Of the following, the MOST important next step in the management of this girl would be to have
A. increase her overall nutritional intake B. increase her calcium and vitamin D intake C. switch to a nonendurance sport D. begin combined oral contraception E. stop exercising till her me.nses returns
A. Increase her overall nutritional intake
A negative energy balance in female athletes may lead to the female athlete triad, which is composed of amenorrhea, osteoporosis, and disordered eating. Restoring a positive energy balance by increasing overall food intake may be all that is needed to restore menses and improve bone density.
You are evaluating a 16-year-old girl who has a 5-day history of progressive cough, shortness of breath, and fever. Her vital signs include a temperature of 39.0°C, a heart rate of 100 beats/min, and a respiratory rate of 35 breaths/min. On physical examination, she has mild respiratory distress, prolonged expiration, and decreased breath sounds over the left chest. You obtain a chest radiograph and decide to admit her to the hospital for further treatment.
[CXR: Left side white out]
Of the following, the MOST appropriate empiric antibiotic regimen to order is
A. ampicillin and gentamicin B. doxycycline C. cefuroxime and nafcillin D. azithromycin E. ceftriaxone
E. Ceftriaxone
Empiric therapy with a third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) is appropriate for hospitalized infants and children who have complicated pneumonias (such as the girl in the vignette with probable empyema), for infants who are not fully immunized, or in areas where high-level penicillin resistance of pneumococcal strains is present.
You are caring for a 10-year-old girl who has cystic fibrosis. In addition to her regular pulmonary care regimen, she is consuming a high-protein diet that provides 125% of her calculated daily requirements for energy and protein. Her diet includes 3 meals plus 2 snacks per day, along with pancreatic enzyme supplements that provide 20,000 lipase units per meal and 12,000 lipase units per snack. She also takes daily supplements of fat-soluble vitamins. Despite this regimen, she has lost 2 kg over the past 6 months, and her stools have become increasingly bulky and frequent. At the time of her office visit today, her height is at the 50th percentile, and her weight is at the 10th percentile for her age. The remainder of the physical examination demonstrates mild expiratory wheezing at the lung bases but is otherwise unchanged from previous examinations. Of the following, you are MOST likely to recommend
A. a hydrolyzed protein–based nutritional supplement B. reducing fat content of the diet C. supplementing with medium-chain triglyceride oil D. increasing mealtime doses of pancreatic enzymes E. nocturnal enteral feedings
D. increasing mealtime doses of pancreatic enzymes
Difficulties in maintaining optimal nutrient intake are the consequence of both malabsorption secondary to pancreatic insufficiency and increased energy requirements resulting from increased work of breathing. The most likely cause of this weight loss is inadequate lipase supplementation at mealtime. Her current mealtime supplement of 20,000 lipase units falls well below the amount recommended for her age which is 24,000 to 40,000 lipase units per meal.
A 12-year-old girl is in your office, complaining of an increase in the quantity of her vaginal discharge. She is a swimmer and uses tampons frequently. She experienced menarche about a year ago and notes that the discharge increases just before the onset of her menses. She denies any sexual activity and has no urinary or gastrointestinal symptoms. A pregnancy test result is negative. You examine the discharge and note that the pH is 4.5, the whiff test result is negative, and there are no clue cells or white blood cells on microscopy. Of the following, the MOST appropriate next step in the management of this girl is to
A. culture the vaginal discharge for Gardnerella vaginalis B. question her further about sexual abuse C. advise her to discontinue the use of tampons D. encourage her to douche with her periods E. reassure her that the discharge is normal
E. reassure her that the discharge is normal
A 14-year-old boy comes to his pediatrician’s office on Long Island, NY, in early September for evaluation of a 3-week history of fatigue and diffuse achiness. There are no noted joint swellings or rashes, and he has had no fever throughout this illness. He has been playing in soccer tournaments across Long Island over the summer. He was seen in an urgent care center the previous weekend for these complaints, and his physical examination was unremarkable. His complete blood cell count and erythrocyte sedimentation rate were also normal, but his Lyme enzyme immunosorbent assay (EIA) result was 2.20 (negative,
C. Western Blot Analysis for Lyme Antibodies
Serologic testing for Lyme disease is performed in a 2-tiered approach. The initial screening test is most often done by enzyme immunosorbent assay (EIA). Although the EIA is easily performed and has good sensitivity, it does not have sufficient specificity. Therefore, a positive or equivocal EIA should be confirmed by the more specific western blot that assesses responses to individual proteins of B burgdorferi. The immunofluorescent antibody (IFA) test is an alternative screening test that is analogous to the EIA. Polymerase chain reaction (PCR) can be used to detect B burgdorferi DNA in cerebrospinal fluid or synovial fluid, but it is not a routine assay for confirming a Lyme EIA result.
A 13-year-old girl is struggling in her eighth grade classes. She is a social girl who is an active participant on her soccer team. Her mother brings you the results of her psychoeducational testing. The Vanderbilt rating form revealed no significant issues with attention or hyperactivity. Cognitive testing revealed a verbal IQ of 95 and a nonverbal IQ of 100 (the normal range for the population is 85-115). There was no significant difference between the score of 95 on the verbal section and the score of 100 on the nonverbal section. Educational testing demonstrated that her reading score was at a sixth grade level and her math score at the eighth grade level.Of the following, the MOST appropriate diagnosis for this girl is
A. attention-deficit/hyperactivity disorder B. autism spectrum disorder C. learning disabilty D. intellectual disability E. motor coordination disorder
C. Learning Disability
The girl described in the vignette has evidence of a learning disability with difficulty in reading. In order for a learning disability to be diagnosed, there must be a significant discrepancy between the child’s achievement scores in reading, writing, or math and the child’s cognitive ability (IQ). The discrepancy must impact the child’s educational success.
The girl described in the vignette does not have significant impairment in social reciprocity or restricted and repetitive behaviors; therefore, she does not have an autism spectrum disorder. Her Vanderbilt screening tool does not raise concern for attention-deficit/hyperactivity disorder. Her cognitive profile is average and not indicative of an intellectual disability. The girl is described as an active participant in her sports team, which indicates there is no evidence of a primary motor coordination disorder.
A 13-year-old boy has complained of dull medial thigh pain for a month, but his parents have only noticed a mild limp for the last 3 days. He has had no trauma, fever, rash, weight loss, or fatigue. His body mass index is at the 95th percentile for his age and he is at sexual maturity rating 3. There is mild tenderness over the thigh. The knee is not red or swollen, and there is no ligamentous laxity. Physical examination of his hip shows mildly limited abduction with decreased internal rotation.
Of the following, the MOST appropriate diagnostic test for this boy is
A. anterior-posterior and frog-leg radiographs of the hip B. bone scan of the hip C. magnetic resonance imaging of the knee and thigh D. serum creatine kinase, complete blood cell count, and C-reactive protein levels E. ultrasonography of the hip
A. Antirior-Posterior and Frog-Leg radiographs of the Hip
Slipped capital femoral epiphysis (SCFE) is the most common hip condition of early adolescence. Those affected are usually above the 90th percentile for weight for age.
The most important diagnostic test for SCFE is a lateral frog-leg radiograph of the hips that shows widening of the physis, shortening of the epiphysis, or posterior-inferior displacement of the femoral head. Once the diagnosis is made, the patient should be placed on bed rest immediately. The treatment of choice is in situ fixation with a single screw. Attempts at reduction have led to an increased risk of avascular necrosis and are contraindicated.
A 13-year-old boy presents with a 1-day history of right-sided scrotal pain. There is no history of sexual activity or trauma. He had some facial swelling about a week ago that has since subsided. He also complains of a mild headache and feels fatigued. He has no history of dysuria, frequency, or penile discharge. On physical examination, he is febrile with a temperature of 38.4°C. There is right hemiscrotal swelling with a tender swollen testicle on palpation. The left testicle and cord are normal. Results of urine microscopy are within reference range. Further laboratory studies reveal a white blood cell count of 12,100/μL (12.1 × 109/L) and a C-reactive protein of 25 mg/L (238.1 nmol/L). Ultrasonography with a Doppler flow shows an edematous right testicle with increased flow.
Of the following, the MOST likely cause of his scrotal pain is
A. epididymitis due to chlamydia infection B. germ cell testicular tumor C. inguinal hernia D. torsion of the testicle E. viral infection of the testicle
E. viral infection of the testicle
The boy described in the vignette has scrotal pain that is most likely caused by orchitis. Infection limited to the testicle is much less common and usually is caused by a virus such as mumps. Evidence of testicular involvement begins 4 to 6 days after the parotid swelling. One or both testicles become swollen and tender; fever, nausea, and vomiting may be present. The cremasteric reflex is usually present and color Doppler ultrasonography shows increased perfusion. Recovery is usually spontaneous and complete within 1 to 9 days.
A 12-year-old boy presents to your office for follow-up after his third wrist fracture in 3 years. As part of his evaluation in the emergency department, a complete metabolic panel was obtained and revealed a low calcium concentration (7.5 mg/dL [1.88 mmol/L]), low phosphorus concentration (2.8 mg/dL [0.90 mmol/L]), normal magnesium concentration (1.9 mg/dL [19 g/L]), and normal albumin (4 g/dL [40 g/L]). With the exception of his recurrent fractures, the boy has had no other medical problems and has not been taking any long-term medications. His height and weight are both at the 75th percentile. His physical examination results are unremarkable except for his casted left wrist.Of the following, the MOST appropriate next step in this boy’s evaluation and management is to measure
A. serum parathyroid hormone B. serum 1,25-dihydroxyvitamin D C. serum 25-hydroxyvitamin D D. urine N-telopeptide E. ionized calcium
C. serum 25-hydroxyvitamin D
The boy described in the vignette has hypocalcemia, hypophosphatemia, and a history of recurrent fractures. The most common cause of hypocalcemia and hypophosphatemia is prolonged vitamin D deficiency. This deficiency can best be determined by measuring 25-hydroxyvitamin D (25[OH]D) levels because it is the primary storage form of vitamin D.
A serum PTH can be helpful in the evaluation of a child who has hypocalcemia and hyperphosphatemia. However, a PTH level is not helpful in the evaluation of patients who have hypocalcemia and hypophosphatemia because the PTH concentration is invariably elevated when both serum calcium and phosphorus concentrations are low.
While performing a newborn examination 18 hours after birth, the mother relates to you that her son has had small green emesis after each of the last 3 feedings. The infant was born at 39 weeks’ gestation by spontaneous vaginal delivery that was complicated by moderate meconium-stained amniotic fluid. He emerged vigorous and did not require tracheal suctioning. Since birth, he has been fed a cow’s milk protein formula every 3 hours and has had 2 wet diapers and 1 stool smear. Physical examination reveals an alert infant with a soft, nondistended abdomen and an externally patent rectum. The infant has another emesis of bilious material immediately after your examination You obtain an abdominal radiograph that is interpreted as normal.
[IMAGE OF GREEN EMESIS]
Of the following, the MOST appropriate next step in the management of this infant is to:
A. obtain abdominal ultrasonography
B. catheterize the urethra for urine culture
C. observe the infant for additional symptoms
D. perform an upper gastrointestinal series
E. prescribe a complete milk protein hydrolysate formula
D. perform an upper gastrointestinal series
When bilious emesis is the primary presenting symptom in the newborn period, an upper gastrointestinal series (UGI) should be performed to evaluate for malrotation. Malrotation with midgut volvulus is a surgical emergency and must be rapidly ruled out in the infant with bilious emesis. A radiograph of the abdomen may reveal evidence of obstruction in malrotation with volvulus, but it also may be normal. The preferred diagnostic study is a UGI, which reveals the position of the ligament of Treitz in relationship to the spine. Although abdominal ultrasonography may identify abnormalities associated with malrotation, it possesses less diagnostic sensitivity than UGI.
You are called to the emergency department to evaluate a 5-year-old girl who was riding a bike without a helmet and fell, striking her head approximately 1 hour ago. The accident was witnessed by her mother who states that the child cried on impact and was able to move all extremities. The girl was driven by the mother directly to the emergency department and has had increasing somnolence over the past 30 minutes.The patient has a temperature of 37.6°C, a heart rate of 130 beats/min, and a respiratory rate of 30 breaths/min. She is drowsy but awakens when spoken to; she complains of a headache. She has a large area of swelling over her right frontal area but no noticeable bone depression. Her pupils are equal and reactive and the results from the remainder of the physical examination are normal.Of the following, the MOST appropriate next step in the management of this child is to
A. discharge the child with head injury precautions
B. obtain skull radiographs
C. obtain computed tomography of the head
D. obtain magnetic resonance imaging of the brain
E. admit the child to the hospital for observation
C. obtain computed tomography of the head
Although she will need to be admitted to the hospital, the initial step in her management should be to obtain a computed tomography of her head because of her clinical appearance and the mechanism of injury. Magnetic resonance imaging offers the advantage of providing no radiation, but the lower cost and speed of a computed tomography scan make it the most appropriate initial step. The girl described in the vignette may have sustained a skull fracture, but plain radiographs of the skull will not define potential cerebral abnormalities. Discharge to home is contraindicated.
Epidural hematomas are often said to present with a period of normal consciousness that occurs after a head injury and is followed by a rapid deterioration in level of consciousness.
You are assessing an infant who was born by spontaneous vaginal delivery at 37 weeks’ gestation to a 19-year-old primigravida who received no prenatal care. The growth parameters include a weight of 2,500 grams (10th percentile), head circumference of 30 cm (3rd percentile), and length of 46 cm (10th percentile). The physical examination is notable for faint facial jaundice, diffuse petechiae on the trunk and extremities, a 1/6 systolic murmur at the left sternal border, a liver edge palpable 2 centimeters below the right costal margin, and a spleen tip palpable 4 cm below the left costal margin.
[IMAGE: Baby w/ distended belly + two spots w/ arrows]
Of the following, the study MOST likely to lead to the correct diagnosis is:
A. serology for Toxoplasma-specific IgM
B. serology for parvovirus B19 IgM
C. blood culture for Listeria monocytogenes
D. urine culture for cytomegalovirus
E. surface culture for herpes simplex virus
D. urine culture for cytomegalovirus
The infant described in the vignette has physical findings that are most consistent with congenital cytomegalovirus (CMV) disease and therefore should have a confirmatory urine culture for the virus. The clinical findings seen in an infant with symptomatic CMV infection include intrauterine growth retardation, jaundice, petechiae, hepatosplenomegaly, and, occasionally, blueberry muffin spots . Further evaluation may reveal chorioretinitis and cerebral calcifications. Diagnosis is often made by rapid CMV shell vial testing or culture of the urine. In addition, real-time polymerase-chain-reaction testing of saliva has recently been developed.
You are asked to speak to emergency medical service responders on the subject of pediatric head injury. As part of your presentation, you plan to emphasize the appropriate initial management of severe traumatic brain injury complicated by increased intracranial pressure in preventing secondary injuries. Of the following, the finding MOST closely associated with a poor outcome in such patients is
A. hypertension B. hyperoxia C. hypotension D. hypercarbia E. hypocarbia
C. hypotension
In an effort to prevent secondary injury, assurance of adequate ventilation, oxygenation, and perfusion is the first priority in the initial and ongoing management of patients with increased intracranial pressure. Children who did not receive treatment for hypotension were 3.4 times as likely to die and 3.7 times as likely to suffer disability.
You are called to evaluate a newborn infant who has cyanosis shortly after birth. The infant was born at 41 weeks’ gestation by spontaneous vaginal delivery and he weighs 3,800 grams. Results from the prenatal testing were unremarkable, including negative group B streptococcal status screening. Artificial rupture of the membranes occurred 3 hours before delivery and revealed scant clear fluid. The infant emerged vigorous. After bonding with his mother, he was brought to the warmer where he was noted to be dusky. His pulse oximetry reading was 78% on his right hand on room air. On arrival to the nursery, you find a cyanotic infant breathing comfortably in a 100% oxygen hood. His vital signs include a heart rate of 140 beats/min, respiratory rate of 50 breaths/min, blood pressure of 68/34 mm Hg, and temperature of 37°C. Auscultation reveals clear lung fields bilaterally and a 2/6 soft systolic ejection murmur over the left sternal border. You place pulse oximetry probes on his right hand and left foot, obtaining saturation readings of 89% and 77%, respectively.
Of the following, the MOST likely diagnosis is:
A. total anomalous pulmonary venous return B. transposition of the great vessels C. persistent pulmonary hypertension D. tricuspid atresia E. group B streptococcal pneumonia
C. persistent pulmonary hypertension
The infant described in the vignette demonstrates clinical findings that are suggestive of persistent pulmonary hypertension (PPHN).
In infants with PPHN, increased pulmonary pressure leads to right-to-left shunting at the level of the patent foramen ovale (PFO) and the patent ductus arteriosus (PDA). Oxygenated blood that has passed through the lungs flows into the right subclavian and right carotid artery via the ascending and transverse aorta. The deoxygenated blood flowing right to left through the PDA then mixes with the oxygenated blood in the descending aorta. This leads to the clinical finding of the preductal (right han) oxygen saturation that measures more than 10 points higher than the postductal (left foot) oxygenation saturation.
In most infants who have cyanotic heart disease, including tricuspid atresia and total anomalous venous return, the preductal and postductal oxygen saturations are the same. The preductal oxygen saturation may be 10 or more points lower than the postductal oxygen saturation in select types of cyanotic heart disease, including some forms of transposition of the great vessels
A 14-year-old girl comes in because of a dark rash around her neck that she first noticed 4 or 5 months ago. She has been otherwise healthy. The girl had menarche at 11 years of age, and her periods are fairly regular. Findings on physical examination are normal except for a body mass index of 28.2 and a velvety thickening of the skin on the sides and nape of her neck
[IMAGE acanthosis nigracans on nape of neck]
Of the following, the MOST appropriate laboratory evaluation for this patient is
A. antinuclear antibody and rheumatoid factor B. antithyroglobulin antibody C. fasting blood glucose and insulin levels D. potassium hydroxide preparation of a skin scraping E. testosterone, follicle-stimulating hormone, luteinizing hormone
C. fasting blood glucose and insulin levels
Acanthosis nigricans (AN) in children and adolescents is most often a manifestation of obesity-related insulin resistance
A 14-year-old girl who has a history of juvenile idiopathic arthritis is brought to the emergency department with severe epigastric abdominal pain. She has been taking ibuprofen to control her joint pains. Physical examination demonstrates a well-developed, well-nourished girl in moderate distress from pain. The remainder of the general physical examination shows direct tenderness in the epigastrium without rebound. The rectal examination shows normal sphincter tone and a scant amount of dark brown, hemoccult-positive stool in the rectal vault. Initial laboratory data include the following:
- White blood cell count, 10,500/µL (10.5 × 109/L)
- Hemoglobin, 11.7 g/dL (117 g/L)
- Erythrocyte sedimentation rate, 32 mm/h
- Serum electrolytes, normal
- Blood urea nitrogen, normal
- Creatinine, normal
Of the following, the MOST likely mechanism responsible for her symptoms is
A. decreased pepsinogen production B. duodenal stress ulceration C. gastritis induced by peptidoglycans D. hypersecretion of gastric acid E. inhibition of prostaglandin synthesis
E. inhibition of prostaglandin synthesis
The girl described in the vignette presents with abdominal pain, hemoccult-positive stools, and anemia. These findings indicate chronic gastrointestinal blood loss, and the presence of epigastric tenderness strongly suggests a lesion in the upper gastrointestinal tract (ie, proximal to the ligament of Treitz). The most likely diagnosis is gastritis or peptic ulcer disease caused by her use of ibuprofen. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, inhibit prostaglandin synthesis. Prostaglandin E stimulates gastric mucus production and helps maintain the protective mucin glycoprotein-bicarbonate layer, without which gastric mucosa is exposed to the deleterious effects of gastric acid as well as to the proteolytic effects of chief cell-produced pepsin, which can result in gastritis or peptic ulcers.
A 14-year-old boy presents with fever, joint aches, and a rash for the past 3 days. He was started on amoxicillin for a sore throat a week ago. One of his classmates had a recent diagnosis of strep throat. He has a history of being successfully treated for acute otitis media with amoxicillin a month ago and has been well in the interim. On physical examination, he has swollen lymph nodes, periarticular swelling, and dusky urticaria-like lesions on his skin
[IMAGE erythematous urticarial macular rash on leg]
Of the following, these findings are MOST likely due to
A. amoxicillin allergy B. infectious mononucleosis C. penicillin allergy D. scarlet fever E. serum sickness–like reaction
E. serum sickness–like reaction
This teenager has the symptoms of a serum sickness–like reaction to amoxicillin. The cardinal features of classical serum sickness are rash, fever, and polyarthralgia or polyarthritis, which begin 1 to 2 weeks after first exposure to the responsible agent and resolve within a few weeks of discontinuation.
Serum sickness–like reactions typically involve a constellation of signs and symptoms, which can include arthralgias, lymphadenopathy, and urticarial rash with or without fever. Fever, when present, is typically low-grade. Children with serum sickness–like reactions may present with acute onset of joint pain that often leads to inability to walk. The most characteristic rash is an urticarial or serpiginous macular rash that starts in the anterior lower trunk, groin, periumbilical, or axillary regions, and spreads to the back, upper trunk, and extremities. The rash generally lasts a few days to 2 weeks.
