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Pediatrics

A 4-month-old male is brought to your office for evaluation of


“bloodshot eyes” of 2 days’ duration. He is otherwise well. He was born
at 35 weeks gestation, weighed 2550 g (5 lb 10 oz), and was discharged
the day after his birth. He has received well child care and
immunizations at the local public health clinic. Examination confirms
bilateral subconjunctival hemorrhages. Except for moderate irritability,
the remainder of the examination is unremarkable. There is no known
family history of bleeding disorders. An urgent evaluation by an
ophthalmologist is requested, and it reveals bilateral retinal hemorrhaging.

Which one of the following is the most likely diagnosis’

a) Acute thrombocytopenia, cause to be determined


b) Hemophilia, type to be determined
c) Retinopathy of prematurity
d) Nonaccidental trauma
e) Childhood glaucoma
The Correct answer is D

Explanation Infants who are shaken may have shaken baby (shaken
impact) syndrome. This syndrome is caused by violent shaking, often
followed by throwing the infant. Infants who are shaken may have no
visible signs of injury and may appear to be sleeping deeply. This
sleepiness is due to brain damage and swelling, which may result from
bleeding between the brain and skull (subdural hemorrhage). Infants may
also have bleeding in the retina (retinal hemorrhage) at the back of the
eye.
You are conducting a routine physical examination on a 6-month-old
infant who is new to your practice. The examination is entirely normal
except that you do not feel a testicle in the right scrotal sac. You do,
however, feel a soft, round, mobile mass high in the right inguinal
area. It cannot be brought down into the scrotal sac with gentle maneuvers.

The most appropriate action would be to

a) Reassure the parents that the testicle will like descend in the next
few months
b) Order pelvic ultrasonography
c) Order serum testosterone, LH, FSH, and müllerian inhibiting
substance levels
d) Refer the patient to a urologist
e) Monitor the patient and refer only if the testicle does not descend
by 2 years of age
The Correct answer is D

Explanation
This patient most likely has an undescended right testicle, which needs
to be addressed as soon as possible, certainly before the child reaches
2 years of age. Testes that have not descended by 6 months of age are
unlikely to descend. Pelvic ultrasonography, with or without the noted
hormonal studies, is appropriate only when testicles are bilaterally absent.
A 1-year-old child presents to the emergency room with a 3-day history
of dehydration. Physical examination of the infant is consistent with
10% dehydration. Serum sodium level is 165. All of the following about
hypernatremic dehydration are true EXCEPT:

a) Subdural hematomas may occur as a result of hypernatremia


b) Hypernatremia may be caused when improperly mixed formulas are used
c) Normal saline boluses should be given until the infant is stable
d) Fluid should be given to rapidly reduce the serum Na in less than 24
hours
e) Hypernatremia is seen in about 10-15% of patients with diarrhea
The Correct answer is D

Explanation
Hypernatremic dehydration is seen in about 10-15% of patients with
dehydration. The serum sodium level should be lowered slowly, no faster
than 10-12 milliequivalents in 24 hours, due to the risk of cerebral
edema and seizures.

A. Subdural hematomas may occur due to intracellular fluid loss.


B. Hypernatremia may be seen with improperly mixed formulas.
C. 20cc/kg normal saline or lactated ringers fluid boluses should be
given until the infant is clinically stable.
E. Hypernatremia is seen in 10-15% of patients.
A 5 year old boy is admitted with a provisional diagnosis of acute renal
failure. The laboratory calls you to report that his serum potassium
level is 7.5 mmol/L. Which one of the following should be your next
investigation?

a) Electrocardiogram
b) Serum creatinine
c) White cell count
d) Serum sodium
e) Serum bicarbonate
The Correct answer is A

Explanation
Hyperkalemia is serum K concentration > 5.5 mEq/L resulting from excess
total body K stores or abnormal movement of K out of cells. The usual
cause is impairment of renal excretion; it can also occur in metabolic
acidosis as in uncontrolled diabetes. Clinical manifestations are
generally neuromuscular, resulting in muscle weakness and cardiac
toxicity that, if severe, can degenerate to ventricular fibrillation or
asystole.

Moderate to severe hyperkalemia: Plasma K > 6 mEq/L, especially with EKG


changes, requires aggressive therapy to shift K into cells.

Administration of 10 to 20 mL 10% Ca gluconate (or 5 to 10 mL 22% Ca


gluceptate) IV over 5 to 10 min. Ca antagonizes the effect of
hyperkalemia on cardiac muscle excitability.

If the ECG has deteriorated to a sine wave or asystole, Ca gluconate may


be given more rapidly (5 to 10 mL IV over 2 min). CaCl can also be used
but can be irritating and should be given through a central venous catheter.
A child is brought to you in the emergency room. He has a temperature of
103F and respiratory distress. He is leaning forward and has a very
anxious look. His voice is muffled, and he is unable to swallow.
Roentgenogram shows a swollen epiglottis. Proper treatment at this time
would include all of the following EXCEPT:

a) Oxygen therapy
b) Have the child lie down on his back so that he can rest properly
c) Reassure the child and allow the parent to hold him
d) Notify an anesthesiologist and/or otolaryngologist
e) Prepare for possible sudden pulmonary arrest
The Correct answer is B

Explanation
Is incorrect and could lead to airway obstruction.

B. Children with epiglottitis should be allowed to sit and lean forward


to help their aiways open. All of these signs and symptoms are typical.
As these children may obstruct totally at any time, rapid preparations
must be made to maintain an airway.
C. Reassurance and allowing the mother to hold the child will decrease
distress while you arrange proper treatment.
D. This child should be evaluated in a controlled setting (i.e., in an
operating room in the presence of an anesthesiologist and/or
otolaryngologist) so that rapid airway control may be achieved if necessary.
E. Sudden pulmonary arrest is a likely occurrence in children with
epiglottitis and should be anticipated.
A 16-year-old male experiences pain on the left side of his chest and
feels short of breath while warming up for a football game. Examination
reveals an anxious adolescent with tachypnea and with diminished breath
sounds on the left side of his chest.

Which one of the following tests would be most helpful for making a
diagnosis’

a) An EKG
b) Atrial blood gas levels
c) A ventilation/perfusion lung scan
d) CT angiography
e) A chest radiograph
The Correct answer is E

Explanation
Spontaneous pneumothorax is often manifested as chest pain of sudden
onset with accompanying dyspnea. The most cost-effective and least
invasive way to diagnose the problem is by chest radiograph.
A 15 year old girl is brought to your office by her mother because of
fatigue, muscle cramps and palpitations.

The patient is 165 cm tall and weighs 60 Kg. Her Temp is 37.0C, BP is
120/75 mmHg and her pulse is 85/min. physical exam shows dental enamel
erosions, enlarged parotids on both sides and erosions over her
metacarpophalangeal joints. Her review of systems is within normal
limits. Her cycles are regular occurring every 28 days and last 6-7 days.

You ordered some lab tests which reveal:


Na+: 136 mEq/L
K+: 2.9 mEq/L
Cl-: 95 mEq/L
HCO3-: 35 mEq/L
Serum amylase: 130 U/L

Based on the information provided in this clinical scenario, what is the


most likely diagnosis’

a) Addison’s disease
b) Anorexia nervosa
c) Bulimia nervosa
d) Conn’s syndrome
e) Laxative abuse
The Correct answer is C

Explanation
The most likely diagnosis of this patient is Bulimia nervosa. Bulimia
nervosa is characterized by frequent episodes of binge eating and a
sense of lack of control over eating; which is followed by compensatory
behaviors aiming to prevent weight gain such as purging, fasting or
strenuous exercise. This patient’s symptoms are due to hypokalemia.

Anorexia nervosa patients are characterized by the amenorrhea and the


significant underweight status.

Conn’s syndrome (hyperaldosteronism) would present with 2ry hypertension


and hypernatremia.

In the presence of hypokalemia and high HCO3-, Addison’s disease is


ruled out.

Laxative abuse would lead to low serum bicarbonate levels.

On the exam, do not look at the behavior (purging, exercise, fasting?)


to differentiate between bulimia and anorexia! Look for amenorrhea and
body weight and you will clench the diagnosis.
You are seeing a previously healthy, 8-month-old male with a 2- to
3-week history of a rash. The rash started on the cheeks and has
subsequently spread to involve the trunk and extremities. He is bathed
once daily and his mother has not been using ointments or creams. She
does not use detergent when washing his clothes. He has not had any
recent URI symptoms or fever. Family history is significant only for
seasonal allergies in the maternal great-grandmother. Physical
examination shows a well-nourished male, who is afebrile and playful.
Examination of the skin reveals lesions on the extensor surfaces of the
upper and lower extremities which are red and dry with small papules,
mild scaling, and areas of excoriation. Compared with the general
population, his risk for developing asthma is which of the following?

a) Greater than the general population


b) Less than the general population
c) Equal to that of the general population
d) There is no clear association
The Correct answer is A

Explanation
Asthma is the most common chronic illness of childhood. This child has
eczema/atopic/dermatitis. Children with allergies and/or eczema are at
an increased risk for developing asthma compared to the general population.
An 18 month old infant is brought to the clinic because of pallor and
irritability. Her mother says the infant's diet consists almost
exclusively of whole milk, approximately 40 oz per day. On physical
examination, the infant has a pulse of 160/min, respirations of 50/min,
and normal heart sounds with a grade 2/6 systolic ejection murmur. Liver
is palpable 3 cm below the right costal margin. Laboratory studies show:

Hematocrit 13%
Hemoglobin 3 g/dL
Mean corpuscular volume 48 µm3
Platelet count 400,000/mm3

Following appropriate evaluation, which of the following is the most


appropriate treatment?

a) Administration of oral folate therapy


b) Administration of parenteral iron therapy
c) Administration of parenteral vitamin B12 (cyanocobalamin) therapy
d) Transfusion with packed erythrocytes
e) Transfusion with whole blood
The Correct answer is D

Explanation
Starting transfusion with packed erythrocytes is the most appropriate
management because this patient has severe iron deficiency anemia.
Pallor is the most important clue to iron deficiency anemia. However,
patients may also have other symptoms such as tachycardia, tachypnea,
heart murmurs, and hepatomegaly. In patients with hemoglobin under 4
g/dL, a blood transfusion with packed erythrocytes should be given
slowly. The quantity of packed erythrocytes administered should be
sufficient to raise the level of hemoglobin to a safe level while
awaiting the response to iron therapy.
An 11 year old boy presents with acute asthma exacerbation. His arterial
blood gas in the ER shows a normal pCO2 value. What is the most likely
reason?

a) Mild asthma
b) Normal value
c) The patient may go into respiratory failure
d) Moderate asthma
The Correct answer is C

Explanation
In cases of mild asthma the patient usually is able to maintain normal
arterial blood oxygen levels. When hyperventilation occurs the CO2 value
decreases. In severe disease the patient can no longer maintain the
adequate alveolar ventilation and the CO2 levels start to rise.

Thus when a patient has a normal or elevated CO2 level during an acute
asthmatic episode, it is a sign of severe disease, since it is evidence
that the body's need to eliminate CO2 is not being met, because of a
decrease in alveolar ventilation.
A child suffering from constipation is shown here. You notice a large
protruding tongue.

What is the most likely diagnosis’

a) Hypothyroidism
b) Downs syndrome
c) Trisomy 13
d) Trisomy 18
The Correct answer is A

Explanation
Cretinism is a condition of severely stunted physical and mental growth
due to untreated congenital deficiency of thyroid hormones (hypothyroidism).

Children with hypothyroidism may develop excessive sleeping, reduced


interest in nursing, poor muscle tone, low or hoarse cry, infrequent
bowel movements, exaggerated jaundice, and low body temperature.
Physical features may include a larger anterior fontanel, persistence of
a posterior fontanel, an umbilical hernia, and a large tongue
(macroglossia).

In the developed world, nearly all cases of congenital hypothyroidism


are detected by the newborn screening program. These are based on
measurement of TSH or thyroxine (T4) on the second or third day of life.
If the TSH is high, or the T4 low, the infant's doctor and parents are
called and a referral to a pediatric endocrinologist is recommended to
confirm the diagnosis and initiate treatment.

The goal of newborn screening programs is to detect and start treatment


within the first 1-2 weeks of life. Treatment consists of a daily dose
of thyroxine, available as a small tablet.

Down syndrome (Trisomy 21), Edwards syndrome (Trisomy 18) and Patau
syndrome (Trisomy 13) would not present like this.
A 2-year-old boy presents to the emergency department for evaluation
following a witnessed seizure. The seizure was described as generalized,
lasting less than 5 minutes with a short post-ictal period. The child
has no history of seizures, no family history of seizures, and no
history of head injury. His exam currently is normal, except for a red,
bulging right tympanic membrane and a temperature of 39C. What is the
most appropriate management for this patient?

a) He should be sent for an urgent CT scan of the head


b) He should be given antibiotics and antipyretics and observed at home
c) He should be admitted to the hospital and an EEG should be performed
d) He should be started on phenobarbital and sent home
e) A lumbar puncture and blood cultures should be obtained and
anticonvulsants started in the hospital
The Correct answer is B

Explanation
This patient most likely experienced a simple febrile seizure. Most
febrile seizures last less than 10 minutes, are generalized and
nonfocal, and do not recur within 24 hours. These simple febrile
seizures do not require evaluation beyond determining and treating the
source of the fever and educating parents.

A. There is no need for neuroimaging studies in a case of simple febrile


seizure.
C. There is no need for an EEG in the case of a simple febrile seizure
with a negative family history, normal neurologic exam, and normal
development.
D. Although anticonvulsant medications are sometimes used for recurrent
episodes of febrile seizures, the initial simple febrile seizure does
not warrant treatment with anticonvulsant drugs.
E. A lumbar puncture is not indicated in this patient unless the
physical exam revealed symptoms suggestive of meningitis or
encephalitis. In this case, the examination is normal except for the
otitis media, the source of the fever.
A newborn is diagnosed with a patent ductus arteriosus (PDA). What type
of murmur will you hear in such a patient?
a) Diastolic murmur
b) Friction rub
c) Continuous machine-like murmur
d) Holosystolic murmur
The Correct answer is C

Explanation
Patent ductus arteriosus (PDA) is a persistence of the fetal connection
(ductus arteriosus) between the aorta and pulmonary artery after birth,
resulting in a left-to-right shunt. Symptoms may include failure to
thrive, poor feeding, tachycardia, and tachypnea. A continuous
machine-like murmur in the upper left sternal border is common.

Diagnosis is by echocardiography. Administration of indomethacin with or


without fluid restriction may be tried in premature infants with a
significant shunt but not in term infants with PDA. If the connection
persists, surgical or catheter-based correction is indicated.
Endocarditis prophylaxis is recommended before and for 6 to 12 months
after correction.
A 10-year-old female is brought in for a scheduled physical examination.
The mother notes that her daughter’s allergies ‘seem to be getting
Worse”, and that her “eyes are puffy in the morning”. The patient has
been healthy on previous examinations. Examination today reveals no
other allergic stigmata. You note a trace of ankle edema and 3 + proteinuria on
urinalysis. The remainder of the examination is normal.

The patient returns the following morning for further studies. She is
fasting.

Laboratory Findings

Hematocrit-----------------------------42% (N 36 - 46)
WBCs-----------------------------6200/mm3 with normal differential
Creatinine-----------------------------0.8 mg/dL (N 0.6 -1.5)
BUN-----------------------------18 mg/dL (N 8 - 25)
Liver function tests-----------------------------normal
Calcium-----------------------------7.4 mg/dL (N 8.5 - 10.5)
Sodium-----------------------------128 mmol/L (N 135 - 145)
Potassium-----------------------------3.7 mmol/L (N 3.4 - 4.8)
Total cholesterol-----------------------------320 mg/dL
Antinuclear antibody-----------------------------negative
Antistreptolysin-----------------------------negative
Urinalysis-----------------------------3 + protein, no WBCs, RBCs, or casts

The most likely diagnosis is

a) Acute glomerulonephritis
b) Acute renal failure
c) Nephrotic syndrome
d) Orthostatic proteinuria
e) Congenital renal artery stenosis
The Correct answer is C
Explanation
This scenario is a classic presentation for nephrotic syndrome. The most
common histologic type in this age group is minimal change disease.
Acute glomerulonephritis would likely present with hypertension and red
cell casts in the urine. The normal BUN and creatinine rule out acute
renal failure. Orthostatic proteinuria, while much more common, is not
associated with edema or the markedly elevated total cholesterol of 320
mg/dL. Congenital renal artery stenosis is an uncommon cause of problems
in childhood and typically presents with hypertension in adults.

Which one of the following is a criterion for obesity in children?

a) Ratio of weight percentile to height percentile >1.5


b) BMI >28
c) BMI >95th percentile for age and sex
d) Weight >15% above ideal body weight
e) Weight >45 kg (100 lb) by 11 years of age
Explanation
Childhood obesity is a growing epidemic. Childhood obesity is defined as
a BMI above the 95th percentile for age and sex. Children with a BMI
between the 85th and 95th percentile are considered overweight. In
adults, an individual with a BMI >30 is considered obese. BMI is
calculated by dividing the weight in kilograms by the square of the
height in meters.
A 4-month-old male is brought to your office for a routine examination.
He has experienced normal growth and development and is current on all
vaccines. The mother’s only concern is persistent tearing in his left eye.

Which one of the following would be the most appropriate course of action?

a) Referral to an ophthalmologist for immediate tear duct dilation


b) Topical corticosteroid drops to facilitate tear duct opening
c) Topical antibiotics to prevent tear duct infection
d) Reassuring the parents that this condition usually resolves
spontaneously by 1 year of age
The Correct answer is D

Explanation
This infant has nasolacrimal duct obstruction. This condition occurs in
up to 20% of children during the first year of life. Spontaneous
resolution occurs by 6 months of age in 90% of children, but the chance
of spontaneous resolution decreases to less than 1% if the obstruction
is still present at 1 year of age. This condition usually has a benign
course. Referral to an ophthalmologist is indicated only if the tear
duct remains clogged at 1 year of age. Antibiotics are necessary only if
signs of infection arise, and daily tear duct massage can help prevent
infection. Topical corticosteroids would be used only after surgery, to
help keep the tear duct open.
A one year old girl presents to the ER. For the past two days she has
been listless and has eaten very little other than juice and milk. Her
temperature is 40 degrees Celsius rectally. Her tympanic membranes are
normal. Her throat is mildly erythematous, with no exudate.

A CBC is drawn and her WBC is 20 x 10^9/L, with a high neutrophil count.
All other investigations are normal. Which of the following would not be
appropriate to give?

a) Aspirin
b) Ibuprofen
c) Acetaminophen
d) Ceftriaxone
The Correct answer is A

Explanation
Reye's Syndrome, a deadly disease, strikes swiftly and can attack any
child or adult without warning. All body organs are affected, with the
liver and brain suffering most seriously. While the cause and cure
remain unknown, research has established a link between Reye's Syndrome
and the use of aspirin and other salicylate-containing medications.
Therefore aspirin should not be given to a child with an acute illness.
Which of the following is NOT true regarding the use of Palivizumab in
the prevention of respiratory synctial virus (RSV) infection?

a) It should be considered for use in infants and children younger than


2 years of age with chronic lung disease.
b) It should be given every other month for six doses for
infants/children that meet specific criteria
c) A 6-month-old term infant with a ventricular septal defect,
requiring ongoing medical therapy, should NOT receive Palivizumab at the
beginning of RSV season
d) A 4-month-old ex-28 weeks gestation female should receive
Palivizumab at the beginning of RSV season
e) A 3-month-old ex-31 weeks gestation male with bronchopulmonary
dysplasia (BDP) on 0.1 L O2 continuously should receive Palivizumab at
the beginning of RSV season
The Correct answer is B

Explanation
Palivizumab should be given monthly during RSV season only to
infants/children who meet specific criteria. Palivizumab is approved for
prevention of RSV disease in children younger than 24 months of age with
bronchopulmonary dysplasia or with a history of premature birth (<35
weeks gestation). It should be considered for use in infants and
children younger than 2 years of age with chronic lung disease who have
required medical therapy within 6 months before the RSV season. Any
infant with chronic lung disease currently or in the last 6 months
requiring O2 meets criteria for prophylaxis.

Note: used seldomly in some patients with severe CLD or congenital heart
disease, who require ongoing medical therapy.
A 3 year old boy presents to your office for evaluation of speech delay.
On examination, he is at the 90th percentile for height, 50th percentile
for weight, and greater than the 98th percentile for head circumference.
He has a long face with large protuberant ears, velvety skin, and is
extremely hyperactive with no eye contact. Which of the following is true?
a) Both parents are gene carriers for this condition
b) He has small genitalia and undescended testicles
c) His mother is a gene carrier for this condition
d) The parents have a 50% recurrence risk for any future pregnancy
e) Chromosome analysis will reveal an extra chromosome
The Correct answer is C

Explanation
This boy has fragile X syndrome, an X-linked disorder caused by
expansion of a trinucleotide repeat region in the FMR-1 gene on
chromosome Xq. Mothers of affected patients are obligate gene carriers
with an intermediate size gene expansion and may have mild learning and
behavior problems.

A. Both parents are gene carriers only in autosomal recessive conditions.


B. Boys with fragile X syndrome have normal genitalia and may develop
macroorchidism at puberty.
D. In an X-linked condition, there is a 50% recurrence risk for brothers
to be affected, but a much lesser risk for sisters.
E. Fragile X chromosome analysis will reveal a “fragile site” on one X
chromosome, not an extra chromosome DNA analysis of the CGG repeat
region of the FMR-1 gene is now the preferred testing method.
A 14-year-old male is brought to your office by his mother to establish
care. The patient has been diagnosed with asthma, but has not been on
any medications for the past year. When questioned, he reports that his
asthmatic symptoms occur daily and
more than one night per week. On examinations, he is found to have a
peak expiratory flow rate of 75%.

Based on these findings, the most accurate classification of this


patient’s asthma is

a) Mild intermittent
b) Mild persistent
c) Moderate persistent
d) Severe persistent
The Correct answer is C
Explanation
The National Asthma Education and Prevention Program (NAEPP) classifies
asthma into four categories. Mild intermittent asthma is characterized
by daytime symptoms occurring no more than 2 days per week, and
nighttime symptoms no more than 2 nights per month. The peak expiratory
flow (PEF), or forced expiratory volume in 1 second (FEV1) is 80% or
more of predicted. Mild persistent asthma is characterized by daytime
symptoms more than 2 days per week, but less than once a day, and
nighttime symptoms more than 2 nights per month. PEF or FEV1 is 80% or
more of predicted. Moderate persistent asthma is characterized by
daytime symptoms daily and nighttime symptoms more than one night per
week. PEF or FEV1 is 60%-80% of predicted. Severe persistent asthma is
characterized by continuous daytime symptoms and frequent nighttime
symptoms. PEF or FEV1 is 60% or less of predicted.
Which one of the following is the most likely cause of hearing loss in
newborns’

a) Intraventricular hemorrhage
b) Anomalies of the external ear canal
c) Congenital cholesteatoma
d) Genetic disorders
e) Infectious diseases
The Correct answer is D

Explanation
Genetic disorders (e.g., Waardenburg syndrome, Usher’s syndrome, Alport
syndrome, and Turner’s syndrome) are responsible for more than 50% of
hearing impairments in children. Intraventricular hemorrhage is a
central cause of hearing loss, and is rare. Conductive abnormalities
such as external canal anomalies and congenital cholesteatoma, and
sensorineural causes other than genetic disorders (e.g., infectious
diseases) are important but less frequent.

Which one of the following is associated with a reduction in risk for


sudden infant death syndrome?

a) Pacifier use
b) A soft mattress
c) Putting the baby to sleep in a prone position
d) Putting the baby to sleep on his or her side
The Correct answer is A

Explanation
Sleeping with a pacifier has been associated with a reduced risk for
sudden infant death syndrome (SIDS), which occurs most frequently
between 2 and 4 months of age. Putting a baby to sleep in a prone
position or on his or her side increases the risk of SIDS. Sleeping on
soft bedding, or with comforters, quilts, or stuffed toys also increases
the risk, as does sleeping with parents or siblings. Sleeping in a
separate bed or crib in the same room with the parents may be a safer
alternative.
The mother of an 11-month-old male asks about the viral gastroenteritis
vaccine. You advise that it is
a) routinely given at the 12-month visit
b) associated with an increased risk for intussusception
c) initiated at 6-12 weeks of age
d) indicated only for immunocompromised children
e) indicated only for children attending day care
The Correct answer is C

Explanation
Rotavirus vaccine (RotaTeq) was licensed in February 2006 to protect
against viral gastroenteritis. The Advisory Committee on Immunization
Practices recommends the routine vaccination of infants with three doses
to be given at 2, 4, and 6 months of age. The first dose should be given
between 6 and 12 weeks of age, and subsequent doses should be given at
4- to 10-week intervals, but all three doses should be administered by
32 weeks of age. Unlike the vaccine RotaShield, which was marketed in
1999, RotaTeq is not known to increase the risk for intussusception.
Which of the following steps is not indicated in the management of croup?

a) Keeping the child calm


b) Hydration
c) Antipyretics
d) Antibiotics
e) Humidified oxygen
The Correct answer is D

Explanation
Croup is acute inflammation of the upper and lower respiratory tracts
caused most commonly by parainfluenza virus type 1 infection. It is
characterized by a barking cough and inspiratory stridor. Diagnosis is
usually obvious clinically but can be made by anteroposterior neck
x-ray. Treatment is antipyretics, hydration, nebulized racemic
epinephrine, and corticosteroids. If O2 saturation falls < 92%,
humidified O2 should be administered.
When prophylactic antibiotic therapy is used for tooth extraction in a
patient with a ventricular septal defect

a) Therapy is started 24 hours prior to the procedure


b) A throat swab should be taken prior to the procedure
c) A second generation cephalosporin (cefuroxime) is the therapy of choice
d) Therapy is given for one week following the extraction
e) Erythromycin is the drug of choice for those allergic to penicillin
The Correct answer is E

Explanation
Antimicrobial prophylaxis is recommended for patients at high to
moderate risk of infective endocarditis before procedures associated
with bacteremias and subsequent infective endocarditis. For most
patients and procedures, a single dose shortly before the procedure is
effective.

Procedures requiring antimicrobial endocarditis prophylaxis include


oral-dental procedures, dental extraction, dental implant placement and
reimplantation of avulsed teeth and periodontal procedures, including
surgery, scaling, root planing, and probing.

Drug treatment in patients allergic to penicillin is with a macrolide


such as erythromycin, clarithromycin or azithromycin.
A 3 year old boy, known to have sickle cell anemia, presents to the
emergency room with sudden onset of severe pallor. Clinical examination
reveals massive splenomegaly. On an earlier clinic visit 2 weeks before
this boy had splenomegaly of only 2 cm. Which one of the following is
the most likely explanation for this acute deterioration?

a) Hemolysis
b) Malaria
c) Hemangioma
d) Folate deficiency
e) Sequestration
The Correct answer is E

Explanation
The spleen filters out abnormal red blood cells and helps the body's
immune system fight infection. Sometimes, as in the case of sickle cell
disease, red blood cells can be trapped in the spleen, a condition known
as splenic sequestration. The body reacts as if it were bleeding
internally because the blood trapped in the spleen cannot circulate to
the heart or brain. This condition can range from mild to life
threatening, depending on how much of the body's red blood cells are
sequestered.

When red blood cells are trapped, the spleen grows tender and becomes
enlarged enough to feel in the upper left part of the abdomen. Doctors
detect splenic sequestration by feeling for this enlarged spleen and
testing for low red-blood cell counts.

The child will look pale. In darker-skinned people, this may be easier
to detect by looking at the lips, the inner eyelids, and the fingernail
beds. Usually these areas are red or dark pink, but if they look light
pink or white, then the child is pale.
A 2-year-old girl with well-demarcated bilateral ‘stocking? distribution
scald burns is brought to your office by her mother. The mother says
that the child climbed into the bathtub before the mother had a chance
to test the water temperature. Which of the following items makes you
highly suspicious that this injury is due to non-accidental trauma?

a) The mother brought the patient to your office immediately, without


applying any ointment or dressing
b) The bilateral sharply demarcated ‘stocking? distribution of the burns
c) The type of burn (scald)
d) The presence of satellite burns caused by splashing water
e) The parents had not turned the temperature settings on the hot water
heater down to a safe level
The Correct answer is B

Explanation
Burns with sharp margins should raise a suspicion of abuse. A child who
steps into hot water with one foot would not place the second foot into
the hot bath water. The stocking distribution is seen when a child is
intentionally “dipped” into hot water, often as punishment.

A. Getting medical care soon after an injury demonstrates parental


concern. Seeking care long after an injury may raise suspicion for abuse.
C. Scaled burns may be the result of intentional or unintentional
mechanisms. In fact, scalds are the most common type of burns in childhood.
D. Splash burns are often the result of unintentional injury.
E. Many good caring parents do not know that hot water heater
temperatures should be set below 125 degrees to minimize the chance of
unintentional scald burns. Most Child Protective Service agencies would
not consider this child neglect.

Which of the following is typically the first sign of puberty in girls’

a) Breast budding
b) Menarche
c) Underarm hair
d) Vaginal discharge
The Correct answer is A

Explanation
The five stages of puberty in girls is as follows:

1 Age Range: Usually 8-11


In Stage 1 there are no outside signs of development, but a girl's
ovaries are enlarging and hormone production is beginning.

2 Age Range: Usually 8-14. Average: 11-12


The first sign is typically the beginning of breast growth, including
"breast buds." A girl may also grow considerable height and weight. The
first signs of pubic hair start out fine and straight, rather than curly.

3 Age Range: Usually 9-15. Average: 12-13


Breast growth continues, and pubic hair coarsens and becomes darker, but
there still isn't a lot of it. The body is still growing, and the vagina
is enlarging and may begin to produce a clear or whitish discharge,
which is a normal self-cleansing process. Some girls get their first
menstrual periods late in this stage.

4 Age Range: Usually 10-16. Average: 13-14


Pubic hair growth takes on the triangular shape of adulthood, but
doesn't quite cover the entire area. Underarm hair is likely to appear
in this stage, as is menarche. Ovulation (release of egg cells) begins
in some girls, but typically not in a regular monthly routine until
Stage 5.

5 Age Range: Usually 12-19. Average: 15


This is the final stage of development, when a girl is physically an
adult. Breast and pubic hair growth are complete, and your full height
is usually attained by this point. Menstrual periods are well
established, and ovulation occurs monthly.
A 5 year old girl with hypogammaglobulinemia and absent immunoglobulin A
(IgA) receives infusions of immune globulin monthly. Shortly after her
most recent infusion began, she developed hypotension, wheezing, and
several urticarial lesions. Which of the following best explains her
reaction?

a) Anaphylactic reaction due to IgE anti-IgA antibodies


b) Gram-negative sepsis due to contaminated immune globulin
c) Idiosyncratic reaction due to rapid infusion of immune globulin
d) Serum sickness reaction from foreign serum in the immune globulin
e) Transfusion reaction due to ABO incompatibility
The Correct answer is A

Explanation
Anaphylaxis is triggered the same way other allergies are: the immune
system, which serves as the body's defense against potentially dangerous
substances such as germs, overreacts to a harmless substance (an
allergen) and in that process can damage the body. As part of the normal
immune response, proteins called antibodies are produced that can detect
and help destroy ?invaders’ in the body. A specific antibody called
Immunoglobulin E, or IgE, is responsible for the adverse reactions in
people with allergies.

When allergens first enter the body of a person predisposed to


allergies, the immune system produces the allergen-specific IgE
antibodies. The IgE antibodies attach themselves to the surface of cells
called mast cells. The next time that allergic individual comes into
contact with the allergen, the IgE identifies it and quickly initiates
the release of chemicals, such as histamine, from the mast cells. These
potent chemicals cause the symptoms seen in allergic reactions and
anaphylaxis.
A 6-month-old infant presents to clinic with a 1-day history of
diarrhea. No emesis has occurred. The infant appears about 3-5%
dehydrated. The initial management should include which of the following?

a) Oral rehydration with observation in the clinic


b) Perform intraosseous access for rehydration
c) Perform a lumbar puncture followed by antibiotic therapy
d) Recommend that the mother give fruit juice until the diarrhea resolves
e) Hospital admission
The Correct answer is A

Explanation
Oral rehydration therapy is the preferable treatment for mild to
moderate dehydration. The World Health Organization (WHO) rehydration
solution contains 90 milliequivalents of sodium per liter, 20
milliequvalents of potassium per liter, and 20 g of glucose per liter.

B. Intraosseous access is obtained when intravenous access cannot be


obtained.
C. Lumbar puncture is performed and antibiotics are given when sepsis is
suspected.
D. Fruit juice may exacerbate diarrhea.
E. This patient does not require inpatient care at this time.
A 3 month old infant is brought to your office with small pustules on
the soles of the feet and a few similar lesions on the palms of her
hands. Scabies is identified in scrapings of the lesions. You should

a) Prescribe 1% lindane (Kwell) to be applied from the neck down and


left on for 8-12 hours
b) Prescribe permethrin (Elimite) 5% cream to be applied to the entire
body, including the scalp
c) Prescribe 10% crotamiton (Eurax) cream to be applied to the
extremities and trunk for 24 hours
d) Prescribe 6% sulphur in petrolatum to be applied for 24 hours
e) Recommend that all family clothing be dry-cleaned to prevent
recurrent infestation
The Correct answer is B

Explanation
Scabies is usually not seen on the head, neck, palms, and soles in
adults, but these areas are often affected in infants. Lindane may be
hazardous to young infants because of its percutaneous absorption and
potential neurotoxicity. Permethrin is at least equally effective, and
because it is poorly absorbed and rapidly metabolized, its toxicity is
low. Crotamiton cream and sulphur in petrolatum are safe options, but
must be applied continuously over 3.5 days. Laundering of clothing and
bedclothes is sufficient to prevent reinfestation. In fact, clothes may
simply be hung outside for 3-4 days, because the isolated mite dies
within 2-3 days.
A 17 year old white female is brought in by her parents because of
concern about her recent weight loss. Her past medical history is
unremarkable. Physical examination is notable for a body mass index of
23, bilateral parotid glad enlargement, dental erosions on the lingual
surfaces of her teeth, submandibular lymphadenopathy, and elongated
abrasions on the dorsal surface of her right hand. The most likely diagnosis

a) Hyperthyroidism
b) Sjögren’s syndrome
c) Sarcoidosis
d) Bulimia nervosa
e) HIV infection
The Correct answer is D

Explanation
Findings associated with self-induced vomiting include swelling of the
parotid gland and submandibular glands, abnormal dentition, perimolysis
(loss of dentin on the lingual and occlusal surfaces of the teeth), and
abrasions on the dorsum of the hand (caused by scraping against the
incisors during attempts to induce vomiting). These signs would most
strongly support the diagnosis of bulimia nervosa.
A young couple comes to your office for their first visit with their
newborn daughter. Upon reviewing the hospital birth records, you note
that the newborn screen is reported as abnormal for phenylketonuria
(PKU). In counseling the parents about this diagnosis, all of the
following are true statements EXCEPT:

a) The parents’ recurrence risk is 25% in future pregnancies


b) The child will need to be on a special formula restricting phenylalanine
c) The prognosis for intellectual development is good with strict
dietary management
d) The dietary restriction may be discontinued when she is a teen
e) Untreated patients develop mental retardation, spasticity, and
behavior problems
The Correct answer is D

Explanation
Dietary restriction for affected females with PKU must be lifelong, due
to the teratogenic potential of maternal PKU, which may cause
microcephaly, mental retardation, congenital heart defects, and other
anomalies in the fetus.

A. This is true, as PKU is an autosomal recessive condition.


B. Strict dietary management with monitoring of phenylalanine blood
levels is essential.
C. Patients who are treated from birth and closely monitored have a good
prognosis for normal intellectual development.
E. Patients whose treatment is delayed or not closely monitored will
become mentally retarded.
Which one of the following is a manifestation of pauci-articular
juvenile rheumatoid arthritis’

a) Uveitis
b) Splenomegaly
c) Thrombocytopenia
d) Glomerulonephritis
e) Erythema nodosum
The Correct answer is A

Explanation
Pauci-articular juvenile rheumatoid arthritis (JRA) is more common than
polyarticular JRA and systemic JRA. Pauci-articular JRA is further
subdivided into two subtypes. Type I is most common in toddlers,
especially girls, and can be associated with chronic anterior uveitis,
which is often asymptomatic yet potentially destructive. The incidence
is higher in children with positive antinuclear antibodies; therefore,
regular ophthalmologic surveillance is necessary. Type II is more common
in boys and has a later onset. Eye problems are less common.

The presentation of systemic JRA includes prolonged fever, rash,


pericarditis or pleuritis, lymphadenopathy, hepatosplenomegaly, anemia,
leukocytosis, thrombocytosis, and, of course, arthritis.
Glomeruolonephritis is uncommon in systemic JRA. Erythema nodosum is not
a feature of JRA.

A 12-month-old girl presents to your office for a well-child


examination. She has been growing and developing well. She is taking
solids well and has not had any gastrointestinal problems. She is happy
and playful, and there are no abnormalities on physical examination.
Routine screening reveals a lead level of 50 ?g/dl. The child lives in a
home built in 1980, and there is no peeling paint. The most appropriate
initial management is:

a) Repeat lead level at 15 months of age

b) Remove child from home; no other management needed

c) If the home is proven to be lead free, no further evaluation or


management needed

d) Report this case. Search for source of lead. Initiate oral chelation
therapy (succimer)

e) Hospitalize immediately for intravenous chelation therapy


The Correct answer is D

Explanation
For lead levels over 45 microg /dl, chelation treatment is usually needed. If
oral chelation with succimer is used as an outpatient, there must be
assurance that the home environment is free of lead.

A. A repeat lead level within 3 months is acceptable for children with


lead levels between 10 and 14 microg /dl, but is not adequate management for
a lead level this high. Action should be taken within 48 hours.

B. A complete investigation must be done to identify whether or not the


home is actually the source of lead. It is less common for a house built
as late as 1980 to contain lead paint. Lead can also come from pottery,
soil, home remedies, plumbing, and automobile repair supplies,
batteries, and various solvents.

C. Any patient who has a blood lead level over 20 microg/dl needs careful
evaluation and repeated blood lead levels.

E. Emergency hospitalization and intravenous chelation is usually


reserved for children with lead levels over 70 microg/dl.

A 13 year old boy comes to the office for a sports participation


physical examination. He has been playing in a summer basketball league
and now wants to try out for the high school team. His last physical
examination was 2 years ago and, according to him, he has been healthy
except for a cold 2 weeks ago. Before you begin the physical
examination, the nurse informs you that his routine urinalysis shows:

Color Tea-colored/dark WBC 7/hpf


Specific gravity 1.030 RBC >100/hpf, a few red cell casts
pH 5.5 Bacteria Negative
Protein 2+ Glucose Negative
Ketones Negative

These laboratory results are most indicative of which of the following?


a) Cystitis
b) Glomerulonephritis
c) Nephrotic syndrome
d) Pyelonephritis
e) Renal calculi
The Correct answer is B

Explanation
The urinalysis in this scenario is significant for a tea-colored
appearance, concentrated urine, proteinuria, hematuria, and red blood
cell casts. The presence of red blood cell casts indicates that the
origin of the bleeding is glomerular in nature, and thus is
pathognomonic for acute glomerulonephritis. Postinfectious
glomerulonephritis is the most common cause of acute glomerulonephritis
in children, with group A beta-hemolytic streptococci being the most
frequently associated bacterial etiology. Presenting clinical signs can
include an asymptomatic individual with microscopic hematuria, or
symptoms such as low-grade fever, malaise, lethargy, abdominal pain, and
headache.
A 3 year old child presents with stridor and drooling. He is diagnosed
with epiglottitis. What is the most appropriate immediate management?

a) Intubation
b) Antibiotics
c) Tracheostomy
d) X-Ray
The Correct answer is A

Explanation
Epiglottitis is a rapidly progressive bacterial infection of the
epiglottis and surrounding tissues that may lead to sudden respiratory
obstruction and death. Symptoms include severe sore throat, dysphagia,
high fever, drooling, and inspiratory stridor. Diagnosis requires direct
visualization of the supraglottic structures, which is not to be
performed until full respiratory support is available.

In children, the airway must be secured immediately, preferably by


nasotracheal intubation. An endotracheal tube is usually required until
the patient has been stabilized for 24 to 48 h (usual total intubation
time is < 60 h).

A beta-lactamase resistant antibiotic, such as ceftriaxone should be


used empirically, pending culture and sensitivity test results.
Epiglottitis is caused by H. influenzae type B can be effectively
prevented with the H. influenzae type B (Hib) conjugate vaccine.
An 8 year old boy presents with a cut with swelling on his arm. His
physical exam also shows swollen lymph nodes. His mother tells you that
he was most likely scratched by their neighbours cat. Which of the
following organisms is most likely involved?

a) Brucella canis
b) Sarcoptes scabiei
c) Chlamydia psittaci
d) Bartonella henselae
The Correct answer is D

Explanation
Cat-scratch disease is infection caused by Bartonella henselae. Symptoms
are a local papule and regional lymphadenitis. Within 3 to 10 days after
a scratch, most patients develop an erythematous, crusted papule
(rarely, a pustule) at the scratch site. Regional lymphadenopathy
develops within 2 weeks. The nodes are initially firm and tender, later
becoming fluctuant, and may drain with fistula formation. Fever,
malaise, headache, and anorexia may accompany lymphadenopathy.

Treatment is local heat application and analgesics. If a lymph node is


fluctuant, needle aspiration usually relieves the pain. Antibiotic
treatment is not clearly beneficial and generally should not be given
for localized infection.
A child presents with the following rash:

You diagnose her with impetigo. What is the


most appropriate treatment?

a) Oral bactrim
b) Oral dicloxacillin
c) Cefuroxime
d) Topical clotrimazole
The Correct answer is B

Explanation
Impetigo typically presents as clusters of vesicles or pustules that
rupture and develop a honey-colored crust (exudate from the lesion base)
over the lesions. Treatment for localized disease is topical mupirocin.
Oral such as dicloxacillin or cephalexin are also used.

A 2 year old boy is brought to the office by his father because of a 3


month history of decreased activity, poor appetite, sporadic vomiting,
clumsiness and speech regression. Since his birth his family has lived
in an old area of the city where there is demolition of old buildings.
Examination of a peripheral blood smear is likely to show which of the
following?

a) Basophilic stippling of erythrocytes


b) Degranulation of eosinophils
c) Diminished numbers of platelets
d) Howell-Jolly bodies
e) Macrocytic erythrocytes
The Correct answer is A

Explanation
This child suffers from lead poisoning. Prior to the 1970s, lead was
used in paint, gasoline, water pipes, and many other products. During
the demolition of older structures, lead is released and can become
ingested by humans, primarily children. Exposure to excessive levels of
lead can cause brain damage; affect a child’s growth; damage kidneys;
impair hearing; cause vomiting, headaches, and appetite loss; and cause
learning and behavioral problems. Lead eventually becomes associated
with mitochondria in red blood cells and appears as basophilic granules
via H & E staining. This is a form of sideroblastic anemia.
During a routine well child examination of a 9 month old female, you
discover labial adhesions with a 5-mm opening anteriorly. Which one of
the following statements is true concerning this condition?

a) It is rarely found in neonates


b) It is rarely associated with urinary tract infections
c) The labia majora are most likely affected
d) Surgery is the treatment of choice
e) Oral estrogens are an accepted alternate treatment
The Correct answer is A

Explanation
The exact cause of labial adhesions is unknown. However, since it rarely
occurs in neonates and responds to estrogen therapy, a hypoestrogenic
state is felt to be a contributing factor. The lesion results from
fusion of the labia minora. There is a 20%-40% incidence of recurrent
urinary tract infections in these patients. The treatment of choice is
2-8 weeks of local treatment with estrogen cream. Oral estrogens are not
indicated and may cause a harmful hyperestrogenic state, with female
virilization features. Because of the possibility of pain, recurrence,
and potential scarring, surgical treatment is recommended only if
medical treatment is unsuccessful.
A 15 month old child has spastic cerebral palsy. Which of the following
is most suggestive of perinatal asphyxia as the cause for this condition

a) Evidence of periventricular calcificatons at birth


b) Microcephaly at birth
c) Recurrent seizures in the newborn period
d) Retinopathy of prematurity
e) Rigidity and spasticity
The Correct answer is C

Explanation
The etiology of cerebral palsy is not well understood, and brain lesions
are thought to be associated with prenatal, perinatal, or postnatal
events of varying causes. Risk factors for cerebral palsy are
multifactorial and can include preterm birth, multiple gestation,
intrauterine growth restriction, male sex, low Apgar scores,
intrauterine infections, maternal thyroid abnormalities, prenatal
strokes, birth asphyxia due to seizures, maternal methyl mercury
exposure, and maternal iodine deficiency.
A 5 day old neonate is brought to the office because of the development
of yellow skin and a rash 1 day after hospital discharge. She weighed
3400 g (7 lb 8 oz) at birth and is the product of a normal
pregnancy. The neonate was breast-feeding and was doing well at the time
of discharge. Her skin color has become yellow. On physical examination
the neonate weighs 3250 g (7 lb 2 oz). There is scleral and skin
icterus. Studies on the neonate show a serum total bilirubin
concentration of 8.7 mg/dL, and concentration of serum conjugated
(direct) bilirubin is 0.7 mg/dL. The most appropriate advice to give the
mother regarding the icterus is to

a) Ask her to avoid eating foods containing large quantities of carotene


b) Begin administering small doses of phenobarbital to the neonate
c) Discontinue breast-feeding until the jaundice has disappeared
d) Recommend home phototherapy for the neonate
e) Recommend no change in child care or feeding of the neonate
The Correct answer is E

Explanation
Physiologic jaundice is very common in newborns, with a total serum
bilirubin concentration of less than 13 mg/dL and a normal direct serum
bilirubin concentration. There should be no change in childcare or
feeding of the neonate. Phenobarbital is not indicated because this
patient has physiologic jaundice and no therapy is required.

A 6 year old boy has been identified as having a cross left eye that was
first noticed six months ago. He started to complain of frontal
headaches when reading. He has a large angle left esotropia, fixing only
with his right eye. On comparing red reflexes with your ophthalmoscope
from right to left eye, the left reflex appears less distinct than the
right. The most likely diagnosis is

a) Convergence insufficiency
b) Accommodative esotropia
c) Infantile esotropia
d) Sixth cranial nerve palsy
e) Thyroid ophthalmopathy
The Correct answer is B

Explanation

Infantile esotropia is a constant inward turning of the eyes that


develops before 6 months of age; it often runs in families and tends to
be severe. The eyes often begin to turn inward by 3 months of age. The
degree of turning is large and easily noticeable.
Surgery, which is accomplished by altering the pull of the eye muscles,
is usually needed to realign the eyes. Repeated operations may be
necessary. Even with the best possible treatment, strabismus may not be
fully corrected. Occasionally, amblyopia develops but usually responds
to treatment.

Accommodative esotropia is inward turning of the eyes that develops


between the ages of 6 months and 7 years, most often in children aged 2
to 3 years and is related to optical focusing (accommodation) of the eyes.
You see a 2-year-old female within 3 hours after she swallows a button
battery. She is asymptomatic. A radiograph demonstrates that the battery
has passed into the stomach, and is less than 2 cm in diameter.

Which one of the following would be most appropriate at this time?

a) Schedule for immediate endoscopic removal


b) Observe and schedule a repeat radiograph in 48 hours
c) Observe and schedule a repeat radiograph weekly until the battery
has been eliminated in the stool
d) Reassure the parents that no follow-up is needed unless the child
develops abdominal pain
The Correct answer is B

Explanation
Early intervention is indicated for patients who have swallowed button
or disc batteries, because of the potential for voltage burns and direct
corrosive effects. Foreign objects that remain in the esophagus should
be immediately removed endoscopically. Button batteries that remain in
the stomach for more than 48 hours or that are larger than 2 cm in
diameter should be removed endoscopically. Once they are past the
duodenal sweep, 85% will pass in less than 72 hours. Radiographs should
be obtained every 3-4 days to follow the progress of the battery until
it has been eliminated.
A 1 year old child presents for the 5th time with symptoms of pain when
he urinates, fever and back/flank pain. What is the most likely diagnosis’

a) Ureteropelvic junction obstruction


b) Vesicoureteral reflux
c) Renal agenesis
d) UTI
The Correct answer is B

Explanation
Vesicoureteral reflux is retrograde passage of urine from the bladder
back into the ureter and renal pelvis. This may damage the upper urinary
tract by bacterial infection and occasionally by increased hydrostatic
pressure. Bacteria in the lower urinary tract can easily be transmitted
by reflux to the upper tract, leading to recurrent parenchymal infection
with potential scarring and renal dysfunction. Chronically elevated
emptying pressures (> 40 cm H2O) and increased bladder volume and
pressure often cause progressive kidney damage, even without infection
or reflux.

Symptoms and signs are typically those of UTI; these may include fever,
abdominal or flank pain, dysuria or flank pain with voiding, frequency,
and urgency. Pyuria, hematuria, proteinuria, and bacteriuria may be
present on urinalysis.

Tests for reflux include filling and voiding cystourethrogram (which is


best to diagnose bladder outlet obstruction) and radioisotope cystogram.
Renal ultrasonography evaluates for size, hydronephrosis, and scarring.

Vesicoureteral reflux is usually mild to moderate. Mild cases often


resolve spontaneously over months to several years while daily
antibacterial prophylaxis is maintained.
While doing a preceptorship in a pediatrician’s office, you perform a
2-week follow-up exam on a large newborn. You feel a firm small mass at
the junction of the middle and distal thirds of the clavicle. Crepitus
is also palpable. The child appears uncomfortable when lying on the
affected side. The Moro reflex is diminished on the same side. These
findings were present at birth also, but seem to be improving. The
pediatrician made a diagnosis of clavicular fracture. Which of the
following statements is most likely true?

a) Clavicular fractures are almost never seen with modern day OB techniques
b) These fractures are commonly associated with brachial nerve plexus
injury or pneumothorax
c) Clavicle fractures heal rapidly (in as little as 7-10 days)
d) Clavicular fractures are commonly associated with shoulder dystocia
e) This baby needs to be seen immediately by an orthopedist to ensure
proper alignment
The Correct answer is D

Explanation
Shoulder dystocia with large infants is commonly associated with
clavicular fracture. Fractures occur when the shoulders are compressed
between the sacrum and the symphysis pubis, or with arms or shoulders
extended during breech delivery.

A. Fractures of the clavicle are the most common neonatal fracture,


occurring in from 2-7 per 1,000 live births even with excellent
obstetrical care.
B. Brachial plexus injury and pneumothorax is very uncommon.
C. Healing normally progresses over several months, first with callous
formation followed by remodeling.
E. This injury is usually benign but is occasionally associated with a
pneumothorax or brachial plexus injury. Neither would be treated by an
orthopedist. Treatment is supportive to decrease pain in the infant by
avoiding positioning the infant on the injured side and immobilizing the
arm until discomfort has resolved.
During a routine physical examination of a 2 week old neonate, a grade
3/6 early systolic murmur is heard. The mother reports no signs or
symptoms of illness in the baby. The neonate is otherwise asymptomatic.
Physical examination at birth was normal. The most appropriate next step
is to

a) Do funduscopic examination
b) Measure arterial blood pressures in the arms and legs
c) Order abdominal ultrasonography
d) Order chest x-ray film
e) Order electrocardiography
The Correct answer is B

Explanation
Measuring arterial blood pressures in the upper and lower extremities is
the appropriate next step when evaluating an infant for congenital heart
disease. This is especially helpful when considering coarctation of the
aorta, as such infants may demonstrate a difference in the pulsations
and blood pressures of the upper and lower extremities.

Abdominal ultrasonography would be done to rule out renal disease.


Likewise, although both a chest x-ray film and an electrocardiograph
should be included in the evaluation of this patient, they are not the
most appropriate next step. Always do the least invasive study on your
patient first.
A 10 year old white male presents to the emergency room with a 24-hour
history of painful lower extremities and severe abdominal pain. On
physical exam, you note a temperature of 37.4°C and severe arthritis of
both knees along with a purpuric rash located on the lower extremities
and buttocks. The stool guaiac is positive, as is a urine dipstick for
protein and blood. Which of the following is the most likely diagnosis’
a) Rocky Mountain spotted fever
b) Juvenile rheumatoid arthritis
c) Schonlein-Henoch vasculitis
d) Meningococcemia
e) Post-streptococcal glomerulonephritis
The Correct answer is C

Explanation
Henoch-Schönlein purpura is a vasculitis affecting primarily small
vessels that occurs most often in children. Common manifestations
include palpable purpura, arthralgias, GI symptoms and signs, and
glomerulonephritis. Diagnosis is clinical. Disease is usually
self-limited. Corticosteroids can relieve arthralgias and GI symptoms
but do not alter the course of the disease.

The disease begins with a sudden palpable purpuric rash that typically
involves the extensor surfaces of the feet, legs, and arms and a strip
across the buttocks. The purpura may start as small areas of urticaria
that become indurated and palpable. Crops of new lesions may appear over
days to several weeks. Many patients also have fever and polyarthralgia
with associated periarticular tenderness and swelling of the ankles,
knees, hips, wrists, and elbows.
A 4-year-old white male is brought to your office in late August. His
mother tells you that over the past few days he has developed a rash on
his hands and “sores” in his mouth. On examination you note a vesicular
exanthem on his hands, with lesions ranging from 3 to 6 mm in diameter.
The oral lesions are shallow, whitish, 4- to 8-mm ulcerations
distributed randomly over the hard palate, buccal mucosa, gingiva,
tongue, lips, and pharynx. Except for a temperature of 37.4°C (99.3°F),
the remainder of the examination is normal. The most likely diagnosis is

a) herpangina
b) hand, foot, and mouth disease
c) aphthous stomatitis
d) herpetic gingivostomatitis
e) streptococcal pharyngitis
The Correct answer is B

Explanation
Hand, foot, and mouth disease is a mild infection occurring in young
children, and is caused by coxsackievirus A16, or occasionally by other
strains of coxsackie- or enterovirus. In addition to the oral lesions,
vesicular lesions may occur on the feet and nonvesicular lesions may
occur on the buttocks. A low-grade fever may also develop. Herpangina is
also caused by coxsackieviruses, but it is a more severe illness
characterized by severe sore throat and vesiculo-ulcerative lesions
limited to the tonsillar pillars, soft palate, and uvula, and
occasionally the posterior oropharynx. Temperatures can range to as high
as 41°C (106°F). The etiology of aphthous stomatitis is multifactorial,
and it may be due to a number of conditions. Systemic signs, such as
fever, are generally absent. Lesions are randomly distributed. Herpetic
gingivostomatitis also causes randomly distributed oral ulcers, but it
is a more severe illness, regularly accompanied by a higher fever, and
is extremely painful. Streptococcal pharyngitis is rarely accompanied by
ulceration except in agranulocytic patients.
A 6-year-old female presents with a 24-hour history of dry cough,
malaise, and a temperature of 39.8°C (103.6°F). She received an
influenza vaccination 7 days ago. A rapid influenza test is positive for
influenza A. Which one of the following would be the best treatment
option for this patient?

a) Oseltamivir (Tamiflu)
b) Amantadine (Symmetrel)
c) Rimantadine (Flumadine)
d) Zanamivir (Relenza)
The Correct answer is A

Explanation
Amantadine and rimantadine are not recommended for the treatment of
influenza A because of the development of resistance to these drugs.
Resistance is not a problem with neuramidase inhibitors such as
oseltamivir in immunocompetent patients. Zanamivir is not recommended
for treatment of children under the age of 7. Although this child has
recently received influenza vaccine, this is not a contraindication to
drug therapy.
Which one of the following is recommended for the treatment of cough and
cold symptoms in children younger than 2 years of age?

a) Cough suppressants and humidified air


b) Intranasal decongestants
c) Nonsedating antihistamines and decongestants
d) Nasal saline with bulb suction
e) Antibiotics and hydration
The Correct answer is D

Explanation
No medication available in Canada has been shown to effectively treat
cough or cold symptoms in children younger than 2 years of age. However,
many agents are commonly prescribed despite reports of numerous minor,
and some serious, adverse effects. For this reason, it is recommended to
using only nasal saline, bulb suction, humidified air, and good
hydration in children younger than 2 years of age.

A 10-year-old male is brought to your office with pain and swelling of


the knee after falling out of a tree. A physical examination is notable
for point tenderness and swelling at the proximal tibia. A radiograph
shows a displaced fracture of the proximal tibia through the physis and
epiphysis.

The most appropriate management is

a) a long leg cast


b) a rigid knee immobilizer
c) a functional (hinged) knee immobilizer
d) orthopedic referral
The Correct answer is D
Explanation
Physeal injuries are unique to children, and account for approximately
one-fourth of all pediatric fractures. This child has a Salter-Harris
fracture that requires referral to an orthopedist. Salter-Harris type I
injury is a fracture through the hypertrophic cartilage that causes
widening of the physeal space. These fractures are difficult to diagnose
radiographically, but their clinical hallmark is point tenderness at the
epiphyseal plate. Type II fractures are the most common, and extend
through both the physis and metaphysis. Although these fractures may
result in some shortening, they rarely cause functional deformities.
Type III injuries extend through the physis and epiphysis, disrupting
the reproductive layer of the physis. These injuries may cause chronic
sequelae because they disrupt the articular surface of the bone, but
they do not produce deformities and generally have a good prognosis.

Type IV injuries cross through the epiphysis, physis, and metaphysis.


These fractures are also intra-articular, increasing the risk for
chronic disability. They can disrupt the proliferative zone, leading to
early fusion and growth deformity. Type V fractures are the least common
but most difficult to diagnose, and have the worst prognosis. The
classic mechanism of injury is an axial force that compresses the
epiphyseal plate without an overt fracture of the epiphysis or metaphysis.
A 5 year old boy with Down syndrome is seen because of torticollis,
clumsiness and gait difficulties for the past month. Which one on the
following is the most likely diagnosis’

a) Behavior disorder
b) Problems with vision
c) Cerebellar damage
d) Atlantoaxial subluxation
e) Myopathy
The Correct answer is D

Explanation
Up to 14 percent of persons with Down syndrome have evidence of
atlantoaxial instability on plain radiographs of the neck. From 1 to 2
percent of all persons with Down syndrome have symptoms of atlantoaxial
subluxation and, in some cases, symptoms have appeared after surgery for
other conditions.

Family members or supervising staff should be advised to monitor for


symptoms and an annual neurologic examination should be performed to
look for upper motor neuron signs of spinal cord compression.

To assess for spinal cord compression from atlantoaxial instability,


test gait, tone, Babinski responses, deep tendon reflexes and clonus.
Assess for neck pain, torticollis, gait disturbances, spasticity and
weakness.
A 15 year old white male is being evaluated after a fall down one flight
of stairs. He was transported by the local rescue squad with his
cervical spine immobilized. He walked briefly at the scene and did not
lose consciousness. His only complaint is a mild, generalized headache.
One episode of vomiting occurred shortly after the accident. No weakness
or numbness has been noted. Vital signs, mental status, and neurologic
findings are normal. Radiologic evaluation of the cervical spine is
remarkable only for an air-fluid level in the sphenoid sinus. Which one
of the following abnormalities is most likely to be associated with this
radiologic finding?

a) A basilar skull fracture


b) An orbital floor fracture
c) An epidural hematoma
d) A zygomatic arch fracture
e) A mandible fracture
The Correct answer is A

Explanation
A post-traumatic air-fluid level in the sphenoid sinus is associated
with basilar skull fractures. This finding is frequently noted on
cervical spine films.

Orbital floor fractures may be associated with double vision, fluid in


the maxillary sinus, an air-fluid level in the maxillary sinus, and
diplopia. Epidural hematomas are more frequently associated with skull
fractures in the area of the meningeal artery. Zygomatic arch fractures
are more visible on Towne’s view. Characteristic swelling and lateral
orbital bruising are typically present. Mandible fractures may be
associated with dental misalignment or bleeding. Panoramic views are
often diagnostic.
A 6 month old baby has had mild inspiratory stridor for the last 2
months. The most likely cause of this is

a) Laryngomalacia
b) Acute epiglottitis
c) Croup
d) Tonsillar hypertrophy
e) Foreign body aspiration
The Correct answer is A

Explanation
Laryngomalacia is the most common cause of chronic stridor in children
younger than two years. It has a male-to-female ratio of approximately
2:1. The condition is due to an intrinsic defect or delayed maturation
of supporting structures of the larynx. The airway is partially
obstructed during inspiration by the prolapse of the flaccid epiglottis,
arytenoids and aryepiglottic folds. The inspiratory stridor is usually
worse when the child is in a supine position, when crying or agitated,
or when an upper respiratory tract infection occurs.
A 5 year old girl is referred to a cardiologist because of a murmur
heard during a routine examination. Which one of the following clinical
characteristics is consistent with an innocent murmur?

a) Audible only in diastole


b) Audible throughout systole
c) Associated with a precordial heave
d) Attenuated with change in body position
e) Radiates from apex to the axilla
The Correct answer is D

Explanation
Heart murmurs is a common finding on routine examination of infants and
children. 50% of normal children have an innocent heart murmur. It is
important to search for symptoms or signs of congenital heart disease.
Patients with innocent heart murmurs should be free of such symptoms or
signs. Murmurs which are attenuated with changing body position are
usually innocent.

Therefore, when history is obtained and during physical examination


symptoms and signs which may point to heart disease should be
identified. The presence of symptoms and/or signs of heart disease will
suggest the pathological nature of the heart murmur being investigated.

Abnormal findings indicating a pathological origin of a heart murmur


include: shortness of breath, easy fatigue, failure to thrive, cyanosis.
All diastolic murmurs are pathological murmurs.
A 3-year-old male was treated for acute otitis media last month. His
mother brings him in for follow-up because she believes his hearing has
not been normal since then. He attends day care and has had several
upper respiratory infections. On examination the tympanic membranes are
not inflamed, but the membrane is retracted on the right side.
Tympanography produces a normal peak (type A) on the left side, but a
flat tracing (type B) on the right side.

Which one of the following would be the most appropriate recommendation?

a) Audiometry
b) Observation with follow-up
c) An antihistamine/decongestant combination
d) Intranasal corticosteroids
e) Systemic corticosteroids
The Correct answer is B

Explanation
This patient has unilateral serous otitis and is unlikely to have
delayed language from decreased hearing on one side. The patient should
be observed for now. Hearing loss of longer than 3 months may indicate a
need for tympanostomy tubes. Surgical treatment has been shown to be
helpful, but should be reserved for patients with chronic problems.
Audiometry is not needed to make a decision about surgery at this point,
and the mother’s judgment is likely correct about his current hearing
loss, so a hearing test most likely would not add any useful
information. Numerous studies have debunked all medical treatments for
serous otitis, including antihistamine and decongestant therapy, and
corticosteroids by any route.
A 5 year old patient has axillary freckling, several firm subcutaneous
masses on both arms and seven light-brown macules on his trunk which are
greater than 1.5 cm. See picture:
Which one of the following is the most likely diagnosis’

a) Peutz-Jeghers syndrome
b) Tuberous sclerosis
c) Sturge-Weber syndrome
d) Albright's disease
e) Neurofibromatosis
The Correct answer is E

Explanation
Neurofibromatosis is an autosomal dominant disorder, producing tumors
along the course of nerves and occasionally resulting in marked soft
tissue or bony deformity.

In > 90%, characteristic skin lesions are apparent at birth or develop


during infancy. Lesions are medium-brown (café-au-lait), freckle-like
macules, distributed most commonly over the trunk, pelvis, and flexor
creases of elbows and knees. During late childhood, flesh-colored
cutaneous tumors of various sizes and shapes appear, ranging in number
from several to thousands.

Diagnosis is clinical. There is no specific treatment, but tumors can be


removed surgically.
In which of the following conditions would you not expect to find an
elevated alpha-fetoprotein level during a routine screen done at 16
weeks gestation?

a) Encephalocele
b) Myelomeningocele
c) Spina bifida
d) Subarachnoid hemorrhage
The Correct answer is D

Explanation
Alpha-fetoprotein is an excellent screening tool used during pregnancy
to identify a fetus with a suspected neural tube defect if measured
between 16-18 weeks gestation. All of the abnormalities listed above are
forms of neural tube defects and therefore would be expected to have an
elevated alpha-fetoprotein level, except for sub-arachnoid hemorrhage.

A 36 year old man has a 4 week history of a generalized, intensely


pruritic papular rash. He is otherwise well. His 9 year old son also has
itching. On examination, there is a generalized rash consisting of
excoriated papules and vesicles on wrists, sides of fingers, arms and
buttocks. No other abnormalities are noted. Which one of the following
is the most likely diagnosis’

a) Pityriasis rosea
b) Neurodermatitis
c) Scabies
d) Impetigo (pyoderma)
The Correct answer is C

Explanation
Scabies is an infestation of the skin with the mite Sarcoptes scabiei.
Scabies causes intensely pruritic lesions with erythematous papules and
burrows in web spaces, wrists, waistline, and genitals. Diagnosis is
based on examination and scrapings. Treatment is with topical scabicides
such as permethrin.
A term newborn infant is noted to have abdominal distention and failure
to pass meconium at 48 hours of age. Sweat chloride test is negative.
Abdominal x-rays show dilated loops with air-fluid levels and a granular
"ground glass" material. A gastrografin enema is administered with good
effect, as the infant passes meconium. Which one of the following
investigations is indicated in the follow-up management of this infant?

a) Glucose tolerance test


b) Barium enema
c) Fluid deprivation test
d) Gastrointestinal motility test
e) Rectal biopsy
The Correct answer is E

Explanation
In Hirschsprung's disease (congenital megacolon), a section of the large
intestine is missing the nerve network that controls the intestine's
rhythmic contractions. Symptoms of intestinal obstruction occur. The
large intestine depends on a network of nerves within its walls to
synchronize rhythmic contractions and move digested material toward the
anus, where the material is expelled as feces. In Hirschsprung's
disease, the affected section of intestine cannot contract normally.

At the time of birth, newborns should pass a dark green fecal material
(meconium). Delayed passage of meconium raises the suspicion of
Hirschsprung's disease. Later in infancy, children with Hirschsprung's
disease can have symptoms that suggest intestinal obstruction,
bile-stained vomit, a swollen abdomen, and refusal to eat. If only a
small section of the intestine is affected, a child may have milder
symptoms and may not be diagnosed until later in childhood. These
children may have ribbon like stools and a swollen abdomen; they often
fail to gain weight. In rare cases, constipation is the only symptom.

Rectal biopsy and measurement of the pressure inside the rectum


(manometry) are the only tests that can reliably be used to diagnose
Hirschsprung's disease. A barium enema may also be performed. During a
barium enema, the doctor instills barium and air into the child's rectum
and then takes x-rays.
A 4 year old girl presents with a 2 day history of low-grade fever and
headaches, followed by an onset of erythematous facial flushing, most
prominent on her cheeks. Examination reveals a macular rash on her face
(particularly cheeks), trunk and extremities and arthritis of wrist
joints. Which of the following is the most likely cause of the infection?

a) Echovirus
b) Adenovirus
c) Parvovirus B19
d) Measles
e) Coxsackie virus
The Correct answer is C

Explanation
Erythema infectiosum (fifth disease, parvovirus B19 infection) is a
contagious viral infection that causes a blotchy or raised red rash with
mild illness. Erythema infectiosum is caused by human parvovirus B19 and
occurs most often during the spring months, often in geographically
limited outbreaks among children and adolescents. Infection is spread
mainly by breathing in small droplets that have been breathed out by an
infected person. The infection can also be transmitted from mother to
fetus during pregnancy, rarely resulting in stillbirth or severe anemia
and excess fluid and swelling (edema) in the fetus (hydrops fetalis).

Symptoms begin about 4 to 14 days after infection but many children have
none. However, some have a low fever and feel mildly ill for a few days.
Seven to 10 days later, children develop red cheeks that often look like
they have been slapped as well as a rash, especially on the arms, legs,
and trunk but not usually on the palms or soles. The rash can be itchy
and consists of raised, blotchy red areas and lacy patterns,
particularly on areas of the arms not covered by clothing, because the
rash may be worsened by exposure to sunlight.
You are called to the newborn nursery to see a baby with a deformed
foot. The affected foot is shorter and smaller than the other. The heel
is turned downward and inward, while the front of the foot is curved
inwardly. The medial crease of the foot is accentuated. The foot has
almost no flexibility. You diagnose a unilateral rigid club foot
deformity. Which statement is NOT true?

a) Rigid clubfoot may require surgery


b) Some of these children have other deformities, i.e., spina bifida,
neuromuscular deformity
c) This deformity usually prevents a child from standing and walking
d) After surgery, long-term observation and bracing is usually necessary
e) These children are active and participate with peers in the usual
physical activities
The Correct answer is C

Explanation
Most of these children are healthy infants with a clubfoot of unknown
cause and will crawl, stand, and walk. Untreated, this condition may
result in severe disability and deformity.

A. Rigid clubfoot may respond to manipulation and casting. However, if


these interventions fail, surgery will be required.
B. Most cases are idiopathic and have no other associated abnormalities.
D. Very early intervention may produce a shorter treatment period, but
if conservative treatment fails (casting), surgery may be required
followed by casting and bracing. Patients must then be followed for any
evidence of recurrence.
E. Even with successful treatment, the foot may be smaller and possibly
less mobile than the normal foot; however, most children will still be
able to participate fully in normal activities.
A 2-month-old black male is rushed into the office. About 30 minutes
earlier, the mother had found him ?not breathing?. He was aroused with
stimulation. The mother reports that he had not been sick, and in fact,
has seemed normal since the incidence. The mother is well known to you,
and is known to have abused alcohol during the past.

Your examination, including thorough cardiac and neurologic evaluations,


is within normal limits. Based on your presumptive diagnosis, which one
of the following should be included in your recommendations to reduce
the risk of a more serious episode?

a) Having the infant sleep in the mother’s bed for the next few weeks
b) Placing the baby in the prone position to sleep
c) Avoiding exposure of the baby to secondhand tobacco smoke
d) Discouraging the use of a pacifier at nap time and bedtime
e) Being sure the child is warmly dressed for sleep
The Correct answer is C

Explanation
An aborted episode of sudden infant death syndrome (SIDS) is the
presumptive diagnosis in this case. SIDS has its peak incidence in
infants 2-3 months of age. Black, Native-American, and Alaskan Native
children have rates of SIDS that are 2-3 times the national average.

Bed sharing can be dangerous under certain conditions; the risk of SIDS
seems to be particularly high when there are multiple bed sharers and
also may be increased when the bed sharer has consumed alcohol or is
overtired. On the other hand, room sharing (i.e., the infant sleeping in
the parent’s room) without bed sharing is associated with a reduced risk
of SIDS. Accordingly, new recommendations for preventing SIDS have been
released. Regarding bed sharing, the AAP recommends that infants 1)
should have a separate but proximate sleeping environment; 2) may be
brought into the parent’s bed for nursing or comforting, but should be
returned to their own crib or bassinet when the parent is ready to
return to sleep; and 3) should not be brought into bed when the parent
is excessively tired or using medications or substances that could
impair his or her alertness. Thus, in the case described, it would
unwise to recommend bed sharing.
The other items listed are in the recommendations. Regarding the use of
pacifier, several studies have reported its use has a protective effect
on the incidence of SIDS. It was concluded that “nonnutritive sucking
behaviors” (i.e., finger or pacifier) are normal in infants and young
children, and in most cases, sucking habits in children up to the age of
5 years are not likely to cause long-term difficulties.
You are evaluating a 5-month-old with fever, tachypnea, and mild
respiratory distress in the emergency department. You hear mild basilar
rales. The child does not appear toxic.

Which one of the following tests would be most appropriate as an initial


study?

a) A chest radiograph
b) CBC
c) A C-reactive protein level
d) Oxygen saturation by pulse oximetry
The Correct answer is D

Explanation
Pulse oximetry should be obtained on all paediatric patients with
significant tachypnea, pallor, or respiratory distress. It has been
found that CBCs, C-reactive protein levels, and erythrocyte
sedimentation rates are not effective in differentiating between viral
and bacterial pneumonia. Chest radiographs are also ineffective in
distinguishing viral and bacterial pneumonia, and should be obtained in
cases of ambiguous clinical findings, prolonged pneumonia, and pneumonia
that is unresponsive to antibiotic therapy, as well as when there is the
possibility of complications such as pleural effusions.

In an 11-year-old male with dark brown urine and hand and foot edema,
which one of the following would be most suggestive of glomerulonephritis’

a) WBC casts in the urine


b) RBC casts in the urine
c) Eosinophils in the urine
d) Positive serum antinuclear antibody levels
e) Elevated C3 and C4 complement levels
The Correct answer is B

Explanation
Acute glomerulonephritis (AGN) in children manifests as brown or
cola-colored urine, which may be painless or associated with mild flank
or abdominal pain. There are many etiologies of AGN but the most common
in children are IgA nephropathy (which may directly follow an acute
upper respiratory tract infection) and acute poststreptococcal
glomerulonephritis following a streptococcal throat or skin infection
(usually 7-21 days later).

In cases with more severe renal involvement, patients may develop


hypertension, edema, and oliguria. RBC casts are the most classic
finding on urinalysis in a patient with AGN. WBC casts are seen in acute
pyelonephritis, often manifested by high fever, and costovertebral angle
or flank pain and tenderness. Patients may also appear septic. Positive
serum antinuclear antibodies are associated with lupus nephritis. Urine
eosinophils are seen in the drug-induced tubulointerstitial nephritis.
Serum complement levels are reduced, not elevated, in various forms of
acute glomerulopathies, including poststreptococcal AGN.

A 3-year-old toddler with myelomeningocele was hospitalized for a


community acquired pneumonia. After a routine urinary catheterization,
the patient became tachypneic, tacycardic, wheezy, and hypotensive. What
is the most likely etiology of this patient’s state of shock?

a) Hypovolemic shock from dehydration


b) Septic shock from streptococcus pnemoniae bacteremia
c) Anaphylactic shock from latex allergy
d) Spinal shock from myelomengocele
e) Cardiogenic shock from obstructive cardiomyopathy
The Correct answer is C

Explanation
Anaphylactic shock from latex allergy has been associated with
myelomeningocele patients. Some authors suggest this may be the result
of chronic exposure to latex (i.e., during repeated urinary
catheterization). The timing as well as symptoms (wheezing) suggest
anaphylaxis.

A to E. Shock, regardless of the etiology, will have similar clinical


manifestations (i.e., hypotension and usually tachycardia). Signs of
sepsis may include fever or rash or evidence of focal infection,
cardiogenic shock may be associated with hepatomegaly, gallop rhythm, or
cyanosis, and a clue to hypovolemic shock may come from a history of
vomiting, diarrhea, or poor intake. The respiratory symptoms and
wheezing should lead to consideration of latex allergy in this case.

A 13 month old infant boy has chronic diarrhea, poor appetite,


irritability and growth failure. He had been well previously, developing
normally until diarrhea began at 3 months of age. Findings include
weight loss less than 5th percentile and length at 25th percentile,
cachectic appearance, wasted extremities and protuberant abdomen. His
labs are: albumin 23, protein 40. Stool positive for reducing sugars and
negative for enteric pathogens and ova and parasites. These findings are
most consistent with

a) Celiac disease
b) Cow milk allergy
c) Crohn disease
d) Cystic Fibrosis
The Correct answer is A

Explanation
Celiac disease is characterized by inflammation of the upper small
intestine in response to dietary gluten. The endomysial antibody test
has led to improvements in the diagnosis of celiac disease.

Minimal or atypical symptoms occur in many patients, especially those


presenting with the disease in adulthood. Severe symptoms are most
common in young children. A fulminant form, characterized by diarrhea,
failure to thrive, abdominal distention and vomiting, occurs in children
younger than two years of age. The median age at the time of diagnosis
in children is four years, and loss of appetite is a common symptom.

Formerly, the classic diagnostic approach was to obtain a series of


intestinal biopsies: before treatment, after dietary withdrawal of
gluten and, finally, following a challenge with gluten. Such a series of
biopsies is now rarely performed. The development of the serum
endomysial antibody test has changed the method of diagnosis. Some
authorities now consider a positive endomysial antibody test plus
clinical improvement following withdrawal of gluten sufficient evidence
for the diagnosis of celiac disease.
While examining a 3 day old infant born at term by NSVD to a 19 year old
primigravida mother without any perinatal infection or complications,
you notice an asymmetric red reflex. The most common cause of this
condition is:

a) Retinoblastoma
b) Congenital cataract
c) Retinopathy of prematurity
d) Congenital glaucoma
e) Ocular toxoplasmosis
The Correct answer is B

Explanation
Congenital cataract is the most common cause of leukocoria in an
otherwise healthy, full term newborn. The other choices are all other
causes of leukocoria or a white pupil.

A. Retinoblastoma should always be considered in the differential of an


asymmetric red reflex. Although uncommon, this diagnosis requires early
intervention.
C. Retinopathy of prematurity is not seen in full term infants.
D. Congenital glaucoma is an uncommon but important diagnosis in infants
with an asymmetric red reflex. Tearing, irritability, and a large pupil
may also be seen.
E. Ocular toxoplasmosis may occur in infants with maternal exposure to
Toxoplasma gondii. Infants with severe disease may have chorioretinitis,
intracranial calcifications, and mental retardation.
In a child, which one of the following is most likely to improve
adherence to a chronic medication regimen?

a) Adding a favorite flavor to bitter liquid medications


b) More frequent dosing of daily medication
c) Having only one person from the health-care team discuss the
medication regimen with the patient and his parents
d) Advising the parents to avoid giving rewards for following the regimen
e) Putting the parents in complete control of the dosing schedule
The Correct answer is A
Explanation
A number of useful strategies for promoting adherence to a chronic
medical regimen can be employed in children. Adding flavors to
unpleasant tasting medicines is helpful (SOR B). Chocolate flavoring is
especially useful for masking the taste of bitter medications. Using
medications that are given only once or twice a day is associated with
compliance rates of greater than 70% (SOR B). Consistent advice given by
multiple members of the health-care team reinforces the importance of
following a medication regimen. Parental use of rewards for children who
take their medicine properly helps improve adherence. Involving children
in decisions concerning their care gives them a sense of control and
improves adherence.

Other strategies for improving adherence include patient handouts,


keeping financial costs in mind when prescribing, advising patients to
incorporate dosing into daily routines such as meals, keeping tally
sheets, and using visual reminders such as notes on the refrigerator.

A 14 year old boy is referred with a blood pressure of 145/80 mmHg.


There is family history of essential hypertension. His general physical
examination and urinalysis are normal. Home blood pressure readings are
consistently between 100-110 mmHg systolic and 70-80 mmHg diastolic.
Which one of the following is the most likely cause of his hypertension?

a) "White coat" hypertension


b) Essential hypertension
c) Reflux nephropathy
d) Pheochromocytoma
e) Renovascular hypertension
The Correct answer is A

Explanation
White coat hypertension is a phenomenon in which patients exhibit
elevated blood pressure in a clinical setting but not when recorded by
themselves at home. It is believed that this is due to the anxiety some
people experience during a clinic visit and see a physican in a ?white
coat?.

As the notion of "normal" is subjective and changes from individual to


individual a reference measurement was necessary. As night-time and self
measured values are often not subject to daily stress and clinical
values are subject to unusual anxiety, daytime ambulatory blood pressure
is used as a reference as it takes into account daily stress but not in
excess. Due to specificity involved in diagnosis of white coat
hypertension, many problems have been incurred in its diagnosis and
treatment.
A 7-year-old African-Canadian male is brought to your office with a
1-day history of purulent, crusted eyelashes in the morning, and red
eye. There is no history of visual change, foreign body, or injury. The
child is otherwise in good health and has normal developmental
milestones. No fever or respiratory distress is noted. A clinical
diagnosis of bacterial conjunctivitis is made.
The mother is anxious to keep the child in school. Which one of the
following would be the most appropriate time for the child to return to
school?

a) Once treatment is started


b) When there is no crusting or drainage in the morning
c) After 1 week of treatment
d) When the absence of fever for 24 hours is documented
e) When there is resolution of conjunctival erythema
The Correct answer is A

Explanation
Once therapy is initiated, children with bacterial conjunctivitis should
be allowed to remain in school. Careful hand hygiene is important,
however, and behavior must be appropriate to maintain adequate hygiene.
No specific length of treatment or evidence of clinical response is
required before returning to school.

A 4-month-old infant presents with a 5-day history of vomiting and


diarrhea. Subsequently, she develops tonic/clonic seizures unresponsive
to antiepileptic medication. A possible cause of seizures in this
patient may be due to:

a) Zinc deficiency
b) Celiac disease
c) Hyperchloremia
d) Hyponatremia
e) Hyperglycemia
The Correct answer is D

Explanation
Hyponatremic dehydration occurs in about 20% of patients with
dehydration. Symptomatic hyponatremia should be treated with 3% NaCl,
until the symptoms resolve and the serum NA is elevated above 120.

A. Zinc deficiency is a chronic disorder with failure to thrive, hair


loss, and dermatitis.
B. Presents at 1-2 years of age after the introduction of gluten in the diet.
C. Does not typically cause seizures.
E. Hypoglycemia, not hyperglycemia, may cause seizures.

A 14-year-old male who is active in sports most of the year presents


with bilateral anterior knee pain that is worse in the right knee. An
examination reveals tenderness and some swelling at the tibial tubercles.

Which one of the following is true regarding this patient’s condition?

a) It is almost never seen in adults


b) Treatment with a straight leg cylinder cast for 6 weeks is often needed
c) Corticosteroid injection of the tibial tubercle is a safe and
effective treatment
d) Radiographs should always be ordered to rule out other conditions
e) Bilateral symptoms are unusual
The Correct answer is A

Explanation
Osgood-Schlatter disease is encountered in patients between 10 and 15
years of age. These patients are often active in sports that involve a
lot of jumping. It is thought to be secondary to repetitive microtrauma
and traction apophysitis of the tibial tuberosity. Bilateral symptoms
are present in 20%?30% of patients. Radiographs may reveal
abnormalities, but are rarely indicated in straightforward cases. This
condition is usually self-limited, and most patients are able to return
to full activity within 2?3 weeks. Treatment includes rest, ice,
anti-inflammatory medications, a rehabilitation program, and an
infrapatellar strap during activities. Casting and corticosteroid
injections are not indicated.
An infant admitted with sepsis has a gram stain of the blood that shows
intracellular and extracellular gram-negative diplocci, which of the
following would be an appropriate next step?

a) Ceftriaxone for the pregnant third-year resident who intubated the


patient on arrival to the intensive care unit
b) Fourteen doses of rifampin (every 12 hours) given to all close
contacts (household, daycare) and all hospital contacts with respiratory secretion
contact
c) High-resolution chromosomal studies if this represented recurrent disease
d) Vaccination for a sibling with a past medical history significant
for multiple treatments for otitis media
e) Continued respiratory isolation for the full course of antibiotics (7 days)
The Correct answer is A

Explanation
I.M. Ceftriaxone is considered adequate prophylaxis for meningococcus
and is often preferred in the pregnant woman.

B. Four doses of rifampin given 12 hours apart are considered adequate


prophylaxis for meningococcus.
C. Terminal complement studies are ordered for patients with recurrent
disease to rule out complement deficiencies, as these patients are more
susceptible to meningococcal disease.
D. The meningococcal vaccine is given to those patients who are without
a spleen, are functionally asplenic (sickle cell), have a terminal
complement deficiency, are living in a dormitory environment, or are in
the midst of an epidemic.
E. Respiratory isolation may be discontinued after 24 hours of
appropriate antibiotic therapy.
A 14-month-old baby is brought to your office because of fatigue,
irritability, and poor appetite. The child had been breast fed until 7
months of age, then switched to whole milk. The child drinks
approximately 48 oz of milk daily, but eats little solid food yet. On
physical examination, the child is found to have generalized pallor but
no cardiorespiratory symptoms. The hemoglobin is 6 g/dl. Your initial
approach is:

a) Order a complete blood count and reevaluate in 2 weeks


b) Order a complete blood count and a serum lead level; check the
child’s home for lead
c) Order a complete blood count and serum ferritin; initiate oral iron
therapy and arrange to repeat the blood count in 2-4 weeks
d) Admit the child to the hospital for a transfusion of packed red
blood cells (20 ml/kg). Transfuse again until the hemoglobin is over 9 g/dl
e) No laboratory tests or medicine are needed at this time. Add meats
to the child’s diet
The Correct answer is C

Explanation
This child has a history that is typical of iron deficiency anemia.
Large amounts of cow’s milk intake, as seen with this child, often
result in chronic blood loss in the stool. While iron is absorbed very
well from breast milk, feeding of other foods will decrease this
absorption. Whole milk does not have adequate amounts of iron. Babies
should continue an iron containing formula until 12 months of age.
Following the initiation of oral iron, the reticulocyte count will begin
to rise in about 10 days and the hemoglobin will be markedly improved by
4 weeks. If these responses are not seen, other diagnoses or compliance
problems must be considered. A low serum ferritin demonstrates poor body
iron stores.

A. This child requires oral iron immediately.


B. While lead poisoning often coexists with iron deficiency, the home
does not need to be checked at this time.
D. Children who have no cardiorespiratory symptoms do not require
transfusion.
E. Dietary changes are not adequate treatment for this degree of anemia.

The presence of nonthrombocytopenic palpable purpura, colicky abdominal


pain, and arthritis is most consistent with which one of the following?

a) Kawasaki disease
b) Takayasu arteritis
c) Wegener granulomatosis
d) Polyarteritis nodosa
e) Henoch-Schönlein purpura
The Correct answer is E

Explanation
The most common pediatric vasculitis is Henoch-Schönlein purpura. It is
an IgA-mediated small-vessel vasculitis that classically presents with
the triad of nonthrombocytopenic palpable purpura, colicky abdominal
pain, and arthritis.

Kawasaki disease is manifested by conjunctival injection, mucosal


erythema, rash, and lymphadenopathy. Takayasu arteritis has numerous
manifestations, including night sweats, fatigue, weight loss, myalgia,
and arthritis. Later findings may include hypertension, skin lesions,
and cardiac disorders. Wegener granulomatosis causes constitutional
symptoms also, including weight loss and fatigue, with later findings
including respiratory problems, ophthalmologic lesions, neuropathies,
glomerulonephritis, and skin lesions.

Polyarteritis nodosa is another disease that causes constitutional


symptoms such as fatigue, fever, and myalgias. It also causes skin
lesions, gastrointestinal symptoms such as postprandial abdominal pain,
and cardiac lesions.
A 5 year old girl is admitted to the Children's Hospital after
swallowing an undisclosed number of her mother's ASA (aspirin) tablets.
She is hypotensive, flushed and tachypneic. Which of the following
acid-base disturbances would be most likely?

a) pH low; HCO3 low; pCO2 low


b) pH normal ; HCO3 high; pCO2 low
c) pH low; HCO3 low; pCO2 high
d) pH low; HCO3 high; pCO2 low
e) pH high; HCO3 high; pCO2 high
The Correct answer is A

Explanation
Salicylate poisoning can cause vomiting, tinnitus, confusion,
hyperthermia, respiratory alkalosis, metabolic acidosis, and multiple
organ failure. Diagnosis is clinical, supplemented by measurement of the
anion gap, ABGs, and serum salicylate levels. Treatment is with
activated charcoal and alkaline diuresis or hemodialysis.

ABGs suggest primary respiratory alkalosis during the 1st few hours
after ingestion, later, they suggest compensated metabolic acidosis.

ASA toxicity in children leads to high anion gap metabolic acidosis and
compensatory respiratory alkalosis (due to tachypnea). Therefore, the pH
will be low or normal (due to compensation). The HCO3 will be low (due
to metabolic acidosis) and the pCO2 will be low (due to respiratory
compensation).
During a health maintenance examination, a 14 year old black male is
noted to have asymmetric breast enlargement with mild tenderness. The
remainder of the physical examination is normal. The most appropriate
management in this case is to

a) Reassure the patient and have him return in 6 months


b) Order a chest radiograph
c) Order serum estrogen and testosterone levels
d) Order chromosomal studies
e) Arrange for a biopsy
The Correct answer is A

Explanation
Some gynecomastia occurs in 30%-50% of pubertal males. It typically
appears between 12 and 15 years of age, at Tanner stages 2 and 3.
Physiologic gynecomastia is usually mild and may be either unilateral or
bilateral. Breast tenderness is common and also mild. The enlargement
typically regresses within a few months to 2 years.
Serum hormone levels are the same as in boys without gynecomastia,
although the ratio of testosterone to estrogen is lower than in males at
similar stages without the condition. There is no indication for
chromosomal investigation or radiography. A biopsy should be considered
only if the condition persists beyond mid-puberty.

A 13 year old boy states that he is growing breasts and that they hurt.
He has been growing taller this past year. He has no other complaints.
On physical examination you note some acne on his face, his testes and
phallus are appropriate for age, and he has fine sparse pubic hair.
Which one of the following is the most likely diagnosis’

a) Normal puberty
b) Klinefelter's syndrome
c) Pituitary tumor
d) Adrenal tumor
e) Gonadal tumor
The Correct answer is A

Explanation
Normal puberty is a period in a boy's life between the ages of 13-18
(may occur as early as 8) in which his body starts to grow and mature.
These changes are the result of chemicals known as hormones. In boys
undergoing puberty, testosterone is the hormone that is responsible for
the changes that will transform them physically and psychologically into
an adult male.

Body changes include: growing taller, growing body hair, growing broader
shoulders, muscles grow bigger and stronger, the hands and feet grow
larger, the ears enlarge, pimples or zits (acne) may develop, the voice
changes and becomes deeper.

In addition penis size increases, enlargement of the testicles (may even


be sensitive), temporarily enlarged and painful breasts and experiencing
more erections.
In Canada the most common form of child abuse is

a) physical abuse
b) emotional abuse
c) sexual abuse
d) child neglect The Correct answer is D

Explanation
Neglect is the most common form of child abuse (60% of cases) and is the
most common cause of death in abused children. It is defined by the
Office on Child Abuse and Neglect as failure to provide for a child’s
basic physical, emotional, educational/cognitive, or medical needs.
The Correct answer is D

Explanation
Neglect is the most common form of child abuse (60% of cases) and is the
most common cause of death in abused children. It is defined by the
Office on Child Abuse and Neglect as failure to provide for a child’s
basic physical, emotional, educational/cognitive, or medical needs.
Organic causes in the differential diagnosis of recurrent abdominal pain
include:

a) UTI
b) Lactose intolerance
c) Chronic giardiasis
d) Inflammatory bowel disease
e) All of the above
The Correct answer is E

Explanation
Recurrent abdominal pain (RAP) is common in children especially in
pre-school children and adolescents. Recurrent abdominal pain is an
expression of physiological maladjustments in response to family or
school problems in predisposed children. Contrary to this belief, many
studies have found organic causes of RAP to be more common. The
occurrence of nocturnal pain is considered an important indicator of an
organic (disease-based). Night pain or pain on awakening suggests a
peptic origin, while pain that occurs in the evening or during dinner is
a feature of constipation.

Organic causes include (but are not limited to) gastrointestinal


disease, urinary tract infections, parasite infestation and
esophagitis/gastritis.

You see a 16-year-old white female for a preparticipation evaluation for


volleyball. She is 183 cm (72 in) tall, and her arm span is greater than
her height. She wears contacts for myopia.

Which one of the following should be performed at this time?

a) An EKG
b) Echocardiography
c) A stress test
d) A chest radiograph
e) Coronary MRI angiography
The Correct answer is B

Explanation
Marfan’s syndrome is an autosomal dominant disease manifested by
skeletal, ophthalmologic, and cardiovascular abnormalities. Men taller
than 72 in and women taller than 70 in who have two or more
manifestations of Marfan’s disease should be screened by
echocardiography for associated cardiac abnormalities.

Any of these athletes who have a family history of Marfan’s syndrome


should be screened, whether they have manifestations themselves or not.
If there is no family history, echocardiography should be performed if
two or more of the following are present: cardiac murmurs or clicks,
kyphoscoliosis, anterior thoracic deformity, arm span greater than
height, upper to lower body ratio more than 1 standard deviation below
the mean, myopia, or an ectopic lens.

Patients with Marfan’s syndrome who have echocardiographic evidence of


aortic abnormalities should be placed on ß-blockers and monitored with
echocardiography every 6 months.
A 12 year old child presents to the ER after he was bitten on his leg by
a street dog.

The dog bite was unprovoked and the dog ran away. His wound was cleaned
with soap and water then debrided carefully. The patient is not allergic
to any mediations and his past medical history is unremarkable.
Amoxicillin/clavulanate is prescribed and tetanus prophylaxis is provided.

Which of the following is the most appropriate next step in management


of this patient?

a) Rabies Immunoglobulins now


b) Rabies Vaccine and Immunoglobulins now
c) Rabies Vaccine now
d) Reassurance
e) Wait for 10 days and then decide
The Correct answer is B

Explanation
The protocol of rabies prophylaxis is very important please know it!

Post exposure rabies prophylaxis always consists of both active and


passive immunization (so you can exclude answers 1 and 3 at a glance).

-If an attempt to capture the dog fails, the dog is assumed rabid and
post exposure prophylaxis is indicated immediately.

- If the dog is available and it does not show any features of rabies,
it should be observed for 10 days for the development of rabies. If it
shows features of rabies, it should be killed and its brain examined by
fluorescent microscopy for the presence of ?Negri bodies’.

-If the dog seems to be rabid from the beginning, it is killed


immediately and its head is sent for examination and if rabies is
confirmed, post exposure prophylaxis is given to the patient.

Tetanus and Rabies prophylaxis protocols are important! Review them


thoroughly and remember that the licensing examiners are concerned about
clinical decisions that have high impact on a patient’s life!
A 32 weeks gestation infant is born with a birth weight of 1000 grams (<
3rd percentile). At birth the infant required no resuscitation but has
quickly developed tachypnea and cyanosis on room air. How would you
classify this infant according to gestational age and measurement
parameters’

a) Adequate for Gestational Age


b) Small for Gestational Age
c) Large for Gestational Age
d) Full term
The Correct answer is B

Explanation
Small for gestational age (SGA) is a term used to describe a baby who is
smaller than the usual amount for the number of weeks of pregnancy. SGA
babies usually have birth weights below the 10th percentile for babies
of the same gestational age. This means that they are smaller than 90
percent of all other babies of the same gestational age.

SGA babies may appear physically and neurologically mature but are
smaller than other babies of the same gestational age. SGA babies may be
proportionately small (equally small all over) or they may be of normal
length and size but have lower weight and body mass. SGA babies may be
premature (born before 37 weeks of pregnancy), full term (37 to 41
weeks), or post term (after 42 weeks of pregnancy).
A 16-year-old male comes to your office after suffering an eversion
injury to his ankle while being tackled in a football game 3 days ago.
He was not able to bear weight after the injury and now has tenderness
at the distal tibiofibular joint with no swelling. Compression of the
fibula against the tibia at the mid-calf elicits pain anterior to the
lateral malleolus and proximal to the ankle joint. Stabilizing the leg
and rotating the foot externally elicits pain at the same location.
Radiographs are negative.

Which one of the following would be most appropriate at this point?

a) Application of an elastic wrap to the ankle for 2 weeks


b) Therapeutic ultrasound
c) Stress radiographs
d) A CT scan
e) Long-term semirigid support
The Correct answer is E

Explanation
Syndesmotic (high ankle) sprains account for as many as 11% of ankle
sprains. The mechanism of injury is dorsiflexion and/or eversion of the
ankle, most commonly in contact sports. The syndesmotic structures
include the anterior, posterior, and transverse tibiofibular ligaments,
as well as the interosseous membrane. These injuries can cause chronic
ankle instability, resulting in recurrent sprains and hypertrophic
ossification.

The diagnosis can be made by several tests. The squeeze test can be
performed by compressing the fibula against the tibia at mid-calf. A
positive test occurs when this elicits pain in the region of the
anterior tibiofibular ligament. A positive external rotation stress test
causes pain at the same site. It is performed by stabilizing the leg and
externally rotating the foot. The crossed-leg test can also detect this
injury. The patient places the involved ankle on the opposite knee and
pressure is applied to the medial side of the involved ankle, which
causes pain at the syndesmosis.

While ankle support is often useful for less serious sprains, a Cochrane
review showed that semirigid supports are better than elastic bandages.
Therapeutic ultrasound has not been shown to have any value for ankle
sprains. The injury can be confirmed with an MRI. Indications for
referral to an orthopedic surgeon include fracture, dislocation or
subluxation, syndesmotic injury, tendon rupture, and uncertain diagnosis.
The disappearance of a ventricular septal defect (VSD) murmur in a
patient known to have a large left-to-right shunt is most likely due to

a) Development of aortic stenosis


b) Closure of ventricular septal defect (VSD)
c) Increase in the left-to-right shunt
d) Development of pulmonary stenosis
e) Development of significant pulmonary arterial hypertension
The Correct answer is E

Explanation
A ventricular septal defect is one or more openings in the
interventricular septum, producing a shunt between ventricles. Large
defects result in a significant left-to-right shunt and produce dyspnea
with feeding and poor growth. A loud, harsh, holosystolic murmur at the
lower left sternal border is common. Recurrent respiratory infections
and heart failure may develop. Diagnosis is by echocardiography. Defects
may close spontaneously during infancy or require surgical repair.
Endocarditis prophylaxis is recommended.

Eisenmenger's syndrome or Eisenmenger's reaction is defined as the


process in which a left-to-right shunt in the heart causes increased
flow through the pulmonary vasculature, causing pulmonary hypertension,
which in turn, causes increased pressures in the right side of the heart
and reversal of the shunt into a right-to-left shunt.
What is the condition most commonly mistaken for appendicitis in children?

a) Mesenteric lymphadenitis
b) Meckels diverticulum
c) Intussussception
d) Constipation
The Correct answer is A

Explanation
Mesenteric lymphadenitis is an inflammation of the lymph nodes on the
wall of the mesentery (the covering of the intestines). It is often a
childhood illness, though occasionally seen in adults. It is a very
common cause of abdominal pain in children, mimicking appendicitis, and
often difficult to differentiate from appendicitis. It is estimated that
1 in 5 children diagnosed with appendicitis actually have mesenteric
lymphadenitis.

The main symptom is abdominal pain. This is often located in the right
lower abdomen or right iliac fossa. It is a colicky abdominal pain which
just resolves momentarily without any intervention. The sufferer,
usually a child, may be completely pain free between attacks.
Characteristically, the pain moves from one spot to the other on the
abdomen, in keeping with the movement of the bowel loops in the
abdominal cavity.

Asking the child to turn to the left side will demonstrate this shift as
the area of pain and tenderness will move along with the bowel to the left.

In appendicitis, the pain may initially start around the umbilicus, then
moves over to the right iliac fossa. Once it settles there, it does not
move around any longer.
A 5-year-old boy develops the acute onset of testicular pain. There is
no fever or history of trauma. You are considering both testicular
torsion and orchitis. Which of the following is false?

a) The pain of orchitis is relieved by gently elevating the testicle


b) Orchitis is more common in childhood than torsion
c) Irreversible damage may occur as a result of testicular torsion
d) When orchitis is diagnosed, antibiotics are normally unnecessary
e) The incidence of orchitis has diminished since the introduction of
the measles/mumps/rubella (MMR) vaccine
The Correct answer is B

Explanation
Torsion is much more common than orchitis in childhood and this should
be kept in mind when considering the diagnosis of testicular pain.

A. Elevation of the testicle results in pain relief.


C. Only a few hours remain for intervention before irreversible damage
occurs.
D. Orchitis is caused by viral infections, which would not respond to
antibiotic treatment.
E. As mumps is a primary cause of orchitis, the widespread use of this
vaccine has decreased the number of cases of orchitis.
Which of the following problems is most likely to occur in a 12 month
old infant who began taking whole cow milk at 6 months of age

a) Increased frequency of otitis media


b) Wheezing episodes
c) Nasal congestion
d) Decreased serum ferritin level
e) Diaper dermatitis
The Correct answer is D

Explanation
Infants who drink cow's milk in the first year of life are at risk for
iron deficiency anemia. Cow's milk is the most common dietary cause of
iron deficiency in infants. Iron deficiency is the most common cause of
anemia and usually results from blood loss. Symptoms are usually
nonspecific. RBCs tend to be microcytic and hypochromic, and iron stores
are low as shown by low serum ferritin and low serum iron with high
serum transferrin. If the diagnosis is made, occult blood loss is
suspected. Treatment involves iron replacement and treatment of blood loss.
A 9 year old boy is brought to the pediatric clinic by his mother, who
noticed that the left side of his mouth has started to droop over the
past several days. In addition, he is unable to close his left eye
completely and complains of it burning. Review of systems reveals a cold
approximately two weeks ago and recent decreased taste sensation. There
is left eye ptosis and mild erythema of the left conjunctiva. His smile
is asymmetrical on the left. Which of the following infections is most
closely associated with this patient's condition?

a) Epstein-Barr Virus
b) Group A Streptococcus
c) Human Immunodeficiency Virus
d) Influenza
e) Measles
The Correct answer is A

Explanation
This patient has Bell palsy, a postinfectious allergic or immune
demyelinating facial neuritis. Epstein-Barr virus is the preceding
infection in approximately 20% of cases. 85% of patients have their
symptoms resolve on their own over a period of several weeks. 10% retain
mild facial weakness and 5% have permanent severe facial weakness.
Therapeutic intervention should include daily and nocturnal eye
lubricants to protect the cornea from drying.

Group A Streptococcus, HIV, and influenza are not associated with Bell
palsy. However, herpes simplex virus, Lyme disease caused by Borrelia
burgdorferi and mumps have been associated with Bell palsy. Measles is
associated with subacute sclerosing panencephalitis, a chronic
encephalitis of the central nervous system manifested by progressively
bizarre behavior and decline in cognitive function.
You see a 9-month-old male with a 1-day history of cough and wheezing.
He has previously been healthy and was born after an uncomplicated term
pregnancy. He is up to date on his immunizations. On examination his
temperature is 38.6°C (101.5°F) and his respiratory rate is 30/min. He
has diffuse wheezing and his oxygen saturation on room air is 94%.
Because it is midwinter, you obtain a swab for influenza, which is
negative. A chest radiograph shows peribronchiolar edema.

Appropriate management would include which one of the following?

a) Supportive care only


b) Inhaled corticosteroids
c) Ribavirin (Rebetol)
d) Palivizumab (Synagis)
e) Supplemental oxygen
The Correct answer is A

Explanation
This child has a respiratory syncytial virus (RSV) infection. Supportive
care is the mainstay of therapy. If the child can take in fluids by
mouth and tolerate room air, outpatient management with close physician
contact as needed is reasonable, especially in the absence of
significant underlying risk factors.
Routine use of corticosteroids is not recommended (SOR B). Although up
to 60% of infants hospitalized for bronchiolitis receive corticosteroid
therapy, studies have not provided sufficient evidence to support their
use. Inhaled corticosteroids have not been shown to be beneficial, and
the safety of high doses in infants is unclear. Supplemental oxygen
should be administered if functional oxygen saturation (SpO )
persistently falls below 90% and can be discontinued when an adequate
level returns (SOR C).

Antiviral therapy for RSV bronchiolitis is controversial because of its


marginal benefit, cumbersome delivery, potential risk to caregivers, and
high cost (SOR B). Studies of ribavirin in patients with bronchiolitis
have produced inconsistent findings.

Palivizumab is a preventive measure, and is not used for treatment of


the active disease. It may be considered in select infants and children
with prematurity, chronic lung disease of prematurity, or congenital
heart disease (SOR A). If used, it should be administered
intramuscularly in five monthly doses of 15 mg/kg, usually beginning in
November or December (SOR C).

Which vitamin deficiency is most likely in a child who is fed a strict


vegetarian diet which excludes meat, eggs, and dairy products’

a) Vitamin A
b) Vitamin B1
c) Vitamin B12
d) Vitamin C
The Correct answer is C

Explanation
There is no known vegetable source for vitamin B12. If the diet contains
milk and eggs, however, the requirement will be satisfied. Vitamin C is
present in high concentrations in fruits and vegetables. Vitamin A is
found in green, leafy vegetables. Thiamine is present in grains,
especially the outer coatings.
Which of the following statements about cancer is true?

a) Cancer is the second most common cause of death in children


b) Hodgkin's lymphoma is the most common childhood cancer
c) Hyperploidy in leukemic cells is a poor prognostic indicator
d) Wilm's tumor is rarely associated with other congenital abnormalities
e) Neuroblastomas usually occur in late adolescence
The Correct answer is A

Explanation This table illustrates the top three most common causes
of death based on age group:
Therefore, for children under the age of 14, the second most common
cause of mortality is cancer.

A 9 month old male is seen for a routine well-baby examination. There


have been no health problems and developmental milestones are normal.
Review of the growth chart shows that length, weight, and head
circumference have continued to remain at the 75th percentile. The
examination is normal with the exception of the anterior fontanelle
being closed. Proper management at this time would include

a) A CT scan of the head


b) MRI of the head
c) A CBC, a metabolic profile, and thyroid studies
d) Referral to a neurologist
e) Serial measurement of head circumference
The Correct answer is E

Explanation
The anterior fontanelle in the newborn is normally 0.6-3.6 cm, with the
mean size being 2.1 cm. It may actually enlarge the first few months,
but the medial age of closure is 13.8 months. The anterior fontanelle
closes at 3 months in 1% of cases, and by 1 year, 38% are closed.

While early closure of the anterior fontanelle may be normal, the head
circumference must be carefully monitored. The patient needs to be
monitored for craniosynostosis (premature closure of one of more
sutures) and for abnormal brain development. When craniosynostosis is
suspected, a skull radiograph is useful for initial evaluation. If
craniosynostosis is seen on the film, a CT scan should be obtained.
A 12 month old girl is brought to the emergency department for the
second time in 2 days for vomiting and passage of 8 to 10 watery stools
per day. The patient has lost 0.6 kg. She is moderately lethargic and
has dry mucous membranes and reduced skin turgor. Blood pressure is
80/40 mm Hg, and pulse is 120 per minute; capillary refill is reasonably
brisk. Lab studies reveal: sodium 131, potassium 4.8, chloride 101,
bicarbonate 16 mEq/L, urea nitrogen 24 mg/dL and creatinine 0.6 mg/dL.
The best strategy for managing this child is to

a) Hospitalize for administration of IV fluid therapy


b) Administer an oral rehydrating solution while the child is under
medical supervision for 4-6 hours
c) Instruct the parents about oral rehydration at home
d) Hospitalize after giving 20 mL/kg of 0.9% saline IV
e) Instruct parents on use of soy formula
The Correct answer is A
Explanation
Dehydration is significant depletion of body water and, to varying
degrees, electrolytes. Symptoms and signs include thirst, lethargy, dry
mucosa, decreased urine output, and, as the degree of dehydration
progresses, tachycardia, hypotension, and shock. Diagnosis is based on
history and physical examination.

Treatment is best approached by considering separately the fluid


resuscitation requirements, current deficit, ongoing losses, and
maintenance requirements. The volume (eg, amount of fluid), composition,
and rate of replacement differ for each. Formulas and estimates used to
determine treatment parameters provide a starting place, but treatment
requires ongoing monitoring of vital signs, clinical appearance, urine
output and specific gravity, weight, and sometimes serum electrolyte
levels.

Children with severe dehydration (eg, evidence of circulatory


compromise) should receive fluids IV. Those unable or unwilling to drink
or who have repetitive vomiting can receive fluid replacement IV,
through an NGT, or sometimes orally through frequently repeated small
amounts.
An 8-year-old female with a history of reactive airway disease presents
to your office for evaluation. She states that she uses her inhaled
beta2agonist 4-5 times a week. She takes no other medications. She was
hospitalized once last winter for an asthma exacerbation, but has been
well since. She has some limitations in her exercise tolerance secondary
to shortness of breath. She denies any pets at home and there is no
tobacco exposure. Which of the following medications should be added to
her current regimen?

a) Antihistamine
b) Cromolyn sodium
c) Theophylline
d) Inhaled steroid
e) Daily prednisone
The Correct answer is D

Explanation
This patient has mild persistent asthma and is requiring use of her
rescue beta2-agonist more than twice a week. An inhaled low dose steroid
is the first line of therapy in controlling her symptoms.

A. There is nothing in the history provided that describes allergic


symptoms that would be better controlled with an antihistamine.
B. Cromolyn sodium is sometimes used in addition to beta2-agonists, but
inhaled steroids are first line therapy.
C. Theophylline is no longer preferred therapy because of side effects
and drug levels that need to be followed.
E. Daily prednisone is used only in severe persistent asthmatics that
are on maximum therapy and still having symptoms.
Regarding sexual abuse of children, each of the following statements is
true, except
a) No genital injury is found in the majority of patients
b) Father-daughter incest is more common than brother-sister
c) Most assailants are unknown to the victim
d) Laboratory findings usually show no presence of sperm
e) Half of the abused children come from single parent families
The Correct answer is C

Explanation
Child victims of sexual abuse may present with physical findings that
can include anogenital problems, enuresis or encopresis. Behavioral
changes may involve sexual acting out, aggression, depression, eating
disturbances and regression. Because the examination findings of most
child victims of sexual abuse are within normal limits or are
nonspecific, the child's statements are extremely important. In most
cases, the adult is known to the child and may be a family member,
stepparent, or a person with authority (eg, a teacher).

The child's history as obtained by the physician may be admitted as


evidence in court trials; therefore, complete documentation of questions
and answers is critical. A careful history should be obtained and a
thorough physical examination should be performed with documentation of
all findings. When examining the child's genitalia, it is important that
the physician be familiar with normal variants, nonspecific changes and
diagnostic signs of sexual abuse. Judicious use of laboratory tests,
along with appropriate therapy, should be individually tailored.
Forensic evidence collection is indicated in certain cases.

A child, 1-2 years old, should have all of the following foods, *except*

a) Low-fat milk
b) Rice and pasta
c) Cheese
d) Bananas and peaches
e) Eggs
The Correct answer is A

Explanation
After a baby is 1 year old, whole milk may replace breast milk or
formula. Children under the age of 2 should not be given low-fat milk
(2%, 1%, or skim) as they need the additional calories from fat to
ensure proper growth and development.

Children under the age of 1 should not be given whole milk as it has
been shown to cause low blood counts. Cheese, cottage cheese, and
yogurt, however, may be given in small amounts. The 1 year old child
should be getting much of their nutrition from meats, fruits and
vegetables, breads and grains, and the dairy group, especially whole milk.

Providing a variety of foods will help to ensure enough vitamins and


minerals. Toddlers do not grow as rapidly as babies do, so their
nutritional needs relative to their size decrease during the second year
of life. Although they continue to gain weight, they no longer double
their weight as infants do.
A mother brings in her 2-month-old infant for a routine checkup. The
baby is exclusively breastfed, and the mother has no concerns or
questions. Which one of the following would you recommend at this time
in addition to continued breastfeeding?

a) Iron supplementation
b) Vitamin D supplementation
c) A multivitamin
d) 8 oz of water daily
e) 4 oz of cereal daily
The Correct answer is B

Explanation
Although breast milk is the ideal source of nutrition for healthy term
infants, supplementation with 200 IU/day of vitamin D is recommended
beginning at 2 months of age and continuing until the child is consuming
at least 500 mL/day of formula or milk containing vitamin D (SOR B). The
purpose of supplementation is to prevent rickets. Unless the baby is
anemic or has other deficiencies, neither iron nor a multivitamin is
necessary. Parents often mistakenly think babies need additional water,
which can be harmful because it decreases milk intake and can cause
electrolyte disturbances. Cereal should not be started until 4 months of
age.
Which of the following is not part of the normal developmental
milestones for a 24 month old child?

a) Builds tower of four blocks or more


b) Begins to run
c) Scribbles spontaneously
d) Begins to copy some capital letters
The Correct answer is D

Explanation
Choices a), b) and c) are part of the developmental milestones up to the
age of 2. Choice d) is part of the developmental milestones by the end
of 4 years.

A 3 year old girl presents with a 2 month history of low-grade fever,


cough, anorexia, and weight loss. A chest x-ray reveals a right-sided
pleural effusion. Which one of the following tests is most likely to
confirm the diagnosis of tuberculosis if a previous culture was negative?

a) Re-culture sputum
b) Pleural tap for cell morphology and acid-fast bacilli
c) Blood culture
d) Computed tomography scan of chest
e) Sedimentation rate
The Correct answer is B

Explanation
In patients with pleural effusion, the diagnosis of TB was made by
detection of acid-fast bacilli by stain or by culture of mycobacteria in
pleural fluid or pleural tissue (obtained by closed biopsy) or by the
presence of caseating granulomas in histological sections.
For several months you have been evaluating a 2 1/2 year old male whose
parents have numerous concerns. The patient has extreme difficulty
mixing with other children, preferring to be alone. He is quite aloof
around others, gesturing or pointing instead of using words. He also
throws extreme tantrums for no apparent reason. The child does not
respond to regular verbal cues and often simply ignores others when
spoken to. His vocabulary is less than 10 words and he has never put two
words together. Hearing screening tests and an EEG are normal.

Which one of the following is true regarding this patient’s disorder?

a) Pathologic parenting is most likely responsible for this etiology


b) Immunizations, particularly MMR, may precipitate the disorder
c) Biologic markers are useful for making the diagnosis
d) The development of specific impairments is varied and unpredictable
e) Behavioral modification programs are not helpful
The Correct answer is D

Explanation
Autism is a pervasive condition affecting 7 out of 10,000 persons.
Defined behaviorally as a syndrome consisting of abnormal development of
social skills, sensorimotor deficits, and limitations in the use of
interactive language, it is characterized by variable development,
resulting in good skills in some areas and poor skills in others. No
single cause has been linked to the development of autism. Studies have
failed to show an association between any vaccine and the disorder. To
date, no biologic markers are available to aid in the identification of
patients with autism. Successful programs in the treatment of autism
include behavioral modification strategies as well as programs
emphasizing the development of social communication and early, active,
and consistent family participation.
Which one of the following is the most common cause of hypertension in
children under 6 years of age?

a) Essential hypertension
b) Pheochromocytoma
c) Renal parenchymal disease
d) Hyperthyroidism
e) Excessive caffeine use
The Correct answer is C

Explanation
Although essential hypertension is most common in adolescents and
adults, it is rarely found in children less than 10 years old and should
be a diagnosis of exclusion. The most common cause of hypertension is
renal parenchymal disease, and a urinalysis, urine culture, and renal
ultrasonography should be ordered for all children presenting with
hypertension. Other secondary causes, such as pheochromocytoma,
hyperthyroidism, and excessive caffeine use, are less common, and
further testing and/or investigation should be ordered as clinically
indicated.
A teenage girl comes to see you for a routine check up. You find 3+
protein in her urine. There is no blood or casts. Nor does she have any
physical abnormality. What is the appropriate next step?

a) Reassurance and follow up after 2 months


b) IVP
c) Renal ultrasound
d) 24 hour urine collection for protein
e) BUN, creatinine, electrolytes.
The Correct answer is D

Explanation
In any child with a positive dipstick result greater than trace for
protein, a quantitative estimate of proteinuria should be determined. In
older children and adolescents, a 24-hour collection may be performed.
The usual rate of excretion of protein is somewhat higher in children
than in adults, perhaps as much as 200 mg/d in older children.

The dipstick test for protein provides a crude semiquantitative


estimation of protein concentration, with results as follows:
Trace = 5-20 mg/dL
1+ = 30 mg/dL
2+ = 100 mg/dL
3+ = 300 mg/dL
4+ = Greater than 2000 mg/dL

The detection of persistent proteinuria (>1+ or protein-to-creatinine


ratio of >0.2) in an apparently well child is a signal for potentially
serious underlying kidney disease.

The next step in the evaluation includes complete history and physical
examination (emphasizing blood pressure measurement and evaluation for
edema, rashes, and assessment of growth status); quantitative urine
protein excretion (protein-to-creatinine ratio of a first-morning
urine); examination of the urine sediment for dysmorphic erythrocytes or
casts; determination of blood concentrations of BUN, creatinine,
electrolytes, albumin, cholesterol, complement, antistreptococcal
antibody, antinuclear antibody (ANA), and anti-DNA; and tests for
hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) infection.

More info:
Proteinuria is protein, usually albumin, in urine. In many renal
disorders, it occurs with other urinary abnormalities (eg, hematuria).
Isolated proteinuria is urinary protein without other symptoms or
abnormalities. Causes may be categorized as glomerular, tubular,
overflow, or physiologic. Exercise proteinuria, sometimes with
hematuria, hemoglobinuria, or myoglobinuria, is proteinuria of unknown
cause that may occur in runners, boxers, and other people engaged in
vigorous exercise.
Proteinuria may be transient, orthostatic (occurring only when upright
and almost always between adolescence and age 30), or persistent. Most
patients with physiologic causes (and many with acute tubulointerstitial
disorders) have transient proteinuria; those with transient or
orthostatic proteinuria usually excrete < 1 g protein/day with no
deterioration of renal function, and the proteinuria resolves spontaneously.
An 18-month-old boy is brought to the emergency room by his parents. He
has been wheezing since this morning. He had a runny nose and fever 2
days prior to this visit, which have resolved. There is no family
history of asthma. On exam, the child appears active and in no acute
distress. You notice nasal flaring and there is wheezing in the right
lung fields. A chest x-ray reveals hyperinflation of the right lung and
there is no infiltrate. The most appropriate next step in management is:

a) Reassurance and home treatment with a beta agonist via small volume
nebulizer
b) Initiate oral prednisone treatment for a 5-day course
c) Immediate chest tube placement
d) Bronchoscopy
e) Treatment with racemic epinephrine via small volume nebulizer
The Correct answer is D

Explanation
This toddler has a foreign body aspiration, as suggested by his lung and
CXR findings. A foreign body should always be considered in the
differential of a wheezing toddler. Management includes removal under
direct visualization by rigid bronchoscopy.

A. Beta agonist therapy is appropriate for the management of asthma.


B. Steroid therapy is used for the management of asthma exacerbation and
is not useful in the treatment of a foreign body aspiration.
C. Chest tube placement is indicated for lung collapse, as opposed to
hyperinflation.
E. Racemic epinephrine is used in the treatment of
laryngotracheobronchitis (croup) and is indicated in patients with
stridor at rest.
A 7 year old male with recurrent sinusitis has difficulty breathing
through his nose. He has had chronic diarrhea and his weight is at the
5th percentile. Nasal polyps are noted on examination in the form of
grayish pale masses in both nares. No nasal purulence or odor is
present. Which one of the following tests should you order?

a) A serum angiotensin-converting enzyme level


b) A serum alpha-1-antitrypsin level
c) A serum ceruloplasmin level
d) An erythrocyte sedimentation rate
e) A sweat chloride test
The Correct answer is E

Explanation
This child has chronic diarrhea, recurrent sinusitis, and nasal polyps,
and is underweight. Nasal polyps tend to occur more often in adult
males, with the prevalence increasing in both sexes after age 50. Any
child 12 years or younger who presents with nasal polyps should be
suspected of having cystic fibrosis until proven otherwise. A sweat
chloride test, along with a history and clinical examination, is
necessary to evaluate this possibility. Nasal polyps are found in 1% of
the normal population, but a full 18% of those with cystic fibrosis are
afflicted. There is no association of polyps with Wilson’s disease,
sarcoidosis, or emphysema, so serum ceruloplasmin,
angiotensin-converting, and alpha-1-antitrypsin levels would not be
useful. An erythrocyte sedimentation rate likewise would yield limited
information.
Which one of the following is true regarding urinary tract infections in
febrile infants and young children (age 2-24 months)?

a) A perineal bag should be used to collect urine for cultures


b) A 3 day course of oral antibiotic therapy is appropriate
c) Ultrasonography should be performed after the first febrile UTI
d) Voiding cystourethrography or radionuclide cystography should be
performed only after recurrent UTI
e) Prophylactic antibiotics should be continued for 1 year in all
children after the first febrile UTI
The Correct answer is C

Explanation
There are published clinical guidelines for treating infants and young
children (2-24 months) with a febrile urinary tract infection (UTI).
They recommend ultrasonography in all these children following the first
episode of febrile UTI, as well as either voiding cystourethrography or
radionuclide cystography to rule out vesicourethral reflux (VUR). More
than 50% of these children will have some VUR on these studies, and the
degree of VUR correlates with renal parenchymal damage.

All children should have urine for culture collected by suprapubic


aspiration or urethral catheterization. The perineal bag has
unacceptable rates of contamination, especially in girls and
uncircumcised boys. A 7- to 14-day course of parenteral or oral
antibiotics is recommended, with prophylactic oral antibiotics
recommended until imaging studies are completed.
A 1 month old female is brought to your office for her 1-month visit.
Her mom states that she spits up about one tablespoon of milk-like
material after each feed. It does not come up forcefully and contains no
blood or bile. She takes 2 oz of Enfamil with iron every 2-3 hours. The
spitting up often occurs after she is placed on her back in the crib.
She is at the 25%ile for length, 5%ile for weight, and 25-50%ile for
head circumference. On physical exam, the baby is well-hydrated with
active bowel sounds and no palpable abdominal masses. The most likely
diagnosis is:

a) Pyloric stenosis
b) Volvulus
c) Gastroesophageal reflux
d) Gastroenteritis
e) Trachoesophageal fistula
The Correct answer is C
Explanation
Gastroesophageal reflux is due to an incompetent lower esophageal
sphincter and is worsened by feeding while lying down. Emesis from
reflux is not projectile and does not contain bilious material.
Complications include aspiration, poor weight gain, esophagitis, and
apneic episodes.

A. Pyloric stenosis is four times more common in males, causes


?projectile? emesis, and is associated with a palpable olive-like mass
or visible peristalsis.
B. Emesis in volvulus is generally bilious.
D. Gastroenteritis implies concomitant diarrhea and often fever.
E. The volume of emesis and the association with the baby lying on her
back are more consistent with reflux.
A 9 year old boy is brought to the hospital with a history of having
fallen from his bike. He fainted and is now complaining of abdominal
pain and thirst. There is general abdominal tenderness and rebound
tenderness. Approximately 4 hours after the accident, the white blood
count is 20 x 10^9/L and the hemoglobin is 80 g/L. What is the most
likely diagnosis’

a) Renal contusion
b) Acute pancreatitis
c) Ruptured spleen
d) Retroperitoneal hematoma
e) Ruptured bowel
The Correct answer is C

Explanation
Splenic rupture generally results from blunt abdominal trauma.
Significant impact (eg, motor vehicle collision) can rupture a normal
spleen.

Rupture of the splenic capsule produces marked hemorrhage into the


peritoneal cavity. The manifestations, including hemorrhagic shock,
abdominal pain, and distention, are usually clinically obvious. However,
splenic trauma can also produce a subcapsular hematoma, which may not
rupture until hours or even months after the injury.

Rupture is generally preceded by left upper quadrant abdominal pain.


Splenic rupture should be suspected in patients with blunt abdominal
trauma and hemorrhagic shock or left upper quadrant pain (which
sometimes radiates to the shoulder); patients with unexplained left
upper quadrant pain, particularly if there is evidence of hypovolemia or
shock, should be asked about recent trauma. The diagnosis is confirmed
by CT scan (in the stable patient), ultrasound, or peritoneal lavage (in
the unstable patient).

Treatment has traditionally been splenectomy. However, splenectomy


should be avoided if possible, particularly in children, to avoid the
resulting permanent susceptibility to bacterial infections. In this
case, treatment is transfusion as needed.
A 7 year old male presents with a 3 day history of sore throat,
hoarseness, fever to 100°F (38°C), and cough. Examination reveals
infection of his tonsils, no exudates, and no abnormal breath sounds.
Which one of the following would be most appropriate?

a) Recommend symptomatic treatment


b) Perform a rapid antigen test for streptococcal pharyngitis
c) Treat empirically for streptococcal pharyngitis
d) Perform a throat culture for streptococcal pharyngitis
e) Perform an office test for mononucleosis
The Correct answer is A

Explanation
Pharyngitis is a common complaint, and usually has a viral cause. The
key factors in diagnosing streptococcal pharyngitis are a fever over
100.4°F, tonsillar exudates, anterior cervical lymphadenopathy, and
absence of cough. Age plays a role also, with those <15 years of age
more likely to have streptococcal infection, and those 10-25 years of
age more likely to have mononucleosis. The scenario described is
consistent with a viral infection, with no risk factors to make
streptococcal infection likely; therefore, this patient should be
offered symptomatic treatment for likely viral infection. Testing for
other infections is not indicated unless the patient worsens or does not
improve.
In a day-care center for which you are the medical consultant, two
children develop systemic Haemophilus influenzae type b infections
within the same month. You recommend prophylaxis with which one of the
following for all children and staff in the classroom?

a) Ceftriaxone (Rocephin)
b) Chloramphenicol (Chloromycetin)
c) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
d) Cefaclor (Ceclor)
e) Rifampin (Rifadin)
The Correct answer is E

Explanation
Whereas many antibiotics temporarily suppress nasopharyngeal
colonization by Haemophilus influenzae type b, only rifampin is
effective in eradicating the organism. It should therefore be
administered to all attendees and staff of a day-care facility in which
two or more children have been diagnosed with disease caused by H.
influenzae, regardless of previous immunization status. The patients
should also receive rifampin before returning to the center. Prophylaxis
after a single case is controversial.
Which of the following is false about physiological jaundice?

a) It rarely presents before the age of 24 hours


b) It may cause kernicterus
c) In premature infants it may persist for 3-4 weeks
d) It is mainly due to temporarily impaired hepatic clearance of bilirubin
e) It does not always require treatment with phototherapy
The Correct answer is B
Explanation
Physiological jaundice occurs in approximately 50% of newborns. It’s
onset is on 2 to 3 days of age, with a peak at day 4 to 5, then
improvement with disappearance usually without treatment by 1 to 2 weeks
of age. It almost never causes kernicterus.
A 4 year old boy is brought to the emergency department by his parents
because of a swollen pinna. The father says that the boy fell off his
tricycle in a playground. On physical examination the child's left ear
is severely edematous and discolored. There is concern for the child
because this is his third emergency department visit in the past 6
months. When discussing these concerns and the need for further
evaluation with the parents, they become angry and want to take the
child home now. It would be most appropriate to

a) Arrange for the child to be admitted for evaluation and protection


b) Discharge the child to another relative or neighbor if available
c) Keep the child and initiate foster care placement
d) Send the child home with his parents, but notify the police of the
situation
e) Send the child home and arrange for a social worker to make a family
assessment on a home visit
The Correct answer is A

Explanation
Most states have laws that mandate that a clinician who suspects
physical or sexual abuse must act immediately, separating the child from
the parents if necessary. Discharge to another relative or neighbor will
not prevent the abusing parent from retrieving the child and inflicting
further abuse. Foster care placement can only be applied for after there
is proof of physical abuse. If your suspicions of abuse are high, do not
send the child home with the parents under any circumstances.

Again, sending the child home, even with an impending social work
evaluation, leaves the child open for continued abuse. When angered, the
abusing parent may inflict greater injury after a quiescent phase,
resulting in death of the child. In a possible abuse case, the physician
should take steps to both protect the child and investigate further.
Which one of the following is true concerning scabies’

a) It is typically spread by contact with infected bedding


b) The classic diagnostic sign is the mite burrow
c) The distribution of lesions is the same in adults and children
d) The absence of a history of itching among family members excludes
the diagnosis
e) Recurrence of symptoms after treatment indicates another diagnosis
The Correct answer is B

Explanation
The mite burrow confirms the diagnosis of scabies, but can be missed if
the skin is excoriated. Scabies spreads by direct skin contact, and is
seldom spread by transfer from bedding. Children frequently have scabies
lesions on the face or neck, while this rarely happens in adults.
Scabies infections usually cause itching among several family members,
but they may not admit it. Scabies can recur after treatment, usually
because of incorrect or insufficient application of the treatment.
A 14-year-old female is brought to your office for evaluation because
she has not yet menstruated. An examination reveals no secondary sexual
characteristics. You order FSH and LH levels, and find that both are low.

Which one of the following would be most appropriate at this time?

a) Watchful waiting
b) Karyotype analysis
c) Ultrasonography of the uterus
d) A progestogen challenge test
e) An estrogen/progestogen challenge test
The Correct answer is A

Explanation
Primary amenorrhea is diagnosed if menarche has not occurred by 16 years
of age. Because this patient had no secondary sexual characteristics,
her FSH and LH levels were measured. The fact that both are low
indicates hypogonadotropic hypogonadism. The most common cause for this
situation in girls with primary amenorrhea is constitutional delay of
growth and puberty. A detailed family history might help confirm this
etiology, because it is often familial. Watchful waiting is appropriate
for this problem.

Karyotype analysis would be the next step in diagnosis if FSH and LH


were elevated, indicating hypergonadotropic hypogonadism, which could be
associated with 46,XX and premature ovarian failure, or 45,XO and
Turner’s syndrome. Ultrasonography would be appropriate if secondary
sexual characteristics were present and would identify whether the
uterus is absent or abnormal, and whether an outflow obstruction exists.
The hormone challenge tests are used to evaluate secondary amenorrhea.
A 10 year old boy is brought to the emergency department by his father
because the boy is slightly lethargic and has labored breathing. The
father, who is a single parent, reports that the boy is "always thirsty"
and "urinates a lot." The boy's pulse is 120/min, respirations are
32/min and blood pressure is 110/65 mm Hg. Laboratory studies show:

Na+ 132 mEq/L


K+ 4.1 mEq/L
Cl 92 mEq/L
HCO3 6.6 mEq/L
Glucose 850 mg/dL

The boy is treated with intravenous insulin and isotonic saline


solution. Several hours later, he is improved and his serum glucose
concentration is 450 mg/dL. Which of the following is the most
appropriate next step?

a) Add glucose to this intravenous solution


b) Add potassium to this intravenous solution
c) Add sodium bicarbonate to this intravenous solution
d) Begin treatment with intermediate-acting insulin
The Correct answer is B

Explanation
This boy obviously has diabetes mellitus. Treatment with insulin has
reduced his serum glucose concentration, and there will also have been a
concomitant shift of K+ from the extracellular compartment into the
cells. Unless replaced, this loss will have dire consequences.
Therefore, the most appropriate next step is to add K+ to the
intravenous fluid.
Nontypable /Haemophilus influenzae/ is frequently responsible for

a) Community-acquired pneumonia in adults


b) Epiglottis in older children
c) Meningitis in college students
d) Cellulites in toddlers
e) Septic arthritis in young children
The Correct answer is A

Explanation
Nontypable /Haemophilus influenzae /is a common cause of
community-acquired pneumonia in adults. /Streptococcus pneumoniae/ is
the most common cause. The other syndrome by /H. influenzae/ type B.
Bacterial meningitis in college students is typically caused by
/Neisseria meningitides./
A full term infant with a birth weight of 3.5 kg, length of 50 cm and
head circumference of 35 cm (all at 50th percentile) comes for an office
appointment at 2 weeks of age. The infant is being fed Carnation milk
diluted to 25%. His weight today is identical to birth. Considering the
appropriate nutritional management of infants, select the appropriate
advice to be given to new mothers

a) Avoid feeding newborn infants in the first 12 hours of life in order


to prevent aspiration
b) Breast milk is deficient in iron and iron supplementation is
recommended for breast fed infants
c) Breast milk does not contain enough vitamin D and vitamin D
supplementation is recommended for exclusively breast fed infants
d) Institute solid food at three months of age
e) Breast milk may causes diarrhea if used exclusively, so formula
should be added
The Correct answer is C

Explanation
To recognize abnormal growth, one needs to understand normal growth. The
average birth weight for a term infant is 3.3 kg. Weight drops as much
as 10% in the first few days of life, probably as a result of loss of
excess fluid; however, birth weight should be regained within 2 weeks
after birth. Breastfed infants tend to regain birth weight a little
later than bottle-fed infants.

In breastfed infants and formula-fed infants, the frequency of feeds,


number of wet diapers and stools each day, and a history of sequential
weights allow the physician the ability to gauge if the child is
receiving adequate amounts of fluid and calories and is gaining weight
appropriately.

Breast milk lacks vitamin D and cows milk lacks iron. Babies who don’t
get enough vitamin D are at risk of getting rickets, a disease that
affects the way bones grow and develop. Vitamin D can also help prevent
certain illnesses in childhood or later in life. This can be prevented
by giving a daily supplement (drops) to babies who are at risk.
A 2 year old boy with visible abdominal distention is found to have a
large left-sided flank mass. Which one of the following is the most
likely diagnosis’

a) Renal cell carcinoma


b) Polycystic kidney
c) Transitional cell carcinoma
d) Wilms tumour
e) Hydronephrosis
The Correct answer is D

Explanation
Wilms tumor is an embryonal cancer of the kidney composed of blastemal,
stromal, and epithelial elements. Genetic abnormalities have been
implicated in the pathogenesis, but familial inheritance accounts for
only 1 to 2% of cases.

Wilms' tumor usually presents in children < 5 yr but occasionally in


older children and rarely in adults. Wilms' tumor accounts for about 6%
of cancers in children < 15 yr.

The most frequent presentation is a painless, palpable abdominal mass.


Less frequent findings include abdominal pain, hematuria, fever,
anorexia, nausea, and vomiting.

Diagnosis is made by ultrasound and abdominal CT scan and confirmed by


biopsy. Treatment may include surgical resection, chemotherapy, and
radiation therapy.
A 12 year old boy develops acute pain in his right testicle while
playing hockey. Examination reveals a very tender mass in the right
scrotum with reddening of the overlying skin. Urinalysis reveals 1-3
white blood cells and 0-2 red blood cells per high power field. The most
likely diagnosis is

a) Testicular tumor
b) Acute hydrocele
c) Torsion of testicle
d) Strangulated inguinal hernia
e) Epididymo-orchitis
The Correct answer is C

Explanation
Testicular torsion is an emergency condition due to rotation of the
testis and consequent strangulation of its blood supply. Symptoms are
acute scrotal pain and swelling, nausea, and vomiting. Diagnosis is
based on physical examination and confirmed by color Doppler. Treatment
is immediate manual detorsion followed by surgical intervention.
A 12 year old boy is brought to the clinic because of a several month
history of strange behavior. According to his parents, the boy
occasionally will start staring and not respond. He will also have tears
in his eyes. These episodes last several seconds and he then returns to
his baseline. He has not sustained any head trauma and is on no
medications. Which of the following drugs is the most appropriate
treatment?

a) Diazepam
b) Diphenhydramine
c) Ethosuximide
d) Phenobarbital
e) Phenytoin
The Correct answer is C

Explanation
The patient is having absence or petit mal seizures, and the drug of
choice is ethosuximide or valproic acid. Diazepam is effective in
treating status epilepticus but is not used in treating petit mal
seizures. Diphenhydramine is an antihistamine and would not be of
benefit in treating this illness. Phenobarbital and Phenytoin are
anticonvulsants, but are not used for absence seizures.
A 16-year-old female presents to the emergency room with a fever of
102?F for 1 day, lower abdominal pain, and vaginal discharge. She admits
to having unprotected sexual intercourse with a new male partner in the
last 2 weeks. Her last menses was 1 week ago. She denies dysuria but
complains of dyspareunia. Physical exam reveals bilateral lower
abdominal tenderness, but no peritoneal signs. There is no suprapubic or
costovertebral angle tenderness. On bimanual exam, she has right-sided
adnexal tenderness, an erythematous, friable cervix with thick yellow
discharge, and cervical motion tenderness. Her cervix is normal in size.
A serum HCG is negative, urinalysis is unremarkable and a cervical swab
gram stain reveals gram-negative diplococci. Which of the following is
the most likely diagnosis’

a) Pyelonephritis
b) Appendicitis
c) Ectopic pregnancy
d) Endometriosis
e) Pelvic inflammatory disease (PID)
The Correct answer is E

Explanation
This adolescent has gonococcal pelvic inflammatory disease. She has
evidence of cervicitis with systemic symptoms including fever and
abdominal pain.

A. A normal urinalysis in the absence of dysuria, suprapubic tenderness,


and cervical motion tenderness virtually exludes pyelonephritis.
B. No right lower quadrant pain or peritoneal signs on examination make
this diagnosis unlikely. However, appendicitis should always be
considered in patients with fever and lower abdominal pain.
C. With no adenxal mass and a negative serum HCG, it is an unlikely
diagnosis.
D. Endometriosis causes chronic, intermittent pelvic and/or abdominal
pain, but not fever and vaginal discharge.
Current thinking regarding infantile colic is that the cause is

a) malabsorption
b) overfeeding
c) excessive air swallowing
d) unknown
e) parental anxiety
The Correct answer is D

Explanation
Colic is a frustrating condition for parents and doctors alike. The
parents would like an explanation and relief, and physicians would like
to offer these things. At this time, however, in spite of numerous
studies and theories, the cause of colic remains unknown.
A 6-year-old male is brought to your office with abdominal pain of 6
months’ duration. He has a history of constipation, with passage of
hard, large-caliber stools approximately once a week. Encopresis also is
a problem, with accidental passage of loose stool. His general
examination is negative, but he and his mother refuse to allow a digital
rectal examination. He does have a normal anal wink and cremasteric reflex.

Which one of the following tests would be most appropriate at this time?

a) CT of the abdomen
b) Ultrasonography
c) A barium enema
d) An abdominal plain film
e) Referral for pediatric colonoscopy
The Correct answer is D

Explanation
A child passing infrequent, large-caliber stools, often with fecal
soiling, suggests functional constipation. Encopresis often results from
passage of loose stool around hardened stool in the rectal vault. A
physical examination will sometimes reveal palpable stool in the left
lower quadrant. If possible, a digital rectal examination should be
done. If this isn’t possible, a plain-film abdominal radiograph will
likely reveal a fecal impaction. A CT scan and a barium enema are not as
helpful. Functional constipation can be managed without colonoscopy.

Constipation in children older than 1 year of age is functional in more


than 95% of cases. However, causes of organic constipation include
Hirschsprung’s disease, hypothyroidism, hypercalcemia, hypokalemia,
diabetes mellitus, diabetes insipidus, cystic fibrosis, gluten
enteropathy, spinal cord lesions, neurofibromatosis, heavy metal
poisoning, medication side effects, developmental delay, and sexual abuse.
Which of the following statements about stuttering in a 4 year old is
incorrect

a) It is characterized by intermittent difficulty in producing a smooth


flow of speech
b) It is more than 3 times more frequent in girls than in boys
c) It is exacerbated by anxiety
d) More than 30% of children who stutter recover spontaneously
The Correct answer is B

Explanation
The etiology of stuttering is controversial. The prevailing theories
point to measurable neurophysical dysfunctions that disrupt the precise
timing required to produce speech. Stuttering is a common disorder that
usually resolves by adulthood. Almost 80 percent of children who stutter
recover fluency by the age of 16 years. As with many behavioral
disorders of childhood, stuttering occurs three to four times more often
in boys than in girls. Mild stuttering is self-limited, but more severe
stuttering requires speech therapy, which is the mainstay of treatment.
Delayed auditory feedback and computer-assisted training are currently
used to help slow down speech and control other speech mechanisms.
Pharmacologic therapy is seldom used, although haloperidol has been
somewhat effective.
The mother of a 4-month-old child is concerned about an upcoming camping
trip and mosquito exposure because of a recent West Nile virus case in
their country. She asks if she can use DEET (N, N diethyl-m-toluamide)
on her child.

Which one of the following would be the most appropriate advice?

a) DEET is not considered safe in children less than 1 year of age


b) DEET is not considered safe for anyone less than 18 months of age
c) DEET at a concentration of 10%-30% is safe for children over 2
months of age
d) DEET at a 50% concentration is more effective than a 30% concentration
The Correct answer is C

Explanation
DEET is safe to use in children over 2 months of age and is associated
with a very rare incidence of major adverse effects (strength of
recommendation C). Concentrations between 10% and 30% prolong the
duration of action. At 30% the efficacy plateaus. Use of DEET at
concentrations above 50% is neither more efficacious nor recommended.
A couple had a child who died from Sudden infant death syndrome (SIDS).
They want to know what they can do to prevent it for their next child.
The most appropriate advice is

a) No smoking in the home


b) Don't put the baby supine (on back) while sleeping
c) Setting an alarm for the baby
d) Put baby to sleep on tummy
e) Wrap infant in warm clothing during winter
The Correct answer is A

Explanation
Sudden infant death syndrome (SIDS) is the sudden and unexpected death
of an infant or young child between 2 weeks and 1 year of age in which a
thorough postmortem examination fails to show cause.

The prevention involves infants be placed supine (on back) for sleep.
The incidence of SIDS increases with overheating (clothing, blankets,
hot room) and in cold weather. Thus, every effort should be made to
avoid an overheated or an overly cold environment, to avoid overwrapping
the infant, and to remove soft bedding, such as sheepskin, pillows,
stuffed toys/animals, and comforters, from the crib. Mothers should
avoid smoking during pregnancy, and infants should not be exposed to smoke.
A 9 year old boy who had been suffering from a gait disturbance for
several weeks was found to have a posterior fossa mass on CT scan. Which
of the following is the most likely cause for these findings’

a) A berry aneurysm
b) Astrocytoma
c) Medulloblastoma
d) Oligodendroglioma
e) Pseudotumor cerebri
The Correct answer is C

Explanation
Tumors of or near the cerebellum (above the back of the neck),
especially medulloblastomas in children, can cause alterations in eye
movements, incoordination, unsteadiness in walking, and sometimes
hearing loss and dizziness. They can block the drainage of cerebrospinal
fluid, causing fluid to accumulate in the spaces within the brain
(ventricles). As a result, the ventricles enlarge (a condition called
hydrocephalus), and pressure within the skull increases. Symptoms
include headaches, nausea, vomiting, difficulty turning the eyes upward,
lethargy, and coma with herniation of the brain. In infants, the head
enlarges.
A 2 year old white male is seen for a well care visit. His mother is
concerned because he is not yet able to walk. The routine physical
examination, including an orthopedic evaluation, is unremarkable. Speech
and other developmental landmarks seem normal for his age. Which one of
the following would be most appropriate?

a) A TSH level
b) Random urine for aminoaciduria
c) Phenylketonuria screening
d) A serum creatinine kinase level
e) Chromosome analysis
The Correct answer is D

Explanation
The diagnosis of Duchenne’s muscular dystrophy, the most common
neuromuscular disorder of childhood, is usually not made until the
affected individual presents with an established gait abnormally at age
4-5. By then, the parents unaware of the X-linked inheritance may have
had additional children who would also be at risk.

The disease can be diagnosed earlier by testing for elevated creatine


kinase in boys who are slow to walk. The mean age for walking in
affected boys is 17.2 months, whereas over 75% of normal children walk
by 13.5 months. Massive elevation of creatine kinase (CK) from 20 to 100
times normal occurs in every young infant with the disease. Early
detection allows appropriate genetic counselling regarding future
pregnancies.

Hypothyroidism and phenylketonuria could present as delayed walking.


However, these diseases cause significant mental retardation and would
be associated with global developmental delay. Furthermore, these
disorders are now diagnosed in the neonatal period by routine screening.
Disorders of amino acid metabolism present in the newborn period with
failure to thrive, poor feeding, and lethargy. Gross chromosomal
abnormalities would usually be incompatible with a normal physical
examination at 18 months.
What is the most common cause of congenital heart failure in a newborn?

a) Ventral septal defect


b) Atrial septal defect
c) Transposition of great arteries
d) Tetralogy of Fallot
The Correct answer is A

Explanation
A ventricular septal defect (VSD) is one or more openings in the
interventricular septum, producing a shunt between ventricles. Large
defects result in a significant left-to-right shunt and produce dyspnea
with feeding and poor growth. A loud, harsh, holosystolic murmur at the
lower left sternal border is common. VSD is the 2nd most common
congenital heart anomaly after bicuspid aortic valve.

Recurrent respiratory infections and heart failure may develop.


Diagnosis is by echocardiography. Defects may close spontaneously during
infancy or require surgical repair. Endocarditis prophylaxis is recommended.
A 12-year-old African-Canadian female with asthma presents with a 2-day
history of increasing cough and wheezing, preceded by symptoms of an
upper respiratory infection. On examination she has a temperature of
37.2° C (99.0° F), 2+ expiratory wheezes throughout, and a peak flow of
50% of expected. Her oxygen saturation is 96%.

Which one of the following is true regarding treatment of this patient?

a) Intravenous corticosteroids have been proven to be more beneficial


than oral
corticosteroids
b) A nebulizer is better than an inhaler with a spacer for
administering ß_2 -agonists
c) Intravenous theophylline is recommended as a second-line therapy in
acute asthma
exacerbations
d) Ipratropium (Atrovent) added to an inhaled ß-agonist lessens the
need for
hospitalization
The Correct answer is D

Explanation
The addition of ipratropium to inhaled ß_2 -agonists has been found to
be more effective in acute asthmatic attacks than ß_2 -agonists alone.
Sudden exacerbations of asthma are common in children. Numerous
treatments have been used in the past.

ß_2 -agonists have been shown to be equally effective whether


administered via an inhaler and spacer device or by nebulization. As
long as the gastrointestinal tract is working, intravenous
corticosteroids have no benefit over oral corticosteroids.

Intravenous theophylline, which once was the mainstay of treatment, now


is used only in a hospital setting to treat severe asthma not responding
to other treatments. The marginal improvement is not great enough to
outweigh the potential risk of cardiovascular, gastrointestinal, or
central nervous system toxicity.
At a well care visit, the father questions you about which car restraint
system is best for his child, who is 48 in tall and weighs 41 kg (90
lb). Which one of the following would be the most appropriate
recommendation?

a) A forward-facing car seat


b) A booster seat
c) Use of the lap and shoulder belt system
d) Use of the lap belt, with the shoulder belt placed behind the back
e) Use of the lap belt, with the shoulder belt placed under the arm
The Correct answer is B

Explanation
Forward-facing seats are intended for children weighing 30-40 lb. A
booster seat is used when a child no longer fits in other child safety
seats but is not big enough for the safety belt. The adult system is
used when it fits the child correctly ? usually when the child is 57 in
tall. The belts fit correctly when the child is tall enough to have legs
bent over the seat while the back is against the seat, the shoulder belt
fits across the midclavicle and midsternum, and the lap belt is low and
tight across the thighs. Shoulder and lap safetly belts are designed to
work as a system. The shoulder belt should not be placed behind the back
because the upper body will not be restrained, and the belt may not work
in this configuration. The shoulder belt portion should never be placed
under the arm because the force of a crash could thereby lead to
fractured ribs, brachial plexus injury, or other chest wall and upper
extremity injuries.
The mother of an 11 year old girl notices her daughter walks with a
droop on right side. What is the most likely diagnosis’
a) Legg-Calvé-Perthes
b) Idiopathic scoliosis
c) Slipped femoral capital epiphysis
d) Osgood-Schlatter
The Correct answer is B

Explanation
Idiopathic scoliosis can be detected in as many as 2 to 3% of children
aged 10 to 16 years, 60 to 80% are girls.

Scoliosis may first be suspected when one shoulder seems higher than the
other or when clothes do not hang straight, but it is often detected
during routine physical examination. Patients may initially report
fatigue in the lumbar region after prolonged sitting or standing.

The curve is most pronounced when patients bend forward. Most curves are
convex to the right in the thoracic area and to the left in the lumbar
area, so that the right shoulder is higher than the left. X-ray
examination should include standing anteroposterior and lateral views of
the spine.

Prompt referral to an orthopedist is indicated. Moderate curves (20 to


40°) are treated conservatively (eg, with a cast or brace) to prevent
further deformity. Severe curves (> 40°) can often be ameliorated
surgically (eg, spinal fusion with rod placement).
A mother is worried about her child, because of a family history of
myopathy. What is the most appropriate investigation to do first in the
child?

a) CPK
b) Muscle biopsy
c) Nerve biopsy
d) EMG
The Correct answer is A

Explanation
Myopathies refer to a class of degenerative skeletal muscle disease that
is not caused by nerve dysfunction. Myopathies cause progressive
weakness and wasting away of skeletal muscles. The causes for Myopathies
vary. They could be hereditary, an inflammatory response, or the result
of an endocrine disorder.

Creatinine phosphokinase (CPK) is an enzyme found in skeletal muscle,


cardiac muscle, and the brain. An initial step is to measure the level
of this CPK enzyme with a simple blood test.
A white male adolescent is concerned because he is the shortest boy in
his class. His age is 14.3 years and his parents are of normal height.
He has a negative past medical history and no symptoms. On physical
examination you note that he is 151 cm (59 in) tall. The average height
for his age is 165 cm. His weight is 43 kg (95 lb). His sexual maturity
rating is 3 for genitalia and 2 for pubic hair. A wrist radiograph shows
a bone age of 12.2 years (the average height is 152 cm for this bone
age). On the basis of this evaluation you can tell the patient and his
parents that

a) he should have a growth hormone stimulation test


b) his adult height will be below average
c) his sexual development is about average for his age
d) he will begin to grow taller within a year or so
e) an underlying nutritional deficiency may be the cause of his short
stature
The Correct answer is D

Explanation
Constitutional growth delay, defined as delayed but eventually normal
growth in an adolescent, is usually genetic. If evaluation of the short
adolescent male reveals no evidence of chronic disease, if his sexual
maturity rating is 2 or 3, and if his height is appropriate for skeletal
age he can be told without endocrinologic testing that he will begin to
grow taller within a year or so. Adult height may be below average, but
cannot be predicted reliably. Average sexual maturity ratings for a male
of 14.3 years are 4 for genitalia and 3 to 4 for pubic hair. The history
and physical examination would have given clues to any illnesses or
nutritional problems.
A 2 year old male is brought in for an initial office visit. He just
moved to your community to live with foster parents. On examination, you
note a thin upper lip, a smooth philtrum, a flat nasal bridge, small
palpebral fissures, ?railroad tract? ears, a curved fifth finger
(clinodactyly), and a widened upper palmar crease that ends between the
second and third fingers.

These findings suggest which one of the following?

a) Trisomy 21 (Down syndrome)


b) Marfan syndrome
c) Oligohydramnios sequence (Potter’s syndrome)
d) Fetal alcohol syndrome
e) Prader-Willi syndrome
The Correct answer is D

Explanation
The child described has the characteristic facial features of fetal
alcohol syndrome. Fetal alcohol spectrum disorders (FASD) are caused by
the effects of maternal alcohol consumption during pregnancy. Fetal
alcohol syndrome is the most clinically recognized form of FASD and is
characterized by a pattern of minor facial anomalies, including a thin
upper lip, a smooth philtrum, and a flat nasal bridge; other physical
anomalies, such as clinodactyly; prenatal and postnatal growth
retardation; and functional or structural central nervous system
abnormalities.

Children with Down syndrome have hypotonia, a flat face, upward and
slanted palpebral fissures and epicanthic folds, and speckled irises
(Brushfield spots); varying degrees of mental and growth retardation;
dysplasia of the pelvis; cardiac malformations; a simian crease; short,
broad hands; hypoplasia of the middle phalanx of the 5th finger; and a
high, arched palate.

Marfan syndrome is characterized by pectus carinatum or pectus


excavatum, an arm span to height ratio >1.05, a positive wrist and thumb
sigh, limited elbow extension, pes planus, and aortic ascendens dilation
with or without aortic regurgitation.

The bilateral renal agenesis seen with Potter’s syndrome is incompatible


with extrauterine life. Other anomalies include widely separated eyes
with epicanthic folds, low-set ears, a broad and flat nose, a receding
chin, and limb anomalies.

Finally, Prader-Willi syndrome is characterized by severe hypotonia at


birth, obesity, short stature (responsive to growth hormone), small
hands and feet, hypogonadism, and mental retardation.
A 5 month old infant has had several episodes of wheezing, not clearly
related to colds. The pregnancy and delivery were normal; the infant
received phototherapy for 1 day after hyperbilirubinemia. He had an
episode of otitis media 1 month ago. There is no chronic runny nose or
strong family history of asthma. He spits up small amounts of formula
several times a day, but otherwise appears well. His growth curve is
normal. An examination is unremarkable except for mild wheezing. Which
one of the following is the most likely diagnosis’

a) Benign reactive airway disease of infancy


b) Cystic fibrosis
c) Unresolved respiratory syncytial virus infection
d) D. Early asthma
e) Gastroesophageal reflux
The Correct answer is E

Explanation
Gastroesophageal reflux is a common cause of wheezing in infants. At 5
months of age, most infants no longer spit up several times a day, and
this is a major clue that the wheezing may be from the reflux. Also,
there is no family history of asthma and the wheezing is not related to
infections. Cystic fibrosis is more likely to present with recurrent
infections and failure to thrive than with intermittent wheezing.
An obese 11 year old boy with diabetes mellitus is admitted to the
hospital because of severe ketoacidosis and cardiovascular collapse.
Initial management consists of cardiac monitoring and intravenous
administration of fluids, electrolytes and insulin. Because of the
difficulty in obtaining satisfactory peripheral venous access, the left
femoral vein is catheterized percutaneously. Six hours later, his mental
status is improved, blood pressure is 120/70 mm Hg and serum glucose
concentration is 250 mg/dL. Physical examination at that time shows a
cold left foot with diminished pulses compared with those of the right
foot. The electrolyte deficit in this patient most likely to cause death is

a) Bicarbonate
b) Calcium
c) Chloride
d) Potassium
e) Sodium
The Correct answer is D

Explanation
Diabetics in DKA are at serious risk for profound hypokalemia. The
hypokalemia results from both profound dehydration and from an
intracellular return of potassium to cells after the requirement to
buffer the acidosis has passed. During acidosis there is an exchange of
potassium for hydrogen with hydrogen moving intra-cellularly to be buffered.
During the newborn period, physical characteristics suggestive of
prematurity include each of the following, except

a) A prominent diastasis of the rectus muscles


b) Scant ear cartilage
c) Absent breast buds
d) Thin skin
e) Hypotonic posture at rest
The Correct answer is A

Explanation
The abdomen is constructed of several layers of muscles many of which
meet in the mid-line of the body. One of the primary sets of muscles
that meet at this middle line are called the rectus muscles. These are
the muscles that give the ripple effect of the lower abdomen in body
builders. However, in newborn babies, these muscles may not be quite
fully developed. In other words, they may not quite meet at this
mid-line. This gap between the rectus muscles of each side of the body
essentially causes a minor weakness of the abdomen. So, when the
abdominal muscles are tightened like when the child cries or sits up
from after lying flat, this vertical line made up of where the rectus
muscles meet distends slightly outward. This phenomenon is called
diastasis recti.

This "defect" is considered normal in infants and almost always goes


away by three years of age. And even if it does not completely resolve,
it generally causes no difficulty for the child.
A 17 year old student is brought to your office by her mother who is
concerned about her daughter's 6 month history of weight loss and
anorexia. The girl states that she feels perfectly well. She is able to
maintain her normal activities, including a rigorous exercise program at
the university. She measures 162 cm and weighs 38 kg. Her skin is dry,
and there is bilateral, painless swelling in both parotid regions.
Investigations are most likely to show

a) Low basal levels of luteinizing hormone


b) A low thyroid-stimulating hormone level
c) An elevated serum glucose
d) A mediastinal mass on chest x-ray
e) An abnormal small bowel biopsy
The Correct answer is A
Explanation
Serum luteinizing hormone level and serum follicle-stimulating hormone
is low in patients with anorexia nervosa. These hormonal alterations in
the hypothalamic-pituitary axis in patients with anorexia nervosa
represent adaptive and protective mechanisms for chronic starvation and
weight loss.
An 8 year old child presents with dehydration. She has dry mucous
membranes, tachycardia decreased urine output. Her initial labs show a
potassium of 5.0 and normal glucose level. What is the most appropriate
IV fluid to administer for maintenance hydration?

a) 0.9% NaCl
b) 0 45% NaCl
c) 0.9% NaCl + 20 KCl
d) 0.45% NaCl + 20 KCl
The Correct answer is B

Explanation
The recommended fluid to be infused as maintenance for well children
with normal hydration is:

0.45% NaCl with 5% Glucose + 20mmol KCl / Liter.


This is often written as D5 ½ NS + 20KCl
The D5 refers to the glucose (dextrose), NS refers to Normal saline
which is 0.9% NaCl. ½ NS would refer to 0.45% NaCl.

In this child the potassium is in the upper limit of normal, since


normal range is 3.5-5.0. So do not add potassium at this time. The
maintenance treatment would be with 0.45% NaCl. If giving a bolus, you
would use 0.9% NaCl normal saline.
Which of the following investigations is most helpful in the assessment
of a child presenting with an acute asthma attack?

a) White cell count and differential


b) Arterial blood gases
c) Chest x-ray
d) Pulse oximetry and either PEF or FEV1 measurement
e) O2 saturation monitoring
The Correct answer is D

Explanation
Known asthmatics with an acute exacerbation should have pulse oximetry
and either PEF or FEV1 measurement. All 3 measures help establish the
severity of an exacerbation and document treatment response. PEF values
are interpreted in light of the patient's personal best, which may vary
widely among patients who are equally well controlled. A 15 to 20%
reduction from this baseline indicates a significant exacerbation. When
baseline values are not known, the percent predicted value gives a
general idea of airflow limitation but not the individual patient's
degree of worsening.
Chest x-ray is not necessary for most exacerbations but should be
obtained in patients with symptoms suggestive of pneumonia or
pneumothorax. ABG measurements should be obtained in patients with
marked respiratory distress or signs and symptoms of impending
respiratory failure.
A 12 month old girl is brought to the emergency department for the
second time in 2 days for vomiting and passage of 8 to 10 watery stools
per day. Of the following, which provides the best estimate of the
patient’s volume deficit?

a) Weight change since the beginning of the illness


b) Hydration of mucous membranes, skin turgor, and level of consciousness
c) Pulse, blood pressure, and peripheral capillary filling time
d) Serum electrolytes
e) Serum urea nitrogen and creatinine levels
The Correct answer is A

Explanation
Dehydration is significant depletion of body water and, to varying
degrees, electrolytes. Symptoms and signs include thirst, lethargy, dry
mucosa, decreased urine output, and, as the degree of dehydration
progresses, tachycardia, hypotension, and shock. Diagnosis is based on
history and physical examination. Treatment is with oral or IV
replacement of fluid and electrolytes.

The most accurate method with acute dehydration is change in body


weight; all short-term weight loss > 1%/day is presumed to represent
fluid deficit. However, this method depends on knowing a precise, recent
pre-illness weight.
A 6-year-old female is brought to your office for recurring limb pain.
For the past 2 weeks she has complained of cramping pain in her thighs
and calves, which has caused her to awaken at times. Massage and
occasional acetaminophen help. In the morning the symptoms are gone and
daily activity is unimpaired. Her physical examination is normal. On
examination she has no inflammatory signs and no joint or muscle tenderness.

Which one of the following would be most appropriate at this point?

a) Radiographs of the hips and knees


b) An erythrocyte sedimentation rate
c) A CBC
d) Antinuclear antibody (ANA) testing
e) No further testing
The Correct answer is E

Explanation
This patient is experiencing benign nocturnal pains of childhood,
formerly called ?growing pains.? These are cramping pains of the thigh,
shin, and calf, and affect approximately 35% of children 4?6 years of
age. The pain typically occurs in the evening or at night, may awaken
the child from sleep, and disappears by morning. This classic
presentation in the absence of other inflammatory or chronic signs and
symptoms should reinforce the benign nature of this condition. Physical
findings are normal, so in the absence of worrisome complaints or
anatomic abnormalities no further diagnostic testing is required.
Parents should be reassured that there are no long-term sequelae. If
activity is impaired, the physical examination is abnormal, or any
constitutional or systemic complaints are present, then further
evaluation with additional testing is indicated, and may include an
erythrocyte sedimentation rate, CBC, antinuclear antibody, or
radiographs of affected bones or joints.
An 18-month-old white male has been brought into your office multiple
times over the past year with a reported fever of over 101°F (38°C). The
child’s reported temperatures at home have usually been higher than
those measured at the time of the office visit. The remainder of the
history is usually unremarkable. The child has a sibling who is in good
health, but another sibling died several years ago for unknown reasons.

On two occasions you diagnosed acute otitis media and acute bronchitis.
However, at most visits the child has not had any abnormal physical
findings. Repeated laboratory studies have been within normal limits,
including complete blood counts, erythrocyte sedimentation rates, blood
cultures, chest radiographs, and urinalyses. Almost always, the mother
has reported little reduction in fever with age-appropriate doses of
acetaminophen or ibuprofen.

At the last visit the child’s temperature was measured at 40.6°C


(105.1°F). Although the examination was once again unrevealing, it was
decided to hospitalize the child for close observation and evaluation by
an infectious disease consultant. Closed-circuit television observation
in the hospital showed the mother putting the thermometer into hot water
before a nurse came to record the patient’s temperature.

During the hospitalization you make a diagnosis. Which one of the


following is a strong indicator of the suspected final diagnosis’

a) The child has seen no other health-care provider but you


b) Both parents have been involved with each office visit
c) The child is afebrile while staying at the day-care center
d) The parents have resisted having painful or risky diagnostic tests
performed on the child
The Correct answer is C

Explanation
This is a characteristic presentation of factitious disorder by proxy,
or what is commonly known as Munchausen syndrome by proxy. Warning signs
for this disorder include episodes of illness beginning only when the
child is, or has recently been, with the parent; the parent taking the
child to numerous caregivers, resulting in multiple diagnostic
evaluations but neither cure nor definitive diagnosis; the other parent
(usually the father) being notably uninvolved despite the ostensible
health crises; the parent not being assured by normal test results and
continually advocating for painful or risky diagnostic tests for the
child; the child persistently failing to tolerate or respond to usual
medical therapies; and another child in the family having an unexplained
illness or childhood death.
A 7-year-old girl remains hospitalized following surgical removal of a
craniopharyngioma. On post-operative day 1, she begins to have an
increased volume of urine output. Which of the following would you also
anticipate if no action is taken?

a) Low urine specific gravity


b) Low urine osmolality
c) Rise in serum sodium
d) Increase in hemoglobin
e) All of the above
The Correct answer is E

Explanation
All of the above abnormalities are associated with diabetes insipidus
(DI), which may occur post-operatively during surgery involving the
pituitary stalk. In DI, there is an absence of anti-diuretic hormone
from the posterior pituitary gland, and therefore there is an inability
to concentrate the urine. Excess free water is lost, causing a dilute
high-volume urine output and subsequent hemoconcentration and
hypernatremia.
A 3-year-old child is seen in the emergency department with a recent
history of eating a fast food hamburger. The child has bloody diarrhea.
Laboratory evaluation reveals anemia, thrombocytopenia, elevated BUN,
and creatinine. Serum potassium is 8. Treatment should include all of
the following EXCEPT:

a) 12 lead EKG
b) Admission to the pediatric intensive care unit
c) Calcium gluconate
d) Insulin and glucose
e) Aggressive fluid management (i.e., 2-3 times maintenance fluids)
The Correct answer is E

Explanation
The child has what appears to be consistent with hemolytic uremic
syndrome due to uncooked or infected beef. The infant is in acute renal
failure with an elevated creatinine and potassium. Fluids should be
given very cautiously due to the inability of the kidneys to remove
excess fluid, leading to pulmonary edema.

A. Patients with acute renal failure may have multiple EKG


abnormalities, including T-wave elevations, loss of P-waves, a widened
QRS, and S-T depression.
B. Intensive monitoring is recommended until potassium levels are in a
safe range.
C. Calcium gluconate is used to help stabilize the cardiac cell membrane.
D. Insulin and glucose drive potassium into the cells, decreasing serum
levels.
A newborn is noted to have a loud holosystolic murmur at the lower left
sternal border. He also has episodes of difficulty breathing and has not
been feeding well. Which of the following congenital heart defects does
he most likely have?
a) ASD
b) VSD
c) PDA
d) Tetralogy of Fallot
e) Coarctation of the aorta
The Correct answer is B

Explanation
A ventricular septal defect is one or more openings in the
interventricular septum, producing a shunt between ventricles. Large
defects result in a significant left-to-right shunt and produce dyspnea
with feeding and poor growth. A loud, harsh, holosystolic murmur at the
lower left sternal border is common. Recurrent respiratory infections
and heart failure may develop. Diagnosis is by echocardiography. Defects
may close spontaneously during infancy or require surgical repair.
Which one of the following is the most effective initial treatment of
head lice in an 8 year old child?

a) Lindane (Kwell)
b) Wet combing every 4 days, to continue for 2 weeks after any louse is
found
c) Head shaving
d) Nightly application of petrolatum to the scalp, covered by shower cap
e) Permethrin 1%
The Correct answer is E

Explanation
Management of pediculosis involves the following:
-permethrin 1% (cream rinse) (ovicidal) or permetrin 1% (shampoo)
-comb hair wine fine-toothed comb using dilute vinegar solution to
remove nits
-repeat in 7 days
-bedding, clothing and towels should be changed and washed with
detergent in hot water cycle then machine dried.
A 5 year old male has moderate persistent asthma and allergic rhinitis.
Which one of the following is true regarding leukotriene inhibitors in
this situation?

a) They are less effective than intranasal corticosteroids for allergic


rhinitis
b) They are more effective than inhaled corticosteroids for asthma
c) They are more effective than long-acting ß_2 -agonists when added to
inhaled
corticosteroids for asthma
d) They are appropriate monotherapy for asthma
The Correct answer is A

Explanation
In general, asthma is most effectively treated with inhaled
corticosteroids. Adding a leukotriene inhibitor 2 may be effective, but
is less effective than adding a long-acting ß_2 -agonist. Leukotriene
inhibitors are also less effective than intranasal corticosteroids for
allergic rhinitis. Leukotriene inhibitors are considered inappropriate
monotherapy for moderate persistent asthma, as they are less effective
than inhaled corticosteroids. However, combined together these two
medications allow significantly greater reduction in the dose of inhaled
corticosteroids required to maintain clinical stability in chronic
asthmatics.
A fourteen year old boy is seen because he is constantly blinking. You
note that he frequently clears his throat, yet he denies sore throat or
other upper respiratory tract symptoms. He blinks frequently, yet is
able to hold his eyes open during examination with an ophthalmoscope.
His fundi, visual acuity, extraocular movements, visual fields, eyelids
and eyelashes are normal. He also exhibits intermittent facial grimacing
without apparent pain. This boy’s eye movements are most consistent with
which of the following?

a) Fidgeting
b) Motor tics
c) Simple partial seizures
d) Blepharospasm
e) Blepharitis
The Correct answer is B

Explanation
Tourette's syndrome often begins with simple muscle tics, such as
grimacing, head jerking, and blinking. Simple tics may be only a nervous
habit and may disappear with time. Such tics do not necessarily lead to
Tourette's syndrome, which involves more than a simple tic. For example,
people with Tourette's syndrome may repeatedly move their head from side
to side, blink their eyes, open their mouth, and stretch their neck.

The disorder may progress to bursts of complex tics, including vocal


tics, hitting, kicking, and sudden, irregular, jerky breathing. Vocal
tics may start as grunting, snorting, humming, or barking noises and
progress to compulsive, involuntary bouts of cursing. For no apparent
reason and often in the midst of conversation, some people with
Tourette's syndrome may call out obscenities or words related to feces
(called coprolalia).
A 5 year old girl presents to the ER with acute onset of muscle
weakness. Her muscle weakness started in her legs yesterday. The
weakness became worse today and progressed to the trunk and both arms.
She was also complaining difficulty of breathing earlier today. She has
been otherwise healthy but had a common cold about 10 days ago. On
examination, her respirations are 25/min and shallow. She has profound
muscle weakness in her lower extremities, and moderate weakness in her
upper extremities. Her deep tendon reflexes are absent. A lumbar
puncture is performed, which shows increased protein concentration.
Which of the following is the most likely diagnosis’

a) Botulism
b) Dermatomyositis
c) Guillain-Barré syndrome
d) Myasthenia gravis
The Correct answer is C
Explanation
The girl in this clinical vignette has classic Guillain-Barré syndrome,
also known as acute inflammatory demyelinating polyneuropathy (AIDP). It
is an acute illness characterized by rapid demyelination of peripheral
nerves. A symmetric ascending weakness progresses rapidly. In this case,
the involvement of the respiratory muscles is potentially life
threatening. Sensory deficit, involvement of facial musculature, and
autonomic insufficiency may occasionally happen. Weakness usually
follows a nonspecific viral infection by about 7-14 days.

Lumbar puncture shows elevation of protein concentration in the absence


of pleocytosis in the CSF. Diagnosis is made by nerve conduction
studies, which will show demyelination. Treatment involves
plasmapheresis or gamma-globulin infusion. Respiratory failure must be
aggressively managed with adequate respiratory support. Children with
this syndrome have a very good prognosis; full recovery is usually the
rule. A few may be left with some residual weakness.
A 6 year old boy comes to your office for evaluation. He is not doing
well in school and has a difficult time finishing his school work in the
time allotted. His mother tells you that his teacher is constantly
having to redirect him, and that at time he is staring off into space
day-dreaming. When you question Mom, she has also noticed that he has
recurrent episodes of brief staring spells. You examine the patient and
order an EEG. What is the EEG likely to show?

a) Generalized symmetric 3-per-second spike and wave pattern


b) Generalized, diffuse slowing
c) Hypsarrhythmia
d) Localized spike and wave pattern
The Correct answer is A

Explanation
The patient described in the clinical vignette most likely has petit mal
or absence seizures. The characteristic EEG pattern for these seizures
is the generalized symmetric 3-per-second spike and wave pattern. Petit
mal or absence seizures are brief, repetitive episodes associated with
alterations in consciousness, and the child is unaware of the episodes.
There is usually no post-ictal period and the child quickly returns to
the task at hand. Hypsarryhthmia is the characteristic EEG pattern seen
in infantile spasm. The two other EEG patterns listed are not specific
for any particular disorder.
The treatment of choice for a 4 month old infant with suspected pertussis is

a) Supportive care (respiratory, fluids) only


b) Ceftriaxone (Rocephin)
c) Ampicillin
d) Gentamicin (Garamycin)
e) Erythromycin
The Correct answer is E

Explanation
In spite of widespread vaccination of infants, pertussis occurs
endemically in 3- to 5-year cycles in Canada. It appears to be more
common within populations not routinely immunized, such as Mennonite
communities, but can occur widely. Infants younger than 6 months are
affected most severely, although pertussis occurs in all age groups. The
diagnosis is made by nasopharyngeal culture, but because the disease is
uncommon and the organism is fastidious, laboratory personnel should be
advised of the physician’s suspicion of pertussis.

Treatment includes respiratory and nutritional supportive care,


particularly for infants younger than 6 months. Antibiotic therapy is
most effective in shortening the illness when given early, during the
upper choice is erythromycin, 40-50 mg/kg/day divided into four doses,
for 14 days. Also effective are azithromycin and clarithromycin, which
may be better tolerated with improved compliance. Resistance to these
agents is rare. Penicillins and cephalosporins are ineffective.
Gentamicin is potentially very toxic and is not indicated.
You are called to the emergency room to see a 7-year-old with an injured
arm after a fall. The child holds the arm in flexion and braces it with
the other arm. There is remarkable point tenderness in the distal
radius. You obtain an x-ray which shows a buckle fracture. Which
statement is false?

a) Forearm fractures are the most common location for children’s fractures
b) Special attention should be given to any rotation or angulation
problems with these fractures
c) Forearm fractures are usually sustained by a fall on an outstretched
hand
d) Buckle fractures have a high incidence of non-union
e) Forearm fractures may be buckle fractures (compression), greenstick
(incomplete), or complete
The Correct answer is D

Explanation
Torus fractures, or buckle fractures, are extremely common injuries seen
in children. Nonunion is rare in uncomplicated cases of buckle fracture.

Forearm fractures account for about one-fourth of all children’s fractures.


Rotation of angulation of forearm fracture requires more complex
management and follow-up with a higher risk of complications.
This is the classic mechanism of injury in children.
Buckle fractures are commonly incomplete (greenstick) but may be
complete in more severe cases.
A 17 year old university student, visits her family physician’s office
complaining of fatigue and ‘strong smelling? urine. She is a member of
the university basketball team and has noted a dip in her performance
since the onset of these symptoms. Urine analysis shows specific gravity
1030, nitrites negative, + protein. A 24 hour urine collection shows a
normal creatinine clearance with 0.41g of protein for this time period.
Which of the following investigation(s) does this patient require?

a) Cystoscopy
b) Repeat 24 hour collection after avoiding exercise
c) Renal biopsy
d) Serum and urine electrophoresis
Which one of the following patients should receive a second dose of
varicella vaccine?

a) A 3-year-old vaccinated at 12 months of age


b) A 13-year-old who had varicella at age 4
c) A 14-year-old immigrant who received his first dose of vaccine 1
month ago
d) A pregnant 16-year-old vaccinated at age 5
e) An HIV-positive nurse born in Canada in 1978
The Correct answer is C

Explanation
Two doses of varicella vaccine are now recommended for almost everyone.
The first dose should be given at 12?15 months of age, and a second dose
at 4?6 years of age. All unvaccinated people over 13 years of age
without evidence of immunity should receive two doses of vaccine given
4?8 weeks apart. The vaccine is not recommended for pregnant women or
immunocompromised patients.
A 5 week old male infant presents with a history of vomiting since
birth. This occurs shortly after feeding and is often associated with
burping. The child is exclusively breastfed. The infant was full term
and the birth weight was 2.7 kg. At present, he weighs 3.7 kg and
physical examination is within normal limits. The most likely diagnosis is

a) Otitis media
b) Urinary tract infection
c) Milk allergy
d) Pyloric stenosis
e) Gastroesophageal reflux
The Correct answer is E

Explanation
Gastroesophageal reflux (GER) occurs when stomach contents reflux, or
back up, into the esophagus during or after a meal. The esophagus is the
tube that connects the mouth to the stomach. A ring of muscle at the
bottom of the esophagus opens and closes to allow food to enter the
stomach. This ring of muscle is called the lower esophageal sphincter
(LES). The LES normally opens to release gas after meals. With infants,
when the LES opens, stomach contents often reflux into the esophagus and
out the mouth, resulting in regurgitation, or spitting up, and vomiting.
GER can also occur when babies cough, cry, or strain.

GER is common in healthy infants. More than half of all babies


experience reflux in the first 3 months of life, but most stop spitting
up between the ages of 12 to 24 months. Only a small number of infants
have severe symptoms.
Children under 1 year of age should not be given honey because of
possible contamination with which one of the following?

a) Staphylococcus aureus
b) Clostridium botulinum
c) Clostridium difficile
d) Escherichia coli
e) Hepatitis A
The Correct answer is B

Explanation The most common cause of infant botulism is ingestion of


Clostridium botulinum spores in honey.

A male infant is delivered by cesarean section because of dystocia due


to macrosomia. Apgar scores are 8 at 1 minute and 10 at 5 minutes.
However, at about 1 hour of age he begins to have tachypnea without
hypoxemia. A chest radiograph shows diffuse parenchymal infiltrates and
fluid in the pulmonary fissures. The symptoms resolve without treatment
within 24 hours. The most likely diagnosis is

a) transient tachypnea of the newborn


b) intracranial hemorrhage
c) laryngotracheomalacia
d) meconium aspiration syndrome
e) hyaline membrane disease
The Correct answer is A

Explanation
This child had transient tachypnea of the newborn, the most common cause
of neonatal respiratory distress. It is a benign condition due to
residual pulmonary fluid remaining in the lungs after delivery. Risk
factors include cesarean delivery, macrosomia, male gender, and maternal
asthma and/or diabetes mellitus. The other conditions listed cause
neonatal respiratory distress, but do not resolve spontaneously. They
also cause additional significant abnormal findings on physical
examination and/or ancillary studies such as imaging and laboratory studies.
Which of the following is TRUE of neonates exposed to intrauterine
maternal cocaine use?

a) They are frequently large for gestational age (LGA)


b) Their risk for sudden infant death syndrome (SIDS) is equal to that
of infants not exposed to intrauterine drugs
c) They are at increased risk of early onset necrotizing enterocolitis
(NEC)
d) They are seldom premature
e) Cocaine addicted neonates have normal sleep patterns
The Correct answer is C

Explanation
Due to the alteration of blood flow and vasoconstriction associated with
cocaine, these infants are at increased risk of early onset NEC.

A. These neonates are frequently small for gestational age (SGA) since
cocaine is a powerful anorexic in the mothers. It also acts as a potent
vasoconstrictor and frequently produces placental insufficiency.
B. Cocaine-exposed infants have a 3-7 times higher risk for SIDS.
D. Cocaine is a common cause of preterm labor and spontaneous abortions.
E. Cocaine-addicted neonates may have abnormal sleep patterns with an
inability to be consoled.
A 13 year old obese child presents with painful right knee and right hip
pain with difficulty walking and reduced abduction and internal
rotation. What is your diagnosis’

a) Juvenile arthritis
b) Septic arthritis of the hip
c) Avascular necrosis of femoral head
d) Cartilage dysplasia
e) Slipped capital femoral epiphysis
The Correct answer is E

Explanation
Slipped capital femoral epiphysis (SCFE) usually occurs in early
adolescence and preferentially affects boys. Obesity is a significant
risk factor. Exact cause is unknown but probably relates to weakening of
the physis (growth plate), which can result from trauma, hormonal
changes, inflammation, or increased shearing forces due to obesity.

Onset is usually insidious, and symptoms are associated with stage of


slippage. The 1st symptom may be hip stiffness that abates with rest; it
is followed by a limp, then hip pain that radiates down the anteromedial
thigh to the knee. Early hip examination may detect neither pain nor
limitation of movement. In more advanced stages, findings may include
pain during movement of the affected hip, with limited flexion,
abduction, and medial rotation; knee pain without specific knee
abnormalities; and a limp. The affected leg is externally rotated.

Because treatment of advanced slippage is difficult, early diagnosis is


vital. Anteroposterior and frog-leg lateral x-rays of both hips are
taken. X-rays show widening of the epiphyseal line or apparent posterior
and inferior displacement of the femoral head. Ultrasonography and MRI
are also useful, especially if x-rays are normal.

SCFE usually progresses; it requires surgery as soon as it is diagnosed.


Patients should not bear weight on the affected leg until SCFE has been
ruled out or treated. Surgical treatment consists of screw fixation
through the epiphysis.
A 3 year old girl, is brought to you because she has developed some
concerning symptoms recently. They include anorexia, vomiting, abdominal
pain and a wobbling gait. The family is poor and live in an old
dilapidated building. What is the likely lab finding on a complete blood
count (CBC) for this child?

a) Macrocytic anemia (MCV > 100)


b) Microcytic anemia (MCV < 80)
c) Normal CBC
d) Thrombocytosis
e) Thrombocytopenia
The Correct answer is B

Explanation
This child has symptoms that are consistent with lead poisoning. A child
can present with symptoms of abdominal pain, vomiting, constipation,
headache and decreased appetite. Some children can also present with
neurologic symptoms such as tremor, confusion, seizures and ataxic gait.
Lead poisoning causes a microcytic anemia, and the mean corpuscular
value (MCV) would be less than 80.

Children who live in old homes or apartment buildings that have lead
paint that is chipping or peeling off the walls are risk of developing
lead poisoning. Especially, if they eat the paint chips that fall off
the walls.

Treatment is with chelation with drugs such as succimer and dimercaprol,


that bind the lead and eliminate it from the body. In addition, a lead
abatement agency must be contacted to go and inspect the home.
A child has juvenile polyposis. What possible complication is likely in
this patient?

a) Diarrhea
b) Painless bleeding
c) Painful bleeding
d) Malignancy
The Correct answer is B

Explanation
The most common symptom is painless rectal bleeding. Other warning signs
include polyps protruding in the rectum; slipping of one part of the
intestine into another; or malnutrition.

A juvenile polyp is a growth that projects from the lining of the


intestine and originates in the tissues supporting that lining. It does
not arise from the colonocytes (colonic lining cells) themselves but
from the tissues underneath the lining cells. It is not neoplastic but
hamartomatous. A hamartoma is a growth that arises from normal tissues.
It is self-limiting and benign. Juvenile polyps can be solitary or
multiple.

Juvenile polyps occur in children, they typically outgrow their blood


supply and autoamputate some time during or after puberty. Treatment is
required only for uncontrollable bleeding or intussusception.
A previously healthy 20-month-old female is brought to the urgent-care
clinic during the evening with a barking cough. On examination her
rectal temperature is 37.9°C (100.2°F), respiratory rate 18/min, heart
rate 120 beats/min, and O2 saturation 94%. She has stridor, with mild
substernal retractions only when her temperature was taken. Which one of
the following would be most appropriate at this point?

a) Dexamethasone, 0.6 mg/kg orally or intramuscularly as a single dose


b) Guaifenesin/pseudoephedrine elixir orally until symptoms improve
c) Azithromycin (Zithromax) orally for 5 days
d) Observation in the clinic, and if there is improvement, a 5-day
course of dexamethasone
The Correct answer is A

Explanation
Croup can be classified as spasmodic croup, laryngotracheitis,
laryngotracheobronchitis (LTB), laryngotracheobroncheopneumonia (LTBP),
or laryngeal diphtheria. Mild croup is manifested by an occasional
barking cough with no stridor at rest, and mild or absent intercostal
retractions. Moderate croup presents with a more frequent barking cough,
stridor with suprasternal and sternal retractions at rest, but no
agitation. Severe croup includes more prominent inspiratory and
expiratory stridor with agitation and distress.

There is good evidence that corticosteroids produce significant


improvement. The regimens studied most frequently have consisted of
single-dose dexamethasone (0.6 mg/kg orally or intramuscularly), with
some studies including up to four more doses over a 2-day period. Longer
courses of corticosteroids have not proven to be more effective and may
be harmful, leading to secondary infections. Racemic epinephrine by
nebulization is indicated in severe croup. Antitussives and
decongestants have not been studied and are not recommended. Antibiotics
are indicated in LTB and LTBP, which can be diagnosed on the basis of
crackles and wheezing on examination, or by an abnormal chest
radiograph. Laryngotracheitis can sometimes be associated with a
bacterial infection, but should be suspected only after a patient does
not improve with corticosteroids and epinephrine.
A woman with a history of a child with cleft lip and plate, is asking
about the possibility of her next child having the same problem. What is
your answer?

a) The chance is not increased


b) The chance is increased only in girls
c) The chance is higher if she has a boy
d) The chance is higher if she has a girl
The Correct answer is C

Explanation
The above table illustrates that the rate of recurrence in a sibling of
a cleft lip/cleft palate child is overall 3.34%. With 3.91% for a male
sibling and 2.67% for a female sibling.
Which one of the following sleep problems in children is most likely to
occur during the second half of the night?

a) Confusional arousals
b) Sleepwalking
c) Sleep terrors
d) Nightmares
The Correct answer is D

Explanation
Nightmares occur in the second half of the night, when rapid eye
movement (REM) sleep is most prominent. Parasomnias are disorders of
arousal from non-REM (NREM) sleep. These are more common in children
than adults because children spend more time in deep NREM sleep. Such
disorders usually occur within 1?2 hours after sleep onset, and coincide
with the transition from the first period of slow-wave sleep. These
disorders include sleepwalking, confusional arousal, and sleep terrors.
A 4-year-old boy is seen in the outpatient clinic for a yearly visit.
His gross motor, visual motor, and social milestones are all
appropriate. However, he uses only two word phrases, no pronouns, and
knows about 50 words total. His language development is best described as:

a) Normal

b) A developmental delay

c) A developmental quotient

d) A developmental dissociation

e) A developmental deviancy
The Correct answer is B

Explanation
Developmental delay refers to a performance significantly below average
in a given skill area. This boy’s language development is delayed to
about the 21-month-old level.

A. The language development described is normal for a 21-month-old, not


a 4-year-old.

C. Developmental quotient is defined as (developmental age divided by


chronological age) x 100.

D. Refers to a substantial difference in the rate of development between


two skill areas.

E. Refers to non-sequential development within a given area of skill.

A 10-year-old child presents with a 1-month history of polydipsia,


polyuria, and a 15 lb weight loss. All of the following will be seen
upon further evaluation EXCEPT:

a) Dehydration
b) Kussmaul respirations
c) Metabolic alkalosis
d) Hyperglycemia
e) Glucosuria
The Correct answer is C

Explanation
This is a classic presentation of insulin dependent diabetes mellitus.
Management includes fluid resuscitation, administration of insulin,
dietary adjustment, and patient and family education. Metabolic acidosis
is seen in diabetes due to elevated ketones, not alkalosis.

A. Dehydration occurs due to osmotic dehydration and increased urination.


B. Kussmaul respirations describe hyperpnea secondary to metabolic acidosis.
D. Hyperglycemia occurs secondary to insulin resistance and pancreatic
insufficiency.
E. Glucosuria occurs when the serum glucose is elevated above a
threshold level, stimulating glucose losses in the urine.
An 11-year-old boy is seen in the emergency department for evaluation of
symptoms of exertional dyspnea, chest pain, and cyanosis. He reports
being previously healthy, but was told in the past that he had an
?innocent? heart murmur. On exam, you detect a short holosystolic
murmur, a right ventricular heave, and a loud pulmonary component of S2.
The EKG demonstrates right ventricular hypertrophy, an increased in
pulmonary vascularity. Cardiomegaly is seen on chest x-ray. What is the
best explanation for this constellation of findings’

a) The patient has pathology in the pulmonary outflow tract leading to


insufficient pulmonary blood flow
b) The patient has an innocent flow murmur and needs no further evaluation
c) The patient has evidence of Eisenmenger physiology
d) The patient has coarctation of the aorta and secondary heart failure
The Correct answer is C

Explanation
Eisenmenger physiology results from excess pulmonary vascular resistance
and subsequent right ventricular enlargement and failure. This is
usually seen in the context of a large VSD, in which the left-to-right
shunt has flooded the pulmonary circulation. Over time this results in
elevated pulmonary vascular resistance, and the ventricular shunt
reverses to a right-to-left shunt which results in cyanosis. The
clinical presentation described above is that of increased pulmonary
vascular resistance and right-to-left shunt characteristic of
Eisenmenger’s syndrome.
A 5 year old boy is brought to the ER with swollen eyelids, loss of
appetite, nausea and vomiting. His blood pressure is high and urine
tests show RBC casts. The treatment of his acute nephritic syndrome
involves all of the following, except

a) Diuretics
b) Salt restriction
c) Fluid restriction
d) Prednisolone
e) Protein restriction
The Correct answer is C

Explanation
Nephritis treatment involves a diet that is low in protein and sodium,
and may be necessary until kidney function recovers. Diuretics may be
prescribed to help the kidneys excrete excess sodium and water and to
treat high blood pressure.

For rapidly progressive glomerulonephritis, drugs to suppress the immune


system are started promptly. High doses of corticosteroids are usually
given intravenously.

Since some patients with nephritic syndrome will have oliguria, fluid
restriction is usually not the mainstay of treatment.
A 3 year old white female is brought to the emergency department with an
acute onset of epistaxis. The child, who has a history of good health,
is brought in by her recently-divorced mother, a registered nurse. The
mother appears relatively unconcerned about the child’s illness, but
otherwise is friendly and interacts appropriately with the health care
team evaluating the child. The child’s vital signs are normal, but she
is bleeding mildly from both nostrils and there are areas of ecchymosis.

Laboratory Findings

Hemoglobin 12.3 g/dL (N 11.5-15.0)


Hematocrit 36% (N 32-42)
WBC count 4500/mm (N 6000-15,000)
Platelets 235,000/mm3 (N>50,000)
Prothrombin time 40.0 sec (N 11.0-15.0)
Partial thromboplastin time 30 sec (N 24-36)
INR 3.9 sec (N 2.0-3.0)
ALT (SGPT) 18 IU/L (N 7-35)
AST (SGOT) 16 IU/L (N 15-60)
Bilirubin 0.8 mg/dL (N 0.3-1.2)

You hospitalize the child for observation and further testing. Her
bleeding subsides in several hours, no new skin lesions develop, and her
PT/INR decreases to 32 sec/3.0, 23 sec/2.1, and 15 sec/1.4 on subsequent
days. You suspect that the child’s condition is due to

a) Acetaminophen overdose
b) Antiphospholipid syndrome with lupus anticoagulant
c) Munchausen syndrome by proxy
d) Henoch-Schonlein purpura
e) Traumatic injury (child abuse)
The Correct answer is C

Explanation
The patient exhibits signs of moderate bleeding diathesis. Her
prothrombin time (PT) elevation, without evidence of hepatocellular
damage or hepatic dysfunction, is highly suspicious for warfarin
ingestion. The normalization of the PT under observation in a hospital
setting is consitent with this suspicion. Although accidental poisoning
is a possibility, the mother’s affect is highly suspicious for
Munchausen syndrome by proxy. The fact that her mother is a health-care
worker and develops a close and appropriate relationship with the
health-care team is consistent with this diagnosis. Acetaminophen
toxicity of this degree would likely produce transaminase and bilirubin
elevations, as well as mental status changes. Antiphospholopid syndrome
produces a hypercoagulable state. Henoch-Schönlein purpura presents with
purpura, joint pain, abdominal pain, and a normal PT. Traumatic injury
would not result in PT elevations.
A 10 year old is referred to you for evaluation of hypertension. He has
a history of recurrent urinary tract infections. Which one of the
following is the most likely diagnosis’

a) Vesico-ureteral reflux
b) Horseshoe kidney
c) Dominant polycystic disease
d) Juvenile diabetes mellitus
e) Post-streptococcal glomerulonephritis
The Correct answer is A

Explanation
Vesicoureteral reflux (VUR) is a cause of recurrent urinary tract
infections in children. VUR predisposes children to recurrent
pyelonephritis and renal scarring. Some children with renal scarring
develop hypertension and renal insufficiency. Recommendations have been
made to identify VUR early to stop this cascade of events, with
interventions to prevent renal scarring, hypertension, and renal
insufficiency.
A 15-year-old white female is brought to you by her parents. They report
a 30-lb (14-kg) weight loss over the last 10-12 months; her current
weight is 39 kg (86 lb). The patient denies any problem exists and says
she is very active in school activities and simply doesn’t fell hungry.
The patient is extremely thin; the physical examination is otherwise
normal.

The most likely diagnosis at this time is

a) Hyperthyroidism
b) Diabetes mellitus
c) Anorexia nervosa
d) Occult neoplasm
e) Addison's disease
The Correct answer is C

Explanation
Anorexia nervosa is an eating disorder seen mainly in young women,
usually beginning in adolescence. There are no specific tests to confirm
the diagnosis. Findings include refusal to maintain normal weight,
denial of any physical problems, amenorrhea, and the absence of findings
that suggest organic illness. There may be several physical and
laboratory abnormalities, but these are not consistent with other diagnoses.

The lack of specific findings on the history and examination rules out
the other problems listed. Hyperthyroidism might be suspected if the
pulse rate were high. In anorexia nervosa the pulse is frequently slower
than normal. Diabetes severe enough to produce such large amounts of
weight loss would present with the classic symptoms of polyphagia,
polydipsia, and polyuria. Addison’s disease would produce skin
pigmentation changes that would be apparent on examination. Occult
neoplasms would produce some subjective symptoms such as fatigue or
malaise.
The most common cause of hypertension in adolescents is

a) Cushing’s syndrome
b) essential hypertension
c) hyperthyroidism
d) pheochromocytoma
e) renal disease
The Correct answer is B

Explanation Primary or essential hypertension accounts for 85%?95% of


adolescent cases.

A 2 week old infant is brought to the office for a newborn visit. His
mother states that the he has been a very slow eater and that he is
constipated, not having had a bowel movement in 3 days. On physical
examination, the infant has poor muscle tone, an enlarged tongue, an
umbilical hernia, an enlarged anterior fontanelle, and hypothermia. He
also looks slightly jaundiced, with slightly dry skin and brittle hair.
Which of the following is the most likely diagnosis’

a) Beckwith-Wiedemann Syndrome
b) Congenital hypothyroidism
c) Trisomy 21
d) Turner syndrome
The Correct answer is B

Explanation
The signs and symptoms of congenital hypothyroidism may not be obvious
for several days or weeks. Symptoms include physical sluggishness,
constipation, large tongue, umbilical hernia, hypothermia, bradycardia,
enlarged fontanelles, and persistent jaundice. Skin may be dry and
scaly, and the hair may be dry, coarse, and brittle.
What is the most common cause of bleeding in patients with Meckel’s
diverticulum?

a) Helicobacter pylori infection causing ileal mucosal ulceration


b) Ectopic (heterotrophic) gastric mucosa causing acid-induced bleeding
of ileal mucosa
c) Arteriovenous malformation causing mucosal bleeding
d) Intussusception causing mucosal bleeding from inflammation
The Correct answer is B
Explanation
Most bleeding in Meckel’s diverticulum is secondary to heterotrophic
gastric mucosa, causing acid-induced ileal ulceration. Heliobacter
pylori has not been shown to be an etiologic agent. Intussusception is
fairly common in patients with Meckel’s diverticulum but is not a
frequent cause of bleeding. Arteriovenous malformation is not a major
complication of Meckel’s diverticulum.
A 4 year old boy is brought to emergency with a 5 day history of fever,
cough, and poor appetite, but no vomiting. On exam, he appears unwell,
is febrile, and has crusty nasal discharge and a wet-sounding cough.
Chest x-ray reveals a pulmonary infiltrate in the right middle lobe. He
is admitted to hospital for pneumonia. What is the best management for
this child?

a) Observe for 24 hours with IV fluids only


b) Observe for 24 hours with IV fluids and acetaminophen
c) Give oral amoxicillin and acetaminophen
d) Give IV ampicillin and oral acetaminophen
e) Give oral erythromycin and acetaminophen
The Correct answer is E

Explanation
Community-acquired pneumonia (CAP) develops in people with limited or no
contact with medical institutions or settings. The most commonly
identified pathogens are Streptococcus pneumoniae, Haemophilus
influenzae, and atypical organisms (ie, Chlamydia pneumoniae, Mycoplasma
pneumoniae, Legionella sp). Symptoms and signs are fever, cough,
dyspnea, tachypnea, and tachycardia.

Diagnosis is based on clinical presentation and chest x-ray. Treatment


is with empirically chosen antibiotics and antipyretics as needed. The
current recommendations for children aged 4 months to 4 years for both
outpatient and inpatient treatment for CAP is with erythromycin 10 mg/kg
po qid.
A mother expresses concerns that her 2 year old son doesn't seem to want
to cuddle with his parents and often doesn't respond to their voices.
The child doesn't smile, laugh or play with his parents, and his
language development is behind that of other children his age. He has
been growing well physically. Which one of the following is the most
likely diagnosis’

a) Mental retardation
b) Deafness
c) Mixed receptive-expressive language disorder
d) Tourette disorder
e) Pervasive developmental disorder
The Correct answer is B

Explanation
Hearing loss can be present at birth or progress over time. Hearing loss
can be hereditary or acquired by environmental means. As the majority of
children with hearing loss have no other abnormalities or distinguishing
features (called non-syndromic hearing loss), many children have late
diagnosis of their loss with significant consequences in delay in
language acquisition from the delay in diagnosis.

Accurate testing in children can be difficult primarily of a child’s


inability to respond during standard testing. Other tests have been
developed that require no direct response from children being tested.
These tests are utilized in the hospital just after birth (universal
screening) that is identifying children with hearing loss at an early
age and allowing for early and appropriate therapy. Advances in genetic
testing (molecular biology) has led to the ability to diagnose the cause
of hearing loss in many felt to previously to have an unknown cause for
their hearing loss.

Behavioral problems may be major or minor, and they are probably best
correlated with the child's personality and with how the parents deal
with what they may consider a stubborn child. Before speech impediments,
mental retardation, autism, attention deficit, or adjustment disorders
are presumed, many children could benefit from a hearing evaluation.

A child is seen to have a retinal hemorrhage on ophthalmoscope exam and


on physical exam he has anterior chest bruises and dilated sutures on
the skull. What is the most likely diagnosis’

a) ITP
b) Keratitis
c) Accidental injury
d) Non-accidental injury
The Correct answer is D

Explanation
This is a case of physical abuse. Infants who are shaken may have shaken
baby (shaken impact) syndrome. This syndrome is caused by violent
shaking, often followed by throwing the infant. Infants who are shaken
may have no visible signs of injury and may appear to be sleeping
deeply. This sleepiness is due to brain damage and swelling, which may
result from bleeding between the brain and skull (subdural hemorrhage).
Infants may also have bleeding in the retina (retinal hemorrhage) at the
back of the eye. Ribs and other bones may be broken.
A 15-year-old male presents for a routine evaluation. He has no
complaints. He has a BMI of 30 kg/m , which places him in the 97th
percentile for his age. The remainder of his examination is normal;
however, a random blood glucose level is 162 mg/dL. Which one of the
following would be the most appropriate next step for this patient?

a) Obtain a fasting blood glucose level


b) Start metformin (Glucophage), 500 mg daily, and follow up in 4 weeks
c) Order a hemoglobin A 1c level
d) Advise the patient to start a weight-loss program and follow up in 4
weeks
The Correct answer is A

Explanation
This patient should have further testing for diabetes mellitus. Current
recommendations for diagnosing diabetes mellitus are based on either a
fasting glucose level or a 2-hour 75-g oral glucose tolerance test. A
casual blood glucose level >200 mg/dL is also diagnostic of diabetes
mellitus in patients with symptoms of hyperglycemia. If unequivocal
hyperglycemia is not present, the diagnosis must be confirmed by testing
on another day. Metformin can be used to treat diabetes mellitus in
adolescents, but it is not recommended for prevention in this age group.
A diagnosis of diabetes mellitus should be established prior to starting
metformin. Hospitalization is not required for this level of blood
glucose unless ketoacidosis is present. Current recommendations for
treating adolescents with type 2 diabetes mellitus include weight loss
through dietary modification and exercise.
A 6 month old infant is brought to the office by his parents because of
intermittent swelling in his right scrotum. They say the swelling is
more pronounced when he cries. The swelling has never been red or
"stuck." A right inguinal hernia is confirmed on physical examination.
In discussing repair of the hernia with the parents, you should inform
them that

a) Herniorrhaphy can be postponed until age 2 years because many


hernias close spontaneously
b) Herniorrhaphy can be postponed until age 12 years because
oligospermia does not develop before age 12
c) Herniorrhaphy should be scheduled at the earliest convenient time
d) Herniorrhaphy should be scheduled as an emergency
e) There is no need to repair a hernia in childhood unless
incarceration occurs
The Correct answer is C

Explanation
Like cryptorchidism, a patent processus vaginalis very often allows
peritoneal fluid (hydrocele) and other peritoneal contents (mainly
intestines) to come in contact with the testicle. This exposes the
descended testis in the scrotum to more or less similar risk factors for
malignant degeneration as an undescended one.

These hernias do not close spontaneously, probably due to the constant


crying, which maintains a high intraabdominal pressure. The main purpose
of the herniorrhaphy is to prevent incarceration and malignant degeneration.

A 7 year old girl presents with multiple hypopigmented skin lesions over
the trunk and elbows, freckling in the axilla and scoliosis of the
spine. Her sister has similar presentation. Which of the following is
the most likely diagnosis’

a) Tuberous sclerosis
b) Sturge-Weber disease
c) Neurofibromatosis
d) Ataxia telangiectasia
e) Von Hippel-Lindau disease
The Correct answer is C
Explanation
Neurofibromatosis is an autosomal dominant disorder producing tumors
along the course of nerves and occasionally resulting in marked soft
tissue or bony deformity.

Most patients are asymptomatic and identified during routine


examination, examination for cosmetic complaints, or when evaluating a
positive family history. Some present with neurologic symptoms or bony
abnormalities. In > 90%, characteristic skin lesions are apparent at
birth or develop during infancy. Lesions are medium-brown
(café-au-lait), freckle-like macules, distributed most commonly over the
trunk, pelvis, and flexor creases of elbows and knees.

During late childhood, flesh-colored cutaneous tumors of various sizes


and shapes appear, ranging in number from several to thousands.

Neurologic symptoms are varied but relate to location and number of


neurofibromas. Skeletal anomalies include fibrous dysplasia,
subperiosteal bone cysts, vertebral scalloping, scoliosis, thinning of
the long-bone cortex, pseudarthrosis, and absence of the greater wing of
the sphenoid bone (posterior orbital wall), with consequent pulsating
exophthalmos.
The most common cause of hemoptysis in a 6 year old boy is

a) Cystic fibrosis
b) Pneumonia
c) Foreign body
d) Tracheobronchitis
e) Neoplasm
The Correct answer is C

Explanation
Hemoptysis is defined as coughing up of blood or the presence of blood
in sputum. It is not a common symptom in children and although not
usually life-threatening, it can become so. Because children younger
than 6 years of age tend to swallow their sputum, they rarely present
with hemoptysis, unless the bleeding is substantial. Foreign body
aspiration remains a leading cause of hemoptysis in children, with the
majority of cases occurring in those younger than 4 years of age.
A 14 year old girl has refused to go to school 3 times in the past 4
months. She says, "My tummy hurts," but she cannot point to where it
bothers her. Her appetite is good, her bowel movements are normal, and
she is sleeping well at night. She is a healthy-looking girl with no
abnormal findings on physical exam. What is the most likely diagnosis’

a) A benign abdominal mass compressing her duodenum


b) Diaphragmatic hernia
c) Somatoform disorder
d) Gastroesophageal reflux disease
e) Early peptic ulcer disease
The Correct answer is C
Explanation
This is a classic example of psychiatric stress that is expressed
through physical symptoms. Somatization disorder is characterized by
multiple physical complaints (which include pain and GI, sexual, and
neurologic symptoms) over several years that cannot be explained fully
by a physical disorder. Symptoms usually begin before age 30 and are not
intentionally produced or feigned. Diagnosis is based on history after
excluding physical disorders. Treatment focuses on establishing a
consistent, supportive physician-patient relationship that avoids
exposing the patient to unnecessary and potentially unsafe diagnostic
testing and therapies.
On examination of a newborn, you note adduction of the left forefoot, a
convex lateral border, and normal ankle motion. The child is otherwise well.

Which one of the following is accurate regarding this condition?

a) Most of these problems will resolve by 1 year of age without treatment


b) Surgical repair should be performed by adduction that persists
despite stretching exercises
c) It is usually bilateral
d) It is a rare cause of congenital foot deformity
The Correct answer is A

Explanation
The condition described is metatarsus, adductus, the most common
congenital foot deformity. It is usually unilateral, occurring on the
left more than the right, and is found in females more often than in
males. By 1 year of age, 85%-90% will resolve without treatment. Surgery
is not recommended due to frequent complications. Serial casting is the
treatment of choice for adductus that persists longer than 8 months
despite stretching exercises.
In a patient who develops strep pharyngitis, what is the best way to
prevent the development of rheumatic fever?

a) Aspirin alone
b) Penicillin IM
c) Penicillin IV
d) Ceftriaxone IV
The Correct answer is B

Explanation
The recommended prophylaxis against group A streptococcal infection is
with Penicillin G benzathine 1.2 million units IM q 3?4 week.

Rheumatic fever is a nonsuppurative, acute inflammatory complication of


group A streptococcal infection, causing combinations of arthritis,
carditis, subcutaneous nodules, erythema marginatum, and chorea.
Diagnosis is based on applying the Jones criteria to information from
history, examination, and laboratory testing.

Once it develops, treatment includes aspirin or other NSAIDs,


corticosteroids during severe carditis, and antimicrobials to eradicate
residual streptococcal infection and prevent reinfection.
A 13 year old girl complains that one of her breasts is much larger and
firmer than the other. These differences were confirmed by examination.
No nipple retraction was seen. Which one of the following is the most
appropriate management?

a) Referral to surgery
b) Fine needle aspiration
c) Ultrasound examination
d) Repeat examination in a year
e) Mammography
The Correct answer is D

Explanation
The most common abnormality seen in a primary caregiver’s office in
children younger than 12 years is a unilateral breast mass corresponding
to asymmetric breast development. One breast commonly develops earlier
than the other. Ultimately, the breasts are symmetric, despite the
discrepancy in the initial development.

Breast asymmetry may develop as thelarche ensues. In this condition, one


breast may develop before or more rapidly than the other. The physical
examination findings usually include homogenous enlargement of one
breast with no discrete masses or discharge. Accompanying breast
tenderness may be present if the breast bud is starting to develop. If a
mass is excluded either by physical examination or ultrasonography, the
patient and parents can be reassured that the asymmetry will become less
noticeable with age.
A term newborn to a mother who had no prenatal care or screening tests,
a few hours after birth develops respiratory difficulty, tachycardia and
temperature instability. What is the most likely cause?

a) Apnea of prematurity
b) Group B septicemia
c) Transient tachypnea of newborn
d) Respiratory distress syndrome
The Correct answer is B

Explanation
Group B streptococcal septicemia is a severe bacterial infection that
affects newborn infants. It is caused by the bacteria Streptococcus
agalactiae. This bacteria is commonly found in the human
gastrointestinal, reproductive, and urinary tracts. If the bacteria
travels from the mother's bloodstream through the placenta the infant
can become infected. The infant may also become infected if the mother's
water breaks (membranes rupture) as the infant passes through the birth
canal.

The infant may also become infected after delivery. The disease may be
seen from birth to 6 days of life (generally in the first 24 hours) or
in children age 7 days to 3 months. Most cases occur in babies around 1
month old. Group B streptococcus was once responsible for about 75% of
sepsis infections in infants. However, the rate of this condition has
dropped since methods to screen and treat pregnant women at risk have
been established.

Symptoms in the infant may include: anxiety or stress, blue appearance


(cyanosis), breathing difficulties such as: grunting, flaring of the
nostrils, rapid breathing, short periods without breathing, coma,
irregular heart rate - may be fast or extremely slow, irregular
heartbeat, lethargy, poor feeding, shock, and unstable body temperature
(low or high).

Diagnosis involves blood cultures, blood gases, complete blood count,


CSF culture, urine culture and X-ray of the chest. Treatment is with
antibiotics, IV fluids and oxygen.
The physicians counseling a 4 year old child about the death of a loved
one should keep in mind that children in this age group

a) Often feel no sense of loss


b) Often believe they are somehow responsible for the death
c) Should not attend a funeral
d) Should usually be told the loved one is having a long sleep
e) Usually accept the finality of death with little question
The Correct answer is B

Explanation
Children from the ages of 2 to 6 often believe they are somehow
responsible for the death of a loved one. The emotional pain may be so
intense that the child may react by denying the death, or may somehow
feel that the death is reversible. If children wish to attend a funeral,
or if their parents want them to, they should be accompanied by an adult
who can provide comfort and support. Telling a child the loved one is
asleep or that he or she “went away” usually creates false hopes for
return, or it may foster a sleep phobia.
A 4 year old boy develops a headache, cough, myalgia and a fever. He has
been a healthy child with all immunizations up to date. He is given a
decongestant and an aspirin for his symptoms with some relief. However,
3 days later, he is brought back by his parents because of persistent
vomiting and irritability. On physical examination, he is found to be
semicomatose, becoming combative on stimulation. Which of the following
levels should be measured to aid in the diagnosis of this patient?

a) Serum ammonia level


b) Serum blood urea nitrogen level
c) Serum calcium level
d) Serum opiate level
e) Serum sodium level
The Correct answer is A

Explanation
The child is presenting with symptoms of Reye syndrome, which is an
acute encephalopathy associated with high ammonia levels. It most
commonly occurs in young children after a viral illness. Administration
of aspirin increases the risk of developing this disorder. The vomiting
is characteristic.
Which of the following is the most significant risk factor for the
development of childhood asthma

a) Family social background


b) Parental asthma
c) Stress in the family
d) Parental smoking
e) Presence of pets in the house
The Correct answer is B

Explanation
A child with one asthmatic parent has a 25% risk of developing asthma;
if both parents have asthma, the risk increases to 50%. Children whose
mothers smoked during pregnancy are more likely to develop asthma. In
Canada, children in urban environments are more likely to develop
asthma, particularly if they are from lower socioeconomic groups.
Although asthma affects a higher percentage of black children than
white, the role that genetic aspects of race play in the increasing rate
of asthma is controversial because black children are also more likely
to live in urban areas.

Children who are exposed to high concentrations of allergens, such as


dust mites or cockroach feces, at an early age are more likely to
develop asthma. Children who have bronchiolitis at an early age often
wheeze with subsequent viral infections. The wheezing may at first be
interpreted as asthma, but these children are no more likely than others
to have asthma during adolescence.
A baby born prematurely develops mild cyanosis, tachypnea, tachycardia
and a machine like murmur. What is the most likely cause of this’

a) Infective endocarditis
b) Heart failure with VSD
c) Patent ductus arteriosus
d) ASD
The Correct answer is C

Explanation

Patent ductus arteriosus (PDA) is a persistence of the fetal connection


(ductus arteriosus) between the aorta and pulmonary artery after birth,
resulting in a left-to-right shunt. Symptoms may include failure to
thrive, poor feeding, tachycardia, and tachypnea.
A continuous machine-like murmur in the upper left sternal border is
common. Diagnosis is by echocardiography.

Small PDAs may not require treatment or may close without treatment. In
premature babies, indomethacin is often given. Indomethacin has been
shown to be very effective in causing the PDA to close.

If a PDA does not respond to medication, or is due to causes other than


prematurity, surgery may be needed. This surgery is called ligation and
involves placing a suture around the ductus to close it.
A 10-year-old male develops a fever 3 months after returning from a year
abroad in the tropics. He was treated with the proper immunizations and
given appropriate prophylactic medications before he went abroad with
his parents.

Which one of the following tropical illnesses should be considered in


the differential diagnosis’

a) Plague
b) Typhoid fever
c) Malaria
d) Dengue fever
e) Yellow fever
The Correct answer is C

Explanation
Immunizations and malaria prophylaxis are not 100% effective. Of the
diseases listed, only malaria is likely to present more than 3 months
after a return from overseas exposure. The other illnesses listed have
incubation periods which are usually less than 10 days. Vivax malaria in
particular can develop months after travel.
A 6-week-old baby presents to the office. His weight is still near birth
weight. He had a normal birth and delivery and has not had any signs of
infection or illness. The physical examination does not reveal any
significant abnormalities except for his thin appearance. A diagnosis of
failure to thrive is made. Which of the following is indicated?

a) Immediate hospitalization and extensive lab tests


b) Increasing the caloric content of formula and frequent weight
measurements
c) Starting solid foods since formula isn’t resulting in good growth
d) Report to child protective services and immediate placement in
foster care
e) Switching formula to a different cow’s milk-based formula
The Correct answer is B

Explanation
Increasing caloric density of feedings and careful frequent follow-up of
weight gain is a good first step. If there is no improvement with good
caloric intake, then consider hospitalization.

A. This is an expensive approach and usually unnecessary.


C. This child is too young to start solid foods and the caloric content
of solid foods is lower.
D. This approach is too aggressive without more information and evidence
of neglect.
E. Switching to another cow’s milk based formula is no significant
change and would not provide additional calories.
A 16-year-old white male is seen for a preparticipation sports
examination. His height is 183 cm (72 in), his weight is 64 kg (141 lb),
and he appears to have long arms. A physical examination reveals a high
arched palate, kyphosis, myopia, and pectus excavatum. Which one of the
following valvular abnormalities is most likely in this patient?

a) Mitral stenosis
b) Pulmonic stenosis
c) Aortic stenosis
d) Aortic insufficiency
e) Bicuspid aortic valve
The Correct answer is D

Explanation
This adolescent has findings of Marfan syndrome. It is associated with
arachnodactly, arm span greater than height, a high arched palate,
kyphosis, lenticular dislocation, mitral valve prolapse, myopia, and
pectus excavatum. Cardiac examination may reveal an aortic insufficiency
murmur, or a murmur associated with mitral valve prolapse.
Cardiovascular defects are progressive, and aortic root dilation occurs
in 80%-100% of affected individuals. Aortic regurgitation becomes more
common with increasing age.
A 5-year-old male is brought in by his parents for advice about primary
nocturnal enuresis. The father had similar problems until age 11. The
parents are not overly concerned, but want to know what should be done.
The child seems to understand his situation, is in charge of cleaning
his bed, and seems unconcerned about the problem.
After a thorough examination and discussion of the options, the most
appropriate recommendation in this case would be

a) Desmopressin nasal spray (DDAVP) at night


b) Behavioral and cognitive therapy
c) Motivational therapy
d) The bell and pad alarm system, and if unsuccessful, another attempt
in 3 months
e) Watchful waiting until the child and parents are motivated
The Correct answer is E

Explanation
Primary nocturnal enuresis is a common condition for which there are
many options. Treatment depends on the motivation of the parents and the
child. Many times, parents and children just need reassurance that the
condition is benign and that nothing needs to be done, especially for
children under the age of 7.

As the child gets older and expresses an interest in tackling the


problem, treatment should be initiated. Options include motivational
training, bladder training, fluid management, use of an alarm clock 2-3
hours after going to bed, enuresis alarms, and desmopression spray or
pills. Research indicates that all of these options are effective.
However, the enuresis alarms have been shown to be the most successful
treatment in the long run. Desmopression has also been successful, but
relapses are frequent when it is discontinued.
A 24 hour old newborn is observed to have a red conjunctival irritation
with a clear discharge after an uneventful delivery. Which one of the
following is the most likely diagnosis’

a) Gonococcal ophthalmia
b) Chlamydial conjunctivitis
c) Staphylococcus aureus conjunctivitis
d) Drug-induced conjunctivitis
e) Lacrimal duct obstruction
The Correct answer is D

Explanation
Neonatal conjunctivitis is purulent ocular drainage due to a chemical
irritant or a pathogenic organism. Topical prevention is routine.
Diagnosis is clinical and confirmed by laboratory testing. Treatment is
with organism-specific antimicrobials.

The major causes are, in decreasing order, chemical inflammation,


bacterial infection, and viral infection. Chemical conjunctivitis is
generally secondary to the instillation of silver nitrate drops for
ocular prophylaxis.

Chemical conjunctivitis secondary to silver nitrate usually appears


within 6 to 8 hours after instillation and disappears spontaneously
within 48 to 96 hours.
A 15 year old boy presents to the clinic complaining of an unbearable
itchy rash on both legs and forearms.

He recalls a 2 month history of bulky, floating, foul smelling stools.


He also complains of weight loss and fatigue.

Physical exam shows a vesicular eruption on the extensor surfaces of


both legs and forearms as well as loss of muscle bulk and pallor. The
lab tests show that the patient is anemic (Hct of 30%) and the serum
ferritin is 30 ng/mL. Regarding the rash, what is the best medical
treatment for it?

a) Amoxicillin
b) Dapsone
c) Diphenhydramine cream
d) Erythromycin
e) Fluconazole orally
The Correct answer is B

Explanation
Celiac disease should be suspected in any patient presenting with
malabsorption and iron deficiency anemia. The patient presents with
symptoms and signs of malabsorption. He is also complaining of a
vesicular eruption on the extensors with a severe itch, which is
characteristic of dermatitis herpetiformis. It is strongly associated
with Celiac disease and it is caused by the IgA antibodies deposited in
the dermis. Dermatitis herpetiformis is best treated with a gluten-free
diet and Dapsone.

Antihistaminics would decrease the itch to certain extent but they are
not as effective as dapsone.

Antibiotics have no role in the treatment.

Fluconazole would be appropriate for an itchy fungal skin infection.

A 3-year-old white male is brought to your office because of coughing,


drooling, chest pain on swallowing, and refusing food for the last 2
days. Other than irritability and clutching his hand to his chest, you
find no abnormalities on physical examination. A radiograph of the chest
shows what appears to be a coin in the area of the lower esophagus.

Which one of the following treatments is most appropriate at this time?

a) Watchful waiting
b) Administering glucagon to advance the foreign body into the stomach
c) Endoscopic removal of the foreign body
d) Use of an inflated Foley catheter with radiocontrast dye under
fluoroscopy to remove the foreign body
e) Use of bougienage to force the foreign body into the stomach
The Correct answer is C
Explanation
This child ingested a coin without the parent’s knowledge (about 40% of
foreign body ingestions in children are not witnessed) and has symptoms
suggesting esophageal obstruction. Coins are the most common objects
ingested by children in Canada. Most blunt objects in the esophagus may
be observed up to 24 hours. If a single coin has been lodged in the
esophagus for less than 24 hours in a child with no respiratory distress
and no prior foreign body ingestion, Foley catheter or bougienage
techniques may be tried.

For the Foley technique, a Foley catheter is passed beyond the coin and
the balloon is inflated with radiocontrast dye, and then is pulled out
under fluoroscopy. The potential for airway compromise has prevented
this technique from becoming universally accepted. Bougienage seems to
be safe, is less costly, and does not require anesthesia. Bougienage is
used to push the coin into the stomach, where it should pass
spontaneously. In some patients, however, pushing the coin into the
stomach may result in an obstruction that requires endoscopic or
surgical removal. Objects lodged in the esophagus for more than 24 hours
should be removed endoscopically. If the object has been lodged in the
esophagus for more than 2 weeks there is a significant risk of erosion
into surrounding structures, and surgical consultation should be obtained.
A 9-year-old girl presents to the emergency department. She appears
acutely ill and complains of headache, nausea, vomiting, and abdominal
pain. She appears moderately dehydrated. Which of the following does not
support the diagnosis of diabetic ketoacidosis’

a) The presence of hyperpnea (Kussmaul’s respiration) on exam


b) Low serum blood glucose
c) A history of polyuria, polydipsia, fatigue
d) Metabolic acidosis on laboratory examination
e) The presence of ketones in the urine
The Correct answer is B

Explanation
The serum blood glucose is grossly elevated in diabetic ketoacidosis
(DKA) because the absence of insulin in the bloodstream makes glucose
unable to enter the cells.

A. Although not specific for DKA, hyperpnea is indicative of the


acidosis associated with DKA.
C. Polyuria, polydipsia, and fatigue are the result of the osmotc
diuresis seen with hyperglycemia.
D. Ketoacidosis is a hallmark of DKA
E. Ketones are seen in the urine during DKA, or any other catabolic
state where proteins are being used as a major energy source.

A 2-year-old child presents to the clinic with a 1-month history of


worsening anorexia, lower extremity edema, periorbital edema, and weight
gain. You suspect nephrotic syndrome. All of the following help confirm
your diagnosis EXCEPT:

a) Proteinuria
b) Hypoalbuminemia
c) Edema
d) Hypertriglyceridemia
e) Red blood cell casts
The Correct answer is E

Explanation
Nephrotic syndrome is a common cause of edema in pediatric patients.
Eighty-five percent of patients have minimal change disease on renal
biopsy. The majority of patients respond to prednisone. Red blood cell
casts are commonly seen in tubular disease or nephritis.

A. Proteinuria is a hallmark of nephrotic syndrome.


B. Hypoalbuminemia occurs as a result of large protein losses in the urine.
C. Edema of the face, extremities, and ascites may develop as protein
losses increase.
D. Triglycerides are typically protein bound and serum levels of
triglycerides will increase as protein losses increase.
Which one of the following is the most common cause of infectious
enteritis in child in temperate climates’

a) Parvo-like virus
b) Cytomegalovirus
c) Campylobacter jejuni
d) Pathogenic Escherichia coli
e) Human rotavirus
The Correct answer is E

Explanation
Rotavirus is the most common agent responsible for infantile diarrhea
throughout the world. In tropical climates, rotavirus is the etiologic
agent in 15%-50% of cases of acute diarrhea in children, and in
temperate climates it accounts for 35%-60% of cases. Parvo-like viruses
have caused major community outbreaks of acute diarrhea. Cytomegaolvirus
has been shown to infect the colon on occasion. Bacterial pathogens
account for 10%-15% of cases of acute childhood diarrhea: the most
commonly identified bacterial pathogens in North American children are
Campylobacter jejuni and various strains of Salmonella and Shigella
species. Some strains of Escherichia coli are pathogenic, causing
sporadic cases of acute enteritis, epidemic diarrhea, and traveler’s
diarrhea.
A 6 year old boy presents to your clinic for a routine physical
examination. His right arm blood pressure is 150/110 mmHg, while his
left leg blood pressure is 80/60 mmHg. On auscultation a systolic murmur
best heard over the mid-upper back is detected. You also find that his
femoral pulses are delayed when compared with his brachial. An ECG shows
left-axis deviation. What is the most likely diagnosis’

a) Patent ductus arteriosus


b) Ventricular septal defect
c) Coarctation of the aorta
d) Aortic stenosis
e) Mitral valve prolapse
The Correct answer is C

Explanation
Coarctation of the aorta is localized narrowing of the aortic lumen that
results in upper-extremity hypertension, left ventricular hypertrophy,
and malperfusion of the abdominal organs and lower extremities. Symptoms
vary with the anomaly's severity and range from headache, chest pain,
cold extremities, fatigue, and leg claudication to fulminant heart
failure and shock. A soft bruit may be heard over the coarctation site.

Diagnosis is by echocardiography or by CT or MR angiography. Treatment


is balloon angioplasty with stent placement, or surgical correction.
Endocarditis prophylaxis is recommended.
A 7 year old boy with occasional nose bleeds is referred to you for
investigations. Which one of the following conditions is the most common
cause of recurrent epistaxis’

a) Allergic rhinitis
b) Digital trauma (nose-picking)
c) Von Willebrand's disease
d) Idiopathic thrombocytopenic purpura (ITP)
e) Nasal angiofibroma
The Correct answer is B

Explanation
Nosebleeds (epistaxis) have a variety of causes, the most common of
which are nose picking and injury. The cold, dry air of winter also
makes nosebleeds more likely. People who take aspirin or other drugs
that interfere with the blood's ability to clot (anticoagulants)
commonly develop nosebleeds. Some people get them rather often, and
others rarely get them.

Bleeding usually comes from the front part of the nasal septum, which
contains many blood vessels. There may be just a trickle of blood or a
strong stream. Most nosebleeds are more frightening than serious.
Approximately 30%-50% of infants born to Chlamydia-positive mothers will
have

a) Conjunctivitis
b) Dermatitis
c) Jaundice
d) Pneumonia
e) Urogenital infection
The Correct answer is A

Explanation
Chlamydial genital infection is reported in 5%-30% of pregnant women,
with vertical transmission to >50% of their infants at birth. An infant
born to a mother with active chlamydial infection has a 50%-70% risk of
acquiring infection at any anatomical site. Approximately 30%-50% of
infants born to Chlamydia-positive mothers will develop conjunctivitis,
and at least 50% of these children will also have nasopharyngeal
infection. Infants born to women with chlamydial infection may also
develop associated pneumonia, but this affects only 10%-20% of this
population.
A 2 year old girl presents because of an apparently absent vagina.
Examination reveals normal external genitalia except for a midline
fusion. The most probable diagnosis is

a) Turner syndrome
b) Congenital absence of the vagina
c) Adrenogenital syndrome
d) Imperforate hymen
e) Labial adhesions
The Correct answer is E

Explanation
Labial adhesion occurs in children when the inner vaginal lips (labia
minora) fuse to each other. It often gives the appearance that the
opening of the vagina has closed off. It may be noticed incidentally by
a parent or by a physician during a medical examination, or the child
may complain of irritation or difficulty urinating.

Because the fusion sometimes creates a little pouch in front of the


vagina where urine can collect, some children experience dribbling when
they stand up after urinating. Occasionally a child will get a bladder
infection or will have difficulty passing urine due to the obstruction
but most often labial adhesions are not significant enough to obstruct
the flow of urine.

The most likely cause is that inflammation of the labia minora creates
two raw surfaces at the edges of the lips, which eventually heal
together in the middle, partly or fully covering the opening of the vagina.

Many factors can lead to inflammation and irritation of the vaginal


lips. Exposure to irritants like fabric softener residue, perfumed
soaps, or bits of stool; or a prolonged exposure to damp (as in wet
diapers) all can cause irritation of the area. The lack of estrogen
(which is normal before puberty) probably plays a role in this process.

A 3 year old child has a blood pressure of 138/95. He has a systolic


murmur in the right 2nd intercostal space, femoral pulse is not
palpable. He was born premature. What is the most likely diagnosis’

a) Coarctation of aorta
b) PDA
c) ASD
d) VSD
The Correct answer is A

Explanation
Coarctation of the aorta is localized narrowing of the aortic lumen that
results in upper-extremity hypertension, left ventricular hypertrophy,
and malperfusion of the abdominal organs and lower extremities. Symptoms
vary with the anomaly's severity and range from headache, chest pain,
cold extremities, fatigue, and leg claudication to fulminant heart
failure and shock. A soft bruit may be heard over the coarctation site.

Diagnosis is by echocardiography or by CT or MR angiography. Treatment


is balloon angioplasty with stent placement, or surgical correction.
Endocarditis prophylaxis is recommended.
You are the team physician for the local high-school swim team. Over the
past week, seven members of the team have developed both folliculitis
and outer ear infections. You suspect bacterial contamination of the
swimming pool. Which one of the following is the most likely cause?

a) Streptococcus pneumoniae
b) Pseduomonas aeruginosa
c) Corynebacterium ulcerans
d) Staphylococcus epidermidis
e) Escherichia coli
The Correct answer is B

Explanation
Athletes, including swimmers, are susceptible to a number of skin
infections. The pH of the external ear is normally acidic. Continued
water exposure raises the pH, creating conditions for bacterial
overgrowth most often caused by either Pseudomonas aeruginosa or
Staphylococcus aureus. Swimming pool folliculitis is most often
attributed to colonization of water with P. aeruginosa.

A 4 year old boy frequently wets his bed with foul smelling urine. His
parents are concerned and would like to what they can do to prevent
this. After obtaining a complete history and physical examination which
of the following is an appropriate next step

a) Urinalysis
b) Prescribe DDAVP (desmopressin)
c) Prescribe imipramine
d) Imaging of the urinary system
e) Give a bed-wetting alarm
The Correct answer is A

Explanation
Nocturnal enuresis is a common problem that can be troubling for
children and their families. Recent studies indicate that nocturnal
enuresis is best regarded as a group of conditions with different
etiologies. A genetic component is likely in many affected children.
Research also indicates the possibility of two subtypes of patients with
nocturnal enuresis: those with a functional bladder disorder and those
with a maturational delay in nocturnal arginine vasopressin secretion.

The evaluation of nocturnal enuresis requires a thorough history, a


complete physical examination, and urinalysis. Treatment options include
nonpharmacologic and pharmacologic measures. Continence training should
be incorporated into the treatment regimen. Use of a bed-wetting alarm
has the highest cure rate and the lowest relapse rate; however, some
families may have difficulty with this treatment approach. Desmopressin
and imipramine are the primary medications used to treat nocturnal
enuresis, but both are associated with relatively high relapse rates.
A 5 year old girl is brought to you by her father. He states that she
has since birth a history of vomiting after meals. She now complains of
dysphagia for solids. The likely cause for her symptoms is

a) Esophagitis
b) Bazoar
c) Hiatal hernia
d) Duodenal ulcer
The Correct answer is C

Explanation Her clinical picture most resembles that of a hiatal hernia.

A hiatal hernia is an anatomic abnormality where the stomach protrudes


through the diaphragm and up into the chest. These hernias can be
present from birth.

Symptoms include reflux, vomiting, difficulty swallowing and heartburn.


Diagnoses is made by EGD, treatment is via surgical repair.
Which one of the following is an indication for a second dose of
pneumococcal polysaccharide vaccine in children?

a) Cerebrospinal fluid leak


b) Cyanotic congenital heart disease
c) Type 1 diabetes mellitus
d) Sickle cell disease
e) Chronic bronchopulmonary dysplasia
The Correct answer is D
Explanation
Patients with chronic illness, diabetes mellitus, cerebrospinal fluid
leaks, chronic bronchopulmonary dysplasia, cyanotic congenital heart
disease, or cochlear implants should receive one dose of pneumococcal
polysaccharide vaccine after 2 years of age, and at least 2 months after
the last dose of pneumococcal conjugate vaccine. Revaccination with
polysaccharide vaccine is not recommended for these patients.
Individuals with sickle cell disease, those with anatomic or functional
asplenia, immunocompromised persons with renal failure or leukemia, and
HIV-infected persons should receive polysaccharide vaccine on this
schedule and should be revaccinated at least 3 years after the first dose.
Imiquimod (Aldara) is approved by the FDA for treatment of which one of
the following conditions’

a) External anogenital warts


b) Plantar warts
c) Flat warts
d) Periungual warts
e) Molluscum contagiosum
The Correct answer is A

Explanation
Since its FDA approval, imiquimod has been used off-label to treat all
of the conditions listed, but is approved only for treatment of external
genital and perianal warts in patients 12 years of age and over.
A 15-year-old white male complains of bilateral foot pain. He does not
recall any injury, and the pain improves with rest. Examination reveals
tenderness over the lateral and anterior ankle, along with a rigid
flatfoot, peroneal tightness, and pain on foot inversion.

The most likely diagnosis is

a) tarsal coalition
b) stress fracture
c) plantar fasciitis
d) turf toe
e) foot sprain
The Correct answer is A

Explanation
Tarsal coalition is the fusion of two or more of the tarsal bones. It is
congenital, and 50% of the time is bilateral. It is asymptomatic until
early adolescence. On clinical examination there is tenderness over the
subtalar joint (lateral and anterior ankle), rigid flatfoot, limited
subtalar motion, peroneal tightness, and pain on foot inversion.
Treatment is conservative.

A stress fracture would present with pain in the forefoot, warmth, mild
swelling, and point tenderness over the affected metatarsals, most
commonly the second or third. Radiographs are often negative initially,
but a callus is usually evident by the third week of symptoms. Plantar
fasciitis presents with pain in the heel or sole of the foot and is most
painful with the first step after arising from bed or prolonged sitting.
It may be associated with pes planus (flat foot), but in plantar
fasciitis the flat foot is flexible, not rigid. Turf toe is inflammation
of the first metatarsophalangeal joint due to acute and/or repetitive
hyperextension injury resulting from sudden toe-off against an
unyielding surface, such as artificial turf. The patient may present
acutely with a tender, red, swollen first metatarsophalangeal joint,
with pain on passive extension. Others may develop a chronic condition
and present with hallux rigidus. Foot sprain is a nonspecific term for
an acute ligamentous injury.
A 17 year old university student, visits her family physician’s office
complaining of fatigue and ‘strong smelling? urine. She is a member of
the university basketball team and has noted a dip in her performance
since the onset of these symptoms. Urine analysis shows specific gravity
1030, nitrites negative, + protein. Urine microscopy reveals a few
vaginal epithelial cells/hpf, 0-1 wbc’s/hpf, and 0-1 hyaline casts/hpf.
A 24 hour urine collection shows a normal creatinine clearance with
0.41g of protein for this time period. Which one of the following is the
most likely diagnosis’

a) IgA nephropathy
b) Membranous glomerulonephritis
c) Exercise-induced proteinuria
d) Urinary tract infection
e) Reflux nephropathy
The Correct answer is C

Explanation
Exercise proteinuria is transient in nature and is not associated with a
pathological condition. The magnitude of proteinuria varies from near
normal to heavy, with the greatest levels (up to 100 times that of rest)
observed after high-intensity exercise.

An increased quantity of protein in the urine may be due to an increased


filtration of plasma protein through the renal glomerulus and into the
renal tubule. This is termed "glomerular proteinuria", with albumin
comprising the greatest proportion of excreted proteins (albuminuria).
Glomerular proteinuria regularly occurs in response to dynamic exercise,
regardless of the exercise intensity.

Changes in renal hemodynamics during exercise can contribute to


glomerular proteinuria. Reductions in renal plasma or blood flow and
glomerular filtration rate have been documented to occur during
exercise; the extent of this decline is related to the exercise intensity.

An 8 month old infant with trisomy 21 (Down syndrome) has a grade 2-3/6
systolic ejection murmur heard best at the left sternal border, but it
can be heard all over the precordium. S2 is split normally and is loud.
She has had two episodes of pneumonia in the past 2 months. Which of the
following is the most appropriate next step?

a) Do a PPD skin test


b) Initiate an immunologic evaluation
c) Order sweat chloride test
d) Presume the murmur is functional and schedule follow-up visits
e) Seek consultation with a cardiologist
The Correct answer is E

Explanation
Seek consultation with a cardiologist, as this patient with grade 2-3/6
systolic ejection murmur (heard best at the left sternal border and over
the entire precordium) associated with two episodes of pneumonia, has a
cardiac abnormality.

A PPD skin test is done in patients who are suspected of having


tuberculosis. Initiating an immunologic evaluation should not be done in
this patient because the patient is having recurrent pneumonia from
heart disease, not because of immunocompromise. Likewise, a sweat
chloride determination should not be done, because although the patient
has had two pneumonias, these were most likely secondary to a heart
defect, not cystic fibrosis.
A 5 year old girl is seen by her pediatrician after she has complained
of headache, dizziness, tinnitus, sweating, and hyperventilation for 3
days. She was recently diagnosed with juvenile rheumatoid arthritis.
Which one of the following drugs is most likely to be associated with
these adverse effects’

a) Naproxen sodium
b) Acetaminophen
c) Tolmetin
d) Aspirin
e) Prednisone
The Correct answer is D

Explanation
Rheumatoid arthritis (RA) is a chronic autoimmune disease, producing
damage mediated by cytokines, chemokines, and metalloproteases.
Peripheral joints (eg, wrists, metacarpophalangeal joints) are
symmetrically inflamed, often resulting in progressive destruction of
articular structures, usually accompanied by systemic symptoms.
Diagnosis requires specific clinical, laboratory, and radiologic criteria.

If a patient takes aspirin daily (for RA, for example), it can cause or
worsen tinnitus. For this reason, aspirin is no longer used for RA, as
effective doses are often toxic.

Which of the following would be the most likely presenting symptom for a
patient with von willebrand disease during the onset on menstruation?

a) Dyspareunia
b) Dysmenorrhea
c) Infertility
d) Menorrhagia
The Correct answer is D

Explanation
Von Willebrand's disease is a hereditary deficiency of von Willebrand's
factor (VWF), which causes platelet dysfunction. Bleeding tendency is
usually mild. Screening tests show a prolonged bleeding time, normal
platelet count, and, possibly, a slightly prolonged PTT.

Bleeding manifestations are mild to moderate and include easy bruising;


bleeding from small skin cuts that may stop and start over hours;
sometimes, increased menstrual bleeding; and abnormal bleeding after
surgical procedures (eg, tooth extraction, tonsillectomy).

Diagnosis is based on low levels of VWF antigen and abnormal ristocetin


cofactor activity. Treatment involves control of bleeding with
replacement therapy (cryoprecipitate or pasteurized intermediate-purity
factor VIII concentrate) or desmopressin.
In a 1 year old, pneumococcal 7-valent conjugate vaccine (Prevnar) is
preferred rather than polyvalent pneumococcal vaccine (pneumovax)
because of which one of the following advantages’

a) It is available in an oral form


b) It is less expensive
c) It requires only one dose
d) It can be combined with MMR in a single injection
e) It is more immunogenic
The Correct answer is E

Explanation
Pneumococcal 7-valent vaccine produces a satisfactory immune response in
a 1 year old, while polyvalent vaccine does not cause a good antibody
response in children under the age of 2. Neither vaccine is available
orally, and cost is not a factor. The 7-valent vaccine requires multiple
doses. Neither vaccine can be combined with MMR.

A 2 month old baby presents with an erythematous, scaling, crusting


eruption of the scalp, face and diaper area. It is greasy yellow in
appearance. Seborrheic dermatitis is managed using all of the following,
except

a) 1% hydrocortisone cream
b) Keeping the diaper area as dry as possible
c) Baby oil applications to scalp
d) Tar-based shampoo
e) Erythromycin ointment
The Correct answer is E

Explanation
Seborrhoeic dermatitis primarily affects the scalp and intertriginous
areas. It is most common in the first 6 weeks of life, but can occur in
children up to 12 months of age. Involvement of the scalp is frequently
termed "cradle cap", and manifests as greasy, yellow plaques on the
scalp. Other commonly affected areas include the forehead and eyebrows,
nasolabial folds, and external ears. Involvement of skin creases, such
as the nappy area, can lead to secondary Candidal infection and maceration.

Treatment includes the use of a mild tar shampoo, oatmeal baths, and
avoidance of soaps. Occasionally, a mild topical steroid may be indicated.
A 3 year old child is brought to the emergency department with a barking
cough, a hoarse voice, and mild stridor. You diagnose acute
laryngotracheitis. Which one of the following treatments in the
emergency department will reduce this child’s chance of subsequent
hospitalization during this acute illness’

a) Dexamethasone (Decadron)

b) Ceftriaxone (Rocephin)
c) Azithromycin (Zithromax)
d) 2.5% racemic epinephrine
e) Placement in a mist test
The Correct answer is A

Explanation
In laryngotracheitis (croup), intramuscular or oral dexamethasone (0.6
mg/kg) has been shown to reduce the rate of subsequent admission after
acute treatment. This disease is usually viral, and antibiotics are not
helpful. Humidified air is of unproven benefit, and mist tents separate
children from caregivers and hinder observation and evaluation.

For an African-Canadian child with a body mass index (BMI) greater than
the 85th percentile for age and gender, and whose mother has type 2
diabetes mellitus, screening for type 2 diabetes should begin at what age?

a) 7 years
b) 10 years
c) 13 years
d) 15 years
e) In adulthood
The Correct answer is B

Explanation
Children and adolescents at increased risk should be screened for type 2
diabetes at age 10, or at puberty if it occurs before age 10. Children
are considered at increased risk if their BMI is >85th percentile for
age and sex, their weight for height is >85th percentile, or their
weight is >120% of ideal for height, AND they have two or more of the
following:

* a family history of type 2 diabetes in first- or second-degree relatives


* ethnicity of Native Indian, African-Canadian, Hispanic, Asian/Pacific
Islander
* signs/symptoms of insulin resistance (acanthosis nigricans,
hypertension, dyslipidemia, polycystic ovary syndrome)
Screening should be performed every 2 years.
Which one of the following topical agents used in the treatment of acne
vulgaris is principally an antibacterial agent?

a) Tretinoin (Retin-A)
b) Adapalene (Differin)
c) Benzoyl peroxide
d) Tazarotene (Tazorac)
e) Salicyclic acid
The Correct answer is C

Explanation
Tretinoin, adapalene, and tazarotene are all retinoids and are primarily
comedolytic and anti-comedogenic agents. Salicylic acid has a
keratolytic effect and can be useful as a peeling agent. Benzoyl
peroxide is an antibacterial and is therefore most useful in treating
inflammatory papules and pustules.
A 9 year old boy has been referred to you for evaluation of bedwetting.
He is dry during the day but wets every night. His physical examination
and urinalysis are normal. Which one of the following is the most
appropriate method for managing this child?

a) Psychiatric counseling
b) Desmopressin (DDAVP)
c) Waking at night
d) Nightly diapers
e) Limitation of fluid intake
The Correct answer is E

Explanation
Nocturnal enuresis is urinary incontinence during sleep. The child is
counseled about the etiology and prognosis of enuresis, the aim of which
is to remove blame and guilt. The child assumes an active role,
including talking to the physician, urinating before going to bed,
recording wet and dry nights, and changing wet clothing and bedding
himself.

The child should not consume fluids during the 2 to 3 hours before
bedtime, and caffeinated beverages should be strictly limited. Positive
reinforcement is given for dry nights (eg, a star calendar, other
age-appropriate rewards).

In addition to counseling, enuresis alarms are effective and often


recommended simultaneously. Drug therapy can be effective in patients
unresponsive to counseling and alarms. Short-term treatment (4 to 6
weeks) with desmopressin acetate nasal spray (a synthetic analog of ADH)
is typically used in patients ? 6 years with persistent, frequent
nocturnal enuresis.
An 11 year old obese male presents with a significant limp for the past
month. The pain began after a fall down the stairs at school. The pain
is greatest in the anterior thigh and knee while walking. On
examination, the leg is most comfortable in external rotation with some
decrease in flexion in the knee and hip. Which of the following is correct?

a) Reassure the family that his pain


will disappear when he grows out
of his baby fat
b) This is referred pain from a knee strain. Prescribe a knee brace and
excuse him from physical education (PE)
c) Obtain x-rays of the hip
d) Explain that the limp is due to extra weight on the pelvic bones and
recommend a diet
e) Make the parents aware that he is probably trying to avoid PE
because he is overweight, resulting in teasing in the locker room
The Correct answer is C

Explanation
Obesity, prepubertal age, and male gender are associated with the
diagnosis of slipped capital femoral epiphysis. It is also associated
with hormonal abnormalities, including hypothyroidism, growth hormone
deficiency, and decreased levels of estrogen or testosterone. Management
of this patient requires an orthopedic evaluation and possible casting
or surgical treatment.

A. Only 25% or less lose their obesity with adolescence.


B. Knee pain may be referred from a hip problem.
D. Obesity is associated with many serious health problem and is
important to treat, but diet will not be enough in this case.
E. This may be true, but now he has a complication from the obesity and
needs immediate referral and treatment.
All of the following groups are at high risk for eye pathology and will
require ophthalmologic follow-up EXCEPT:

a) Children with a family history of amblyopia


b) Premature infants
c) Patients with cerebral palsy
d) Patients exposed to TORCH infections in utero
e) Patients with frequent conjunctivitis
The Correct answer is E
Explanation
Frequent infections do not present a high risk for eye pathology.

A. Family history of amblyopia is a risk factor for amblyopia.


B. Premature infants are at risk for retinpathy of prematurity.
C. Patients with cerebral palsy are at risk for strabismus.
D. Maternal intrauterine TORCH infections may result in cataracts or
chorioretinitis.
A mother calls your office regarding her 14-month-old son who has fallen
against a door and completely avulsed a lower front tooth. The child is
otherwise healthy. There is no dentist available for consultation.

Which one of the following would be the most appropriate advice?

a) Reimplant the tooth as soon as possible


b) Reimplant the tooth as soon as possible only if the child is no
longer bottle fed
c) Reimplant the tooth as soon as possible and begin antibiotic therapy
d) Do not reimplant the tooth
The Correct answer is D

Explanation
Dental injuries are very common in childhood. If a primary tooth is
completely avulsed, it should NOT be reimplanted, as this may cause
injury to the developing tooth bud. The tooth should be examined to make
sure that the entire root and crown are present. Radiographs may be
needed if there is concern that the tooth was aspirated, swallowed, or
impacted against the alveolus. If the physician is concerned that an
injured, but incompletely avulsed, tooth may be aspirated, he or she can
remove the tooth if a dentist is not immediately available. This is of
particular concern if a child is still bottle fed.
A 2-year-old white female is brought to your office by her parents, who
are concerned about the child’s ?flat feet?. On evaluation, the child’s
feet are flat with weight-bearing, but with toe standing and with
sitting the arch appears.

You would

a) Reassure the parents


b) Recommend orthotics
c) Recommend surgery
d) Recommend casting
e) Recommend foot-stretching exercises
The Correct answer is A

Explanation
Flexible flat feet as described are not pathologic unless painful, which
is uncommon. Flexibility of the flat foot is determined by appearance of
an arch when the feet are not bearing weight. No treatment is indicated
for painless flexible flatfoot. Spontaneous correction is usually
expected within 1 year of walking.
After stepping on a rusty nail, a 5 year old comes to the emergency
room. History reveals that he had his DTaP vaccinations at 2, 4, 6
months and 18 months of age and a booster DT vaccination one year ago.
Which of the following would you recommend?

a) Recombinant human anti-tetanus toxin


b) Metronidazole
c) Vaccination with tetanus and diphtheria toxoids
d) Intramuscular immunoglobulin
e) No further immunizations are required
The Correct answer is E

Explanation
There are four combination vaccines used to prevent diphtheria, tetanus
and pertussis: DTaP, Tdap, DT, and Td. Two of these (DTaP and DT) are
given to children younger than 7 years of age, and two (Tdap and Td) are
given to older children and adults.

Children should get 5 doses of DTaP, one dose at each of the following
ages: 2, 4, 6, and 15-18 months and 4-6 years. DT does not contain
pertussis, and is used as a substitute for DTaP for children who cannot
tolerate pertussis vaccine.

Td is a tetanus-diphtheria vaccine given to adolescents and adults as a


booster shot every 10 years, or after an exposure to tetanus under some
circumstances. Tdap is similar to Td but also containing protection
against pertussis. A single dose of Tdap is recommended for adolescents
11 or 12 years of age, or in place of one Td booster in older
adolescents and adults age 19 through 64.
An 8 year old black male comes in with an asymptomatic erythematous
eruption characterized by oval patches with collarette scaling. It is
distributed as a "Christmas tree" pattern on the back. The father states
that there was originally one lesion on the abdomen a few weeks prior.
What is the most likely diagnosis

a) Pityriasis rosea
b) Tinea corporis
c) Lichen planus
d) Psoriasis
The Correct answer is A

Explanation
Pityriasis rosea (PR) is a condition that classically begins with a
single, primary, 2- to 10-cm ?herald? patch that appears on the trunk or
proximal limbs. A general centripetal eruption of 0.5- to 2-cm rose- or
fawn-colored oval papules and plaques follows within 7 to 14 days. The
lesions have a scaly, slightly raised border (collarette) and resemble
ringworm (tinea corporis). Most patients itch, occasionally severely.
Papules may dominate with little or no scaling in blacks, children, and
pregnant women; the rose or fawn color is not as evident in blacks;
blacks also more commonly have inverse PR (lesions in the axillae or
groin that spread centrifugally).
Classically, lesions orient along skin lines, giving PR a Christmas
Tree-like distribution when multiple lesions appear on the back. A
prodrome of malaise and headache precedes the lesions in a minority of
patients. Diagnosis is based on clinical appearance and distribution.
Out of the following, what is the first event in puberty in females’

a) Menarche
b) Growth spurt (height)
c) Pubic hair
d) Thelarche
e) Voice changes
The Correct answer is D

Explanation
Thelarche or the appearance of breast buds is the first event in puberty
in females. It is followed by the height growth spurt, pubic hair growth
and menarche (in this order). Voice change is not an event in female
sexual development.

/Wish to know more? Read below...


/
-Normal female puberty occurs between 8-13, though can begin as early as
6 in black girls.
-Thelarche, onset of breast development, is the first stage. Asymmetry
is common.
-Adrenarche is the increase in adrenal androgens occurring before
changes in the HPG axis, and is reponsible for growth of pubic and
axillary hair, body odour, and acne.
-Menarche occurs at a mean of 13 years, perhaps 2 years after breast
development. It indicates the growth spurt is nearing completion.
Physiologic leukorrhea occurs 6 months prior to menarche, appearing as
asymptomatic clear or milky vaginal discharge. It is due to endometrial
stimulation by estrogen Menstruation is often at first irregular, and it
takes ~18 months for the first 12 periods.

A 3-week-old male is brought to your office because of a sudden onset of


bilious vomiting of several hours’ duration. He is irritable and refuses
to breastfeed, but stools have been normal. He was delivered at term
after a normal pregnancy, and has had no health problems to date. A
physical examination shows a fussy child with a distended abdomen.
Radiography of the abdomen shows a ?double bubble? sign. Which one of
the following is the most likely diagnosis’

a) Infantile colic
b) Necrotizing enterocolitis
c) Hypertrophic pyloric stenosis
d) Intussusception
e) Midgut volvulus
The Correct answer is E

Explanation
Volvulus may present in one of three ways: as a sudden onset of bilious
vomiting and abdominal pain in a neonate; as a history of ?feeding
problems’ with bilious vomiting that appears to be a bowel obstruction;
or less commonly, as failure to thrive with severe feeding intolerance.
The classic finding on abdominal plain films is the ?double bubble?
sign, which shows a paucity of gas (airless abdomen) with two air
bubbles, one in the stomach and one in the duodenum. However, the plain
film can be entirely normal. The upper gastrointestinal contrast study
is considered the gold standard for diagnosing volvulus.

Infantile colic usually begins during the second week of life and
typically occurs in the evening. It is characterized by screaming
episodes and a distended or tight abdomen. Its etiology has yet to be
determined. There are no abnormalities on physical examination and
ancillary studies, and symptoms usually resolve spontaneously around 12
weeks of age.

Necrotizing enterocolitis is typically seen in the distressed neonate in


the intensive-care nursery, but it may occasionally be seen in the
healthy neonate within the first 2 weeks of life. The child will appear
ill, with symptoms including irritability, poor feeding, a distended
abdomen, and bloody stools. Abdominal plain films will show pneumatosis
intestinalis, caused by gas in the intestinal wall, which is diagnostic
of the condition.

Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused


by hypertrophy of the musculature. It usually presents during the third
to fifth weeks of life. Projectile vomiting after feeding, weight loss,
and dehydration are common. The vomitus is always nonbilious, because
the obstruction is proximal to the duodenum. If a small olive-size mass
cannot be felt in the right upper or middle quadrant, ultrasonography
will confirm the diagnosis.

Intussusception is seen most frequently between the ages of 3 months and


5 years, with 60% of cases occurring in the first year and a peak
incidence at 6?11 months of age. The disorder occurs predominantly in
males. The classic triad of intermittent colicky abdominal pain,
vomiting, and bloody, mucous stools is encountered in only 20%?40% of
cases. At least two of these findings will be present in approximately
60% of patients. The abdomen may be distended and tender, and there may
be an elongated mass in the right upper or lower quadrants. Rectal
examination may reveal either occult blood or frankly bloody,
foul-smelling stool, classically described as ?currant jelly.? An air
enema using fluoroscopic guidance is useful for both diagnosis and
treatment.

A 10 year old boy with cough, fever and night sweats has a positive skin
test for tuberculosis. A chest x-ray reveals minimal hilar adenopathy
and a small pulmonary infiltrate. The current recommended treatment is

a) Isoniazid alone
b) Isoniazid plus rifampin and pyrazinamide
c) Isoniazid plus rifampin and streptomycin
d) Rifampin and corticosteroids
e) Rifampin and ethambutol
The Correct answer is B

Explanation
All patients with new, previously untreated TB should receive a 2 month
initial phase of treatment followed by a 4 or 7 month continuation
phase. Initial-phase therapy is with a combination of antibiotics for
the first 2 months which are isoniazid (INH), rifampin (RIF), and
pyrazinamide (PZA).
A newborn male has a skin eruption on his forehead, nose, and cheeks.
The lesions are mostly closed comedones with a few open comedones,
papules, and pustules. No significant erythema is seen. Which one of the
following is the most likely diagnosis’ a

a) Erythema toxicum neonatorum


b) Localized superficial Candida infection
c) Herpes simplex
d) Milia
e) Acne neonatorum
The Correct answer is E

Explanation
Acne neonatorum occurs in up to 20% of newborns. It typically consists
of closed comedones on the forehead, nose, and cheeks, and is thought to
result from stimulation of sebaceous glands by maternal and infant
androgens. Parents should be counseled that lesions usually resolve
spontaneously within 4 months without scarring. Findings in erythema
toxicum neonatorum include papules, pustules, and erythema. Candida and
herpes lesions usually present with vesiculopustular lesions in the
neonatal period. Milia consists of 1- to 2-mm pearly keratin plugs
without erythema, and may occur on the trunk and limbs.
A parent comes to your office for a well-child visit. You notice the
patient hopping to the exam room, singing ?London Bridge Is Falling
Down.? Mom states the patient does a great job playing cooperatively.
The age of the patient according to his observed milestones may best be
described as:

a) 2 years old
b) 3 years old
c) 4 years old
d) 5 years old
e) 6 years old
The Correct answer is C

Explanation
4 years old. Gross motor skills at 4 years of age include hopping,
skipping, and alternating feet going downstairs. Visual motor skills at
4 years of age include buttoning clothing fully and catching a ball.
Language skills at 4 years of age include knowing colors, singing songs
from memory. Social skills at 4 years of age include cooperative play.

A. 2-year-old infants are able to walk up and down stairs, but not hop,
may remove pants and shoes, but does not exhibit fully developed
language usage or parallel play.
B. 3-year-old infants may alternate feet going up steps, dress and
undress partially, use 3-word sentences, and begin group play.
D. 5-year-old infants may skip alternating feet, tie shoes, print their
first name, and play competitive games.
E. 6-year-old children are in kindergarten to 1st grade and know their
ABCs, may count up to ten, form friendships, and do household chores.
A 5 year old child is diagnosed as having juvenile rheumatoid arthritis.
Which of the following is the least likely side effect of therapy with a
non-steroidal anti-inflammatory drug

a) Abdominal pain
b) Lymphadenopathy
c) Tinnitus
d) Anemia
e) Rash
The Correct answer is B

Explanation
NSAIDs are associated with a number of side effects. The most common
side effects are nausea, vomiting, diarrhea, constipation, decreased
appetite, rash, dizziness, headache, and drowsiness. NSAIDs may also
cause tinnitus and fluid retention, leading to edema. The most serious
side effects are kidney failure, liver failure, ulcers and prolonged
bleeding after an injury or surgery. Some individuals are allergic to
NSAIDs and may develop shortness of breath when an NSAID is
administered. People with asthma are at a higher risk for experiencing
serious allergic reaction to NSAIDs.
A healthy, full-term, breastfed infant is jaundiced at 24 hours of age.
The indirect serum bilirubin level is 210 umol/L. The mother is blood
type O, Rh positive. Which of the following is the most appropriate step

a) Culture the blood


b) Interrupt breast feeding
c) Obtain a reticulocyte count
d) Obtain blood type and Coombs test
The Correct answer is D

Explanation
The Coombs' test looks for antibodies that act against red blood cells.
An abnormal (positive) direct Coombs' test means the patient has
antibodies that act against their red blood cells. This may be due to
autoimmune hemolytic anemia without another underlying cause,
drug-induced hemolytic anemia (many drugs have been associated with this
complication) or erythroblastosis fetalis (hemolytic disease of the
newborn).
You admit a 16-month old male to the hospital with a 24-hour history of
high fever and respiratory symptoms have been present for 24 hours.
Laboratory testing is positive for influenza B. The patient has asthma
but is otherwise healthy.

Which one of the following would be appropriate to shorten the course of


this patient’s illness’

a) Amantadine (Symmetrel)
b) Rimantadine (Flumadine)
c) Zanamir (Relenza)
d) Oseltamivir (Tamiflu)
The Correct answer is D

Explanation
This child would be a candidate for treatment, as his underlying asthma
increase his risk for severe or complicated influenza infection.
Amantadine is approved for use in children but has not efficacy against
influenza B. The other two medications are in the class of antiviral
drugs called neuraminidase inhibitors. Zanamivir is approved for
children age 7 and above and is effective for both type A and type B.
Osteltamavir is the only medication in this class that is appropriate
for a 16-month-old, as it can be used for children age 1 and above. It
is effective for both type A and type B. Oseltamivir decreases symptoms
in children ages 1-12 years by approximately 1.5 days. Therapy should be
initiated as rapidly as possible after symptom onset.

Which of the following is not required for a diagnosis of juvenile


rheumatoid arthritis’

a) Arthritis in at least one joint


b) Arthritis lasting for at least 6 weeks
c) Positive rheumatoid factor
d) Onset before the age of 16
e) Other causes of arthritis excluded
The Correct answer is C

Explanation
Juvenile rheumatoid arthritis (JRA) should be suspected in children with
symptoms of arthritis, signs of iridocyclitis, generalized adenopathy,
splenomegaly, or unexplained fever lasting more than a few days, or
rash. Diagnosis is primarily clinical. Patients suspected of having JRA
should be tested for rheumatoid factor (RF), antinuclear antibodies
(ANA), and ESR as these tests may be helpful in diagnosing JRA and
distinguishing its subtypes. In Still's disease, RF and ANA are absent.
In pauciarticular-onset JRA, ANA are present in up to 75%. In
polyarticular-onset JRA, RF usually is negative, but in some patients,
mostly adolescent girls, it can be positive.
A small child with failure to thrive is found to have a bone age that is
markedly delayed relative to height age and chronologic age. The most
likely etiology is

a) Cystic fibrosis
b) Hypothyroidism
c) Down syndrome
d) Fetal alcohol syndrome
e) Gonadal dysgenesis
The Correct answer is B

Explanation
Hypothyroidism is associated with markedly delayed bone age relative to
height age and chronologic age. In cystic fibrosis, bone age and height
age are equivalent, but both lag behind chronologic age. Children with
chromosomal anomalies such as trisomy 21 (Down syndrome) or XO have a
height age which is delayed relative to bone age. This pattern is also
seen as a result of maternal substance abuse.
A 10-year-old presents with a 1-year history of abdominal pain which is
“always there”, but waxes and wanes. She is an “A” student and competes
on a state level in figure skating. Mom describes her as a happy child
who doesn’t seem to be stressed. Most likely diagnosis:

a) Appendicitis
b) Parasitic enteritis
c) Inflammatory bowel disease (IBD)
d) Chronic abdominal pain
e) Gallbladder disease
The Correct answer is D

Explanation
The duration of the symptoms, history of being an ?A? student, and type
A competitive personality all make chronic abdominal pain most likely.
As stress is internalized and somaticized, stress often is not shown
outwardly.

A. The history is too chronic to be typical for appendicitis.


B. There is no history of diarrhea or blood in the stools, and no
history of bloating/gaseous pain.
C. IBD tends to have a more chronic history of diarrhea with blood in
the stools, and progressive worsening of the disease.
E. Gallbladder disease is unlikely in pediatrics unless there is a
history of hemoglobinopathy, chronic TPN, or other underlying illnesses.

An 8 year old boy is admitted with a diagnosis of acute renal failure.


The serum potassium level is 7.0 mmol/L. Which one of the following is
most likely to be observed on the electrocardiogram?

a) Increased P wave amplitude


b) ST segment elevation
c) Increased T wave amplitude
d) Increased R wave
e) Absent Q waves
The Correct answer is C

Explanation
Characteristic ECG changes occur at various levels of hyperkalemia. The
QRS complexes begin to widen when the patient's serum potassium level
reaches about 6-6.5 mEq/L, becoming markedly slurred and abnormally
widened at 10 mEq/L.

The QRS complexes may widen so that they merge with the T waves,
resulting in a "sine wave" appearance. The ST segments disappear when
the serum potassium level reaches 6 mEq/L and the T waves typically
become tall and peaked at this same range. The P waves begin to flatten
out and widen when a patient's serum potassium level reaches about 6.5
mEq/L; this effect tends to disappear when levels reach 7-9 mEq/L.
All of the following are appropriate in the initial assessment of a
child with failure to thrive, except

a) Diet history
b) Social history
c) Measurement of height, weight and head circumference
d) Growth hormone levels
e) Bone age x-ray
The Correct answer is D

Explanation
Failure to thrive is a condition commonly seen by primary care
physicians. Prompt diagnosis and intervention are important for
preventing malnutrition and developmental sequelae. Medical and social
factors often contribute to failure to thrive. Either extreme of
parental attention (neglect or hypervigilance) can lead to failure to
thrive. About 25 percent of normal infants will shift to a lower growth
percentile in the first two years of life and then follow that
percentile; this should not be diagnosed as failure to thrive.

Infants with Down syndrome, intrauterine growth retardation, or


premature birth follow different growth patterns than normal infants.
Many infants with failure to thrive are not identified unless careful
attention is paid to plotting growth parameters at routine checkups. A
thorough history is the best guide to establishing the etiology of the
failure to thrive and directing further evaluation and management.

All children with failure to thrive need additional calories for


catch-up growth (typically 150 percent of the caloric requirement for
their expected, not actual, weight). Few need laboratory evaluation.
Hospitalization is rarely required and is indicated only for severe
failure to thrive and for those whose safety is a concern. A
multidisciplinary approach is recommended when failure to thrive
persists despite intervention or when it is severe.
A 12 month old infant boy was brought in by his mother for required
(routine and non-routine) vaccination before they leave the country to
go to Peru. The mother tells you that 2 weeks ago, he tried a small
amount of scrambled eggs and developed hives, wheezing and swelling. He
was treated in the emergency room. Which of the following would you be
particularly concerned that he may react to?

a) Diphtheria toxoid
b) Flu vaccine
c) MMR vaccine
d) Polio vaccine
e) Yellow fever vaccine
The Correct answer is E

Explanation
Children with egg allergy present the biggest concern when receiving
childhood vaccines. The following routine childhood immunizations may
contain egg or egg-related proteins: influenza (flu) and
measles-mumps-rubella (MMR) vaccines. In addition, the following
non-routine vaccines contain egg protein: yellow fever and typhoid vaccines.

Yellow fever vaccine, which contains the highest amount of egg protein
of all the egg-based vaccines. Live yellow fever vaccine is produced in
chick embryos and should not be given to persons hypersensitive to eggs.
A 3-week-old infant is brought to your office with a fever. He has a
rectal temperature of 38.3°C (101.0°F), but does not appear toxic. The
remainder of the examination is within normal limits. Which one of the
following would be the most appropriate management for this patient?

a) Admit to the hospital; obtain urine, blood, and CSF cultures; and
start intravenous antibiotics
b) Admit to the hospital and treat for herpes simplex virus infection
c) Follow up in the office in 24 hours and admit to the hospital if not
improved
d) Order a CBC and urinalysis with urine culture, and send the patient
home if the results are normal
The Correct answer is A

Explanation
Any child younger than 29 days old with a fever, and also any
child, regardless of age, who appears toxic, should undergo a complete
sepsis workup and be admitted to the hospital for observation until
culture results are known or the source of the fever is found and treated.

Observation only, with close follow-up, is recommended for nontoxic


infants 3-36 months of age with a temperature <39.0°C (102.2°F).
Children 29-90 days old who appear to be nontoxic and have negative
screening laboratory studies, including a CBC and urinalysis, can be
sent home with precautions and with follow-up in 24 hours. Testing for
neonatal herpes simplex virus infection should be considered in patients
with risk factors, including maternal infection at the time of delivery,
use of fetal scalp electrodes, vaginal delivery, cerebrospinal fluid
pleocytosis, or herpetic lesions. Testing also should be considered when
a child does not respond to antibiotics.
A 2 month old boy has a calcium of 1.80 (corrected) after an assessment
for failure to thrive (FTT). The mother informs you she has been
consistently breastfeeding without trouble as corroborated by a visiting
nurse. What is at the top of your differential?

a) Malabsorption
b) Pseudohypoparathyroidism
c) Mother didn’t supplement with Vitamin D supplement
d) DiGeorge syndrome
The Correct answer is C

Explanation
Vitamin D or properly termed cholecalciferol, formed in the skin is the
precursor to the biologically active form 1,25(OH)2D, a steroid hormone
that is synthesized via a number of steps in the liver and the kidney.
It is this final form 1,25(OH)2D of "vitamin" D that performs the
important calcium utilization function.

Adequate intakes of calcium and sufficient exposure to sunlight is the


normal, biologically safe way to ensure normal calcium metabolism for
exclusively breastfed infants. "Vitamin" D supplementation is a
therapeutic means to prevent and treat rickets and ensure that adequate
bone mineralization occurs for those at risk. Those who may be at risk
are dark skinned infants who are born to mothers who did not receive
vitamin D supplements or consumed vitamin D supplemented milk or who
themselves were not adequately exposed to sunlight during pregnancy and
who exclusively breastfeed without exposing themselves and their infants
to sunlight.
A 16-year-old high-school cross-country runner presents with bilateral
leg pain for the past several weeks. She complains of tightness and
swelling of the anterior lateral aspect of both legs. The pain occurs
with running and lasts 30 minutes after completion of a run. She is in
the middle of the season and does not wish to quit or decrease her
activity level.

A physical examination is negative except for mild tenderness over the


affected area. Palpation of the posterior medial aspect of the tibia is
negative and there is no point tenderness along the anterior or
posterior medial tibia.

Which one of the following is most likely to confirm the diagnosis’

a) A bone scan
b) MRI of the lumbar spine
c) Nerve conduction velocity testing
d) Angiography of the popliteal artery
e) Measurement of compartmental pressures
The Correct answer is E

Explanation
Chronic compartment syndrome is becoming more frequently recognized. It
tends to affect young athletes, particularly girls, and is more common
in runners and soccer players. The most common compartments involved are
the anterior and deep posterior compartments. Symptoms appear to be due
to the increase in blood volume and edema which occurs with exercise,
increasing muscle mass by up to 20%. The resulting elevated pressure
within the compartment leads to diminished capillary flow and tissue
ischemia, causing pain which is not usually severe.

The pain tends to recur at a specific distance and usually resolves


within minutes to hours after stopping the activity. Physical
examination may reveal tenderness over the involved compartment, but is
often negative. The examination does help rule out other entities such
as shin splints, stress fracture, claudication, disc herniation,
popliteal artery entrapment, peroneal nerve entrapment, and
gastrocnemius strain. The diagnosis is confirmed by measuring the
pressure in the involved compartment.
You are seeing a 13 year old female with a history of asthma and a
seizure disorder who has recently developed acne. The mother is
concerned that this may be due to one of her medications. Which of the
following drugs is least associated with acne?

a) Corticosteroids
b) Lithium
c) Ventolin (Albuterol)
d) Phenytoin
e) Alesse (OCP)
The Correct answer is C

Explanation
Some drugs that can cause acne:
Anticonvulsants (such as Phenytoin)
Corticosteroids
Lithium
Anabolic-Androgenic steroids (such as Danazol, Stanozolol)
DHEA
OCP (Oral contraceptives that are most likely to cause worse acne are
those that have a low estrogen content and a type of progestin that
increases the androgen levels - such as Loestrin, Alesse)

Metered-dose inhaler (MDI) and/or nebulizers can be used to administer


short-acting Alfa_2 agonists for treating acute asthma exacerbations in
children. Which one of the following is true regarding these delivery
methods’

a) The use of nebulizers is associated with lower pulse rates than use
of an MDI with a spacer
b) Children must be capable of understanding and following simple
instructions for effective use of MDIs with spacers
c) MDIs with spacers are as effective as nebulizers, and treatment
costs are lower
d) Nebulizer treatment results in a statistically significant reduction
in length of stay in the emergency department when compared to treatment
with MDIs
e) The use of MDIs with spacers must be limited to a maximum of 2 puffs
every 6 hours in children
The Correct answer is C

Explanation
The treatment of acute asthma exacerbations in children using ?2
agonists delivered by metered-dose inhalers (MDIs) with spacers has been
shown to be as effective as nebulized administration. The use of MDIs
with spacers in this clinical setting has the advantage of lower costs,
lower increases in pulse rate, and shorter emergency department stays.
MDIs with spacers have been used successfully in children as young as 10
months of age and at doses as high as 10 puffs at once.
A 5 year old boy develops a rash. He also has Koplik's spots that have
appeared. His other symptoms include fever and cough. Which of the
following illnesses does he most likely have?

a) Measles
b) Mumps
c) Rubella
d) Diptheria
e) Polio
The Correct answer is A

Explanation
Measles is a highly contagious, viral infection that is most common in
children. It is characterized by fever, cough, coryza, conjunctivitis,
enanthem (Koplik's spots) on the buccal or labial mucosa, and a
maculopapular rash that spreads cephalocaudally. Diagnosis is usually
clinical. Treatment is supportive. Vaccination is highly effective.
Which of the following congenital anomalies usually resolves spontaneously?

a) Club foot
b) Genu varum
c) Tibial torsion
d) Flexible flat feet
e) Femoral torsion
The Correct answer is B

Explanation
Clinical assessment for Genu varus or bow-leggedness is often made with
the legs together by measuring the distance between the knees for bowing
and the ankles for knock knee (genu valgum) deformity. A more accurate
measurement would be the tibial femoral angle as seen on the standing
x-ray. One must be careful that the legs are in neutral rotation when
the x-ray is taken, as internal or external rotation will alter this angle.
Physiologic bow leg deformity should spontaneously correct by two years
of age. No x-rays are usually necessary before then. Internal tibial
torsion and external rotation contracture of the hips often accompany
genu varum and tend to accentuate the deformity.

Treatment is reassurance and observation. Shoe corrections, splints and


exercise programs do not produce any change different than the normal
expected spontaneous correction.

The mother of a 3-year-old male is concerned that he doesn’t like being


help, doesn’t interact much with other children, and rarely smiles. Of
the following, which feature would be most helpful in distinguishing
Asperger’s syndrome from autism in this patient?

a) Normal language development


b) Delayed gross motor development
c) Repetitive fine motor mannerisms
d) Preoccupation with parts of objects
e) Focused patterns of intense interest
The Correct answer is A

Explanation
The DSM-IV categorizes Asperger’s syndrome and autism as pervasive
developmental disorders. In both conditions, children have
significant difficulties with social interactions, although the
impairment is more severe and sustained in autism. Both Asperger’s and
autism may be associated with symptoms of repetitive motor mannerisms,
restricted patterns of interest (which are abnormal in focus or
intensity), or preoccupation with parts of objects.

However, unlike children with Asperger’s syndrome, autistic children


have serious problems with communication skills, either in the
development of speech itself or in the ability to carry on a
conversation. Normal, age-appropriate language skills in a 3-year-old
would rule out a diagnosis of autism.

It is an important distinction to make, as the prognosis for independent


functioning in children with Asperger’s syndrome is significantly better
than in children with autism.
Which of the following would NOT be seen in patients with pulmonary
hemosiderosis’

a) Frothy, blood tinged sputum


b) A normal chest x-ray
c) Association with a milk allergy
d) Alveolar hemorrhages on lung biopsy
e) Iron deficiency anemia
The Correct answer is B

Explanation
The chest x-ray in pulmonary hemosiderosis usually reveals diffuse
fluffy infiltrates, secondary to alveolar hemorrhaging. Lung biopsy
typically reveals alveolar hemorrhages with hemosiderin laden macrophages.

A. Blood-tinged sputum is associated with coughing secondary to alveolar


hemorrhaging.
C. Some cases of pulmonary hemosiderosis are associated with a milk
allergy. This is called Heiner syndrome. Many of these children may have
upper airway obstruction. Milk products should be eliminated as part of
therapy.
D. Lung biopsy typically reveals alveolar hemorrhages with hemosiderin
laden macrophages.
E. Iron deficiency anemia may be present secondary to the chronic
pulmonary hemorrhaging.

All infants less than 2 months of age who have fever and no localizing
signs should have all of the following evaluations, *except*

a) Blood cultures
b) Spinal tap
c) Chest x-ray
d) CBC (with differential)
e) Urine culture
The Correct answer is C

Explanation
In infants younger than 2 months of age who have a fever, you may order
blood and urine tests and perform a spinal tap to look for occult
bacteremia, urinary tract infection, and meningitis. The reason for
these tests is that in infants, the source of fever is difficult to
determine. They are also at risk of serious infection compared with
older children because of their immature immune system. You may also
order an x-ray if the infant's breathing is abnormal.
For infants older than 2 months of age, testing may not be needed, but
you might want to order blood and urine tests and perform a spinal tap
if the source of the fever is not obvious and the child appears ill.
A 10 month old child develops low-grade fever and sunburn-like erythema
over much of the body, but most prominently in the intertriginous areas.
Within 36 hours, sheet-like desquamation is noted in the flexures and
around the mouth. The mucous membranes are spared. Which of the
following is the most likely diagnosis

a) Kawasaki disease
b) Staphylococcal scalded skin syndrome
c) Stevens-Johnson syndrome
d) Toxic epidermal necrolysis
e) Toxic shock syndrome
The Correct answer is B

Explanation
Staphylococcal scalded skin syndrome is an acute epidermolysis caused by
a staphylococcal toxin. Newborns and children are most susceptible.
Symptoms are widespread bullae with epidermal sloughing.

The initial lesion is usually superficial and crusted. Within 24 h, the


surrounding skin becomes painful and scarlet, changes that quickly
spread to other areas. The skin may be exquisitely tender and have a
wrinkled tissue paper?like consistency. Large, flaccid blisters arise on
the erythematous skin and quickly break to produce erosions. Intact
blisters extend laterally with gentle pressure (Nikolsky's sign). The
epidermis may peel easily, often in large sheets. Widespread
desquamation occurs within 36 to 72 h, and patients become very ill with
systemic manifestations (eg, malaise, chills, fever). Desquamated areas
appear scalded. Loss of the protective skin barrier can lead to sepsis
and to fluid and electrolyte imbalance.

Diagnosis is by examination and sometimes biopsy. Treatment is


antistaphylococcal antibiotics and local care. Prognosis is excellent
with timely treatment.
A 13 year old male is found to have asymptomatic hypertrophic
cardiomyopathy. His father also had hypertrophic cardiomyopathy, and
died suddenly at age 38 following a game of tennis. The boy’s mother
asks you for advice regarding his condition. What advice should you give
her?

a) He may participate in noncontact sports


b) Cardiac catheterization should be performed immediately.
c) His condition usually decreases lifespan
d) His hypertrophy will regress with age
e) His siblings should undergo echocardiography
The Correct answer is E

Explanation
Hypertrophic cardiomyopathy is an autosomal dominant condition and close
relatives of affected individuals should be screened (with
echocardiography). The hypertrophy usually stays the same or worsens
with age. This patient should not participate in strenuous sports, even
those considered noncontact. The mortality rate is believed to be about
1%, with some series estimating 5%. Thus, in most cases, lifespan is
normal. Cardiac catheterization should be performed in patients with HCM
who have angina, syncope, resuscitated sudden death, or a worrisome
stress test.
A 4 year old girl has a 6 day history of high fever, unresponsive to
penicillin. She has conjunctival injection, red cracked lips, marked
cervical adenopathy, and a macular exanthem which involves the palms and
soles. The most likely diagnosis is

a) Stevens-Johnson syndrome
b) Mucocutaneous lymph node (Kawasaki) syndrome
c) Scarlet fever
d) Mononucleosis
e) Measles
The Correct answer is B

Explanation
Kawasaki Disease is an illness that involves the skin, mouth, and lymph
nodes, and typically affects children who are under the age of 5. The
cause of Kawasaki Disease is unknown, but if the symptoms are recognized
early, kids with the disease can fully recover within a few days. If it
goes untreated, it can lead to serious complications that can involve
the heart.

The symptoms of Kawasaki Disease typically appear in phases. The first


phase, which can last for up to 2 weeks, usually involves a persistent
fever that is higher than 104 degrees Fahrenheit (39 degrees Celsius),
and lasts for at least 5 days. The other symptoms that typically develop
include: severe redness in the eyes, a rash on the child's stomach,
chest, and genitals, red, dry, cracked lips, swollen tongue with a white
coating and big red bumps, sore, irritated throat, swollen palms of the
hands and soles of the feet with a purple-red color and swollen lymph nodes.

During the second phase of the illness, which usually begins within two
weeks of when the fever first begins, the skin on the child's hands and
feet may begin to peel in large pieces. The child may also experience
joint pain, diarrhea, vomiting, or abdominal pain.

Which one of the following statements concerning childhood sexual abuse


is true?

a) The abused child is usually a male child


b) The abused child usually comes from a two-parent home
c) The psychological effects on the abused child are short-term
d) There is a higher rate of alcohol use in the family
The Correct answer is D

Explanation
The risk factors associated with childhood sexual abuse are:

Gender: female predominance.


Disabilities: Risk increased for those with physical disabilities,
especially those that impair the child’s perceived credibility:
blindness, deafness, and mental retardation.

Family Constellation: Absence of one or both parents is a risk factor.


Presence of stepfather in home doubles the risk for girls. Parental
impairments are also associated with increased risk.
The mother of a newborn has agreed to your suggestion that she
breastfeed for at least the first 6 months of her daughter’s life.
Before being discharged from the hospital, she asks you to clarify some
advice she received from friends about the storage and handling of
expressed breast milk.

Which one of the following would be accurate advice?

a) Breast milk can safely be stored at room temperature for up to 8 hours


b) Frozen breast milk should be thawed quickly, preferably in a
microwave oven
c) Once thawed, breast milk may safely be refrozen within 4 hours
d) If stored breast milk has separated, it is spoiled
e) OSHA guidelines prohibit the storage of human milk in a common
refrigerator in the workplace
The Correct answer is A

Explanation
With many nursing mothers returning to work it is frequently necessary
to shift lactation and feeding schedules using techniques such as
expressing milk with pumps and storing the excess. Human breast milk may
safely be stored up to 10 hours at room temperature, up to 8 days in the
refrigerator, and up to 12 months when frozen. When frozen, it should be
thawed slowly to preserve nutritious proteins and should not be
refrozen. Human breast milk naturally separates and can easily be
re-emulsified by shaking. Exposure to human milk is not an occupational
hazard under OSHA standards.
A 15-year-old male presents to your office with a 2-week history of
progressively worsening dry cough and post-tussive emesis. You highly
suspect pertussis and obtain cultures.

While awaiting the culture results, you should

a) Do nothing, and determine the most appropriate course of action


based on the culture results
b) Treat the patient empirically for pertussis
c) Treat the patient and any of the patient’s household contacts who
are symptomatic
d) Treat the patient and all of the patient’s household contacts
regardless of symptoms
e) Treat the patient, and determine the course of care for all other
close contacts based on the culture results
The Correct answer is D
Explanation
There has been a recent rise in the incidence of pertussis, especially
among adolescents and young adults. In adolescents, the disease presents
as a nonspecific cough with or without the typical paroxysms of severe
coughing and inspiratory whoop. Recommendations state that pertussis
should be suspected in any adolescent who has had a cough for 2 weeks or
longer. When pertussis is highly suspected, nasopharyngeal specimens
should be collected and treatment should be started immediately for the
patient and close contacts, regardless of symptoms.
A 6 day old white male is brought to your office with a 12 hour history
of the sudden onset of vomiting and apparent abdominal pain. The emesis
was initially clear, but over the last few hours it has become quite
bilious. The pregnancy was uncomplicated and the child was delivered at
term. On examination the child is lethargic with a tender abdomen, but
no bowel distention. Of the following, which one is the most likely
diagnosis’

a) Duodenal atresia
b) Malrotation and midgut volvulus
c) Pyloric stenosis
d) Necrotizing enterocolitis
e) Jejunoileal atresia
The Correct answer is B

Explanation
Infants with malrotation and midgut volvulus often present in the first
week of life with symptoms of bilious vomiting and bowel obstruction.
Both duodenal and jejunoileal atresia most commonly present within the
first 24 hours of life. Vomiting associated with pyloric stenosis is
always non-bilious, and the diagnosis is most commonly made after the
first week of life. Necrotizing enterocolitis may also be associated
with bilious vomiting, but typically occurs at 10-12 days of life and is
accompanied by abdominal distension and visible and/or palpable loops of
bowel.
A 3 year old is admitted to the hospital with a very pruritic rash. The
infectious disease consultant identifies it as varicella (chickenpox).
Which of the following is NOT true:

a) Varicella is highly contagious and this patient should be carefully


isolated
b) Varicella may be lethal in immunocompromised hosts
c) Varicella is no longer contagious when all lesions are crusted over
d) Varicella is pruritic to the extent that antipruritic drugs may be
appropriate
e) Varicella has an incubation period of only 5 days
The Correct answer is E

Explanation
Varicella has an incubation period of 11-21 days.

A. The child should be placed in respiratory isolation until there are


no new lesions and all of the lesions are scabbed.
B. Varicella is very dangerous in immunocompromised hosts and should be
treated aggressively in those cases.
C. Once all lesions are crusted, varicella is no longer contagious.
D. The pruritus with varicella may result in scratching, scarring, and
secondary infection.
The most common cause of proteinuria in children is

a) Acute postinfectious glomerulonephritis


b) Lupus glomerulonephritis
c) Hydronephrosis
d) Orthostatic proteinuria
e) Reflux nephropathy
The Correct answer is D

Explanation
Orthostatic proteinuria accounts for up to 60% of all cases of
asymptomatic proteinuria reported in children, with an even higher
incidence in adolescents.
An 8 year old boy presents with sudden onset of pain in the distal
femur. His parents recall that he was hit with a hockey stick during a
street hockey game last week. The most likely diagnosis is

a) Osteomyelitis
b) Fracture of the distal femur
c) Juvenile rheumatoid arthritis
d) Septic arthritis
The Correct answer is A

Explanation
Osteomyelitis is inflammation and destruction of bone caused by
bacteria, mycobacteria, or fungi. Common symptoms are localized bone
pain and tenderness with constitutional symptoms (in acute
osteomyelitis) or without constitutional symptoms (in chronic
osteomyelitis).

Trauma, ischemia, and foreign bodies predispose to osteomyelitis.


Patients with acute osteomyelitis of peripheral bones usually experience
weight loss, fatigue, fever, and localized warmth, swelling, erythema,
and tenderness. Diagnosis is by radiography and cultures. Treatment is
with antibiotics and sometimes surgery.
A 12-month-old toddler presents with a 10-day history of acute otitis
media unresponsive to amoxicillin therapy (80 mg/kg/day). On physical
exam, he is febrile to 100.8?F. There is erythema and edema above the
right ear with down and outward displacement of the pinna. The tympanic
membrane is dull, opaque, and bulging. The light reflex is absent, and
you are unable to move the tympanic membrane with insufflation. You are
concerned that this patient has mastoiditis. If you are correct, what CT
scan findings would verify your clinical diagnosis’

a) Normal ossicles and temporal bone, with soft tissue swelling behind
the right ear
b) Destruction of septa between the mastoid cells on the right, with
soft tissue swelling behind the right ear
c) Free fluid surrounding the ossicles with normal temporal bone and
clear mastoid cells on the right
d) Normal CT scan
The Correct answer is B

Explanation
Mastoiditis presents clinically as described above. CT scan will reveal
clouding to destruction of septa between mastoid cells with soft tissue
swelling behind the affected ear. Temporal bone destruction may also be
seen along with soft tissue abscesses.

A. With otitis media, you would expect to see some free fluid around the
ossicles when a suppurative effusion is present. This is also seen with
mastoiditis. See Answer B.
C. Clear mastoid cells with surrounding free fluid of the ossicles is
consistent with acute otitis media.
D. In patients with clinical mastoiditis, you would not expect to have a
normal CT scan.
The most likely complication of an undescended testis is

a) Inguinal hernia
b) Hydrocele
c) Malignancy
d) Torsion
The Correct answer is C

Explanation
Cryptorchidism is defined as failure of the testis to descend from its
intra-abdominal location into the scrotum. Incidence in premature male
infants is 9.2-30%. In full-term infants, the incidence is 3.3-5.8%, and
in infants aged 1 year, it is 0.8%.

The lifetime risk of death from testicular malignancy in men of any age
with undescended testis is approximately 9.7 times the risk in men with
normally descended testis.

Malignant degeneration: Testicular malignancies occur in 10% of men with


cryptorchid testis. The incidence of malignant degeneration in an
undescended testis is reportedly as high as 48 times greater than in a
normal testis. Seminoma is the most commonly reported malignancy.

Torsion is a rare condition, if present, usually is secondary to the


presence of a mass.
A 1 year old child with a rapid pulse, slightly low blood pressure,
lethargy, oliguria and dry oral mucosa should be considered most likely
to be

a) 5% dehydrated
b) 10% dehydrated
c) 15% dehydrated
d) 2% dehydrated
e) Normal hydration status
The Correct answer is B
Explanation
In infants, signs of 5% (mild) dehydration are slightly dry buccal
mucous membranes, increased thirst and slightly decreased urine output.

In infants, signs of 10% (moderate) dehydration are dry buccal mucous


membranes, tachycardia, little or no urine output, lethargy, sunken eyes
and fontanelles, loss of skin turgor.

In infants, signs of 15% (severe) dehydration are same as moderate plus


a rapid, thready pulse, no tears, cyanosis, rapid breathing, delayed
capillary refill, hypotension, mottled skin and coma.
A 6-year-old male presents with a 3-week history of leg pain which has
increasingly worsened. He has spiking fevers at night, but no rashes. He
now awakens at night crying with pain, and his mother is worried that he
is fatigued and pale. Blood counts reveal a hemoglobin of 10.4 g/dl,
platelet count of 85,000, and WBC is 28,000, with 80% lymphs and 10%
blast forms. A diagnosis of leukemia is made. Further testing is
consistent with L2 morphology and is PAS negative. Unfavorable or
high-risk prognostic factors in this case include all of the following
EXCEPT:

a) Male sex
b) Age
c) Cell morphology
d) Platelet count
e) Hemoglobin
The Correct answer is B

Explanation
Acute lymphocytic leukemia (ALL) is the most common form of childhood
malignancy. The age of the child is important in evaluating the
prognosis in a specific case and is an important factor in choosing the
appropriate chemotherapeutic regimen. Children less than 2 years of age
or greater than 10 years of age are at much higher risk than children
between the ages of 2 and 10. This child’s age of 6 years places him in
a favorable prognostic category.

A. The male sex is an unfavorable or high risk factor in childhood ALL.


C. The cell morphology is critical in evaluating prognosis and treatment
decision. The L1 morphology is the most favorable cell type in childhood
ALL. L2 and L3 morphologies are unfavorable as is PAS negative staining.
D. A very low platelet count (<100,000) is an unfavorable finding in
this case. Very low (<10,000) or very high (>50,000) white blood counts
are also high risk factors.
E. The hemoglobin levels >10 g/dl in this case is an unfavorable
prognostic factor.
The parents of a 20 month old female bring her to your office because
she has lost consciousness twice recently. They describe two episodes
where the child was crying vigorously then ?turned purple and passed
out?. The child is an otherwise healthy product of a term delivery.
There is no history of head trauma and no family history of seizures or
cardiac problems. The episodes are not associated with fever or other
symptoms. Physical examination of the child is normal. Which one of the
following would be most appropriate at this point?
a) Reassurance
b) A CT scan of the brain
c) An EKG and chest radiograph
d) Measurement of serum glucose, electrolytes, and hematocrit
e) Echocardiography
The Correct answer is A

Explanation
The parents are describing classic breath-holding spells. These are a
form of autonomic syncope frequently misdiagnosed as seizures. They
occur in early childhood and infancy. They can be of two forms:
cyanotic, as described here, and pallid. The cyanotic form usually
occurs after vigorous crying, while the pallid form commonly occurs
after a sudden fright or minor injury. The history of a prodrome of
injury, vigorous crying, or sudden fright is key to distinguishing a
breath-holding spell from a seizure. Parents can be reassured that no
brain damage occurs and, in the presence of a classic history, no
further workup is necessary. An EKG and chest radiograph would be
indicated if the history or examination suggested cardiac syncope. Blood
testing would be indicated if the history suggested orthostatic
hypotension or diabetes. A head CT scan would be indicated in the
evaluation of seizures.
A full-term infant presents to your office at 7 days of age with
bilateral purulent conjunctive discharge, erythema and swelling at the
medial aspect of the eyes. Which one of the following is the most likely
diagnosis’

a) Neisseria gonorrhoeae infection


b) Herpes simplex infection
c) Nasolacrimal duct inflammation due to Staphylococcus aureus
d) Chemical irritation from eye ointment received at delivery
e) Chlamydia infection
The Correct answer is E

Explanation
Neonatal conjunctivitis is purulent ocular drainage due to a chemical
irritant or a pathogenic organism. Topical prevention is routine.

/Chlamydia trachomatis/ is the most common cause of bacterial


conjunctivitis in neonates.
Chlamydial ophthalmia usually occurs 5 to 14 days after birth. It may
range from mild conjunctivitis with minimal mucopurulent discharge to
severe eyelid edema with copious drainage and pseudomembrane formation.
Follicles are not present in the conjunctiva, as they are in older
children and adults.

In chlamydial ophthalmia, systemic therapy is the treatment of choice,


because at least 1-2 of affected neonates also have nasopharyngeal
infection and some develop chlamydial pneumonia. Erythromycin 12.5 mg/kg
po q 6 h for 2 weeks is recommended. Efficacy of this therapy is only
80%, so a 2nd treatment course may be needed.
Which one of the following historical features is most suggestive of
congestive heart failure in a 6-month-old white male presenting with
tachypnea?

a) Diaphoresis with feeding


b) Fever
c) Nasal congestion
d) Noisy respiration or wheezing
e) Staccato cough
The Correct answer is A

Explanation
Symptoms of congestive heart failure in infants are often related to
feedings. Only small feedings may be tolerated, and dyspnea may develop
with feedings. Profuse perspiration with feedings is characteristic, and
is related to adrenergic drive. Older children may have symptoms more
similar to adults, but the infant’s greatest exertion is related to feeding.

Fever and nasal congestion are more suggestive of infectious problems.


Noisy respiration or wheezing does not distinguish between congestive
heart failure, asthma, and infectious processes. A staccato cough is
more suggestive of an infectious process, including pertussis.

A few hours after eating a dinner of stuffed turkey, a previously well 7


year old boy and his parents develop vomiting, abdominal cramps, and
diarrhea. Differential diagnosis of the cause of these gastrointestinal
symptoms should include which one of the following?

a) Streptococcus pyogenes
b) Campylobacter
c) Pinworms
d) Staphylococcus aureus
e) Clostridium botulinum
The Correct answer is D

Explanation
Staphylococcal food poisoning results from eating food contaminated with
toxins produced by certain types of staphylococci, resulting in diarrhea
and vomiting.

The staphylococci bacteria grow in food, in which they produce their


toxins. Thus, staphylococcal food poisoning does not result from
ingesting the bacteria but rather from ingesting the toxins that are
already present in the contaminated food.

Typical contaminated foods include custard, cream-filled pastry, milk,


processed meats, and fish. The risk of an outbreak is high when food
handlers with skin infections contaminate foods that are undercooked or
left at room temperature.

Symptoms usually begin abruptly with severe nausea and vomiting starting
about 2 to 8 hours after the contaminated food is eaten. Other symptoms
may include abdominal cramping, diarrhea, and sometimes headache and
fever. Severe fluid and electrolyte loss may cause weakness and very low
blood pressure (shock). Symptoms usually last less than 12 hours, and
recovery is usually complete.

Of the following, an 11 year old who presents with knee pain is most
likely to have

a) Gout
b) Tibial apophysitis
c) A popliteal cyst
d) Inflammatory arthropathy
e) Pes anserine bursitis
The Correct answer is B

Explanation
The three most common knee conditions in children and adolescents are
patellar subluxation, tibial apophysitis, and patellar tendonitis. Gout,
osteoarthritic, and popliteal cysts presents in older adults.
Inflammatory arthritis is more common in adults than in children.
The only antidepressant approved by the Food and Drug Administration for
the treatment of depression in children 8?17 years of age is

a) venlafaxine (Effexor)
b) amitriptyline
c) lithium
d) paroxetine (Paxil)
e) fluoxetine (Prozac)
The Correct answer is E

Explanation
Fluoxetine is the only SSRI approved by the FDA for the treatment of
depression in children 8?17 years of age. Tricyclic antidepressants are
ineffective in children and have limited effectiveness in adolescents,
with safety concerns in both groups. In children and adolescents, there
is limited or no evidence evaluating the use of lithium, monoamine
oxidase inhibitors, St. John’s wort, or venlafaxine.

A 3 year old boy comes to the ER wheezing. It was sudden in onset. On


chest x-ray you notice hyperinflation in the right part of the chest.
What is the most appropriate next step?

a) Albuterol
b) Bronchoscopy
c) Antibiotics
d) Oxygen
The Correct answer is B

Explanation
Wheezing is a symptom as well as a physical finding. Wheezing occurs as
a result of airway narrowing. Asthma is the most classic cause of
wheezing, but wheezing may be part of COPD, heart failure exacerbation
(cardiac asthma), bronchiolitis in children, anaphylaxis, toxic
inhalation, foreign body aspiration, tracheomalacia, or vocal cord
dysfunction

A pulse oximetry reading and a chest x-ray should be taken. Segmental or


subsegmental atelectasis or infiltrate suggests an obstructing
endobronchial lesion. Radio-opacity in the airways or focal areas of
hyperinflation suggests a foreign body. The object should be removed
immediately via bronchoscopy.
You see a 5-year-old white female with in-toeing due to excessive
femoral anteversion. She is otherwise normal and healthy, and her
mobility is unimpaired. Her parents are greatly concerned with the
cosmetic appearance and possible future disability, and request that she
be treated. You recommend which one of the following?

a) Observation
b) Medial shoe wedges
c) Torque heels
d) Sleeping in a Denis Browne splint for 6 months
e) Derotational osteotomy of the femur
The Correct answer is A

Explanation
There is little evidence that femoral anteversion causes long-term
functional problems. Studies have shown that shoe wedges, torque heels,
and twister cable splints are not effective. Surgery should be reserved
for children 8?10 years of age who still have cosmetically unacceptable,
dysfunctional gaits. Major complications of surgery occur in
approximately 15% of cases, and can include residual in-toeing,
out-toeing, avascular necrosis of the femoral head, osteomyelitis,
fracture, valgus deformity, and loss of position. Thus, observation
alone is appropriate treatment for a 5-year-old with uncomplicated
anteversion.
A father brings his 6 year old son to your office for evaluation of
moderate pain in his left knee and thigh. Over the past 3 days the
father has noted reduced physical activity and a slight limp. There is
no known history of trauma and the child has otherwise been well. There
is no fever, and a physical examination is remarkable only for the
presence of slight flexion, abduction, and external rotation of the left
hip. The erythrocyte sedimentation rate is normal.

Which one of the following is the most likely diagnosis’

a) Transient (toxic) synovitis


b) Growing pains
c) Benign osteoid osteoma
d) Septic arthritis
e) Legg-Calvé-Perthes disease
The Correct answer is A

Explanation
Transient (toxic) synovitis and septic arthritis of the hip present
acutely with pain and activity limitation. These conditions tend to
affect younger children compared to osteomas, growing pains, and
Legg-Calvé-Perthes disease. The classic patient is a 6-year-old male who
is otherwise healthy with no trauma history. There may be a low-grade
fever, but the erythrocyte sedimentation rate is normal. On presentation
there is limited pain and spasm.

Septic arthritis has a more severe presentation, with the patient’s


temperature likely to be >38?C, the erythrocyte sedimentation rate >20
mm/h, and severe tenderness present on palpitation. Growing pains are
idiopathic leg pains that affect children 3-12 years of age, with
symptoms including nocturnal leg pains and restlessness that may awaken
the child from sleep. Both Legg-Calvé-Perthes disease and benign osteoid
osteoma have more protracted clinical presentations, with the pain
developing more gradually. Pain is the prominent symptom of osteoid
osteoma have more protracted presentations, with the pain developing
more gradually. Pain is the prominent symptom of osteoid osteoma, with
nocturnal accentuation.
You see a 16 year old white female for a pre-participation evaluation
for sports, and she asks for advice about the treatment of acne. She has
a few inflammatory papules on her face. No nodules are noted. She says
she has not tried any over-the-counter acne treatments. Which one of the
following would be considered first-line therapy for this condition?

a) Oral tetracycline
b) Oral isotretinoin (Accutane)
c) Topical sulfacetamide (Sulamyd)
d) Topical benzoyl peroxide
The Correct answer is D

Explanation
The Academy of Dermatology grades acne as mild, moderate, and severe.
Mild acne is limited to a few to several papules and pustules without
any nodules. Patients with moderate acne have several to many papules
and pustules with a few to several nodules. Patients with severe acne
have many or extensive papules, pustules, and nodules.

The patient has mild acne according to the Academy of Dermatology


classification scheme. Topical treatments including benzoyl peroxide,
retinoids, and topical antibiotics are useful first-line agents in mild
acne. Topical sulfacetamide is not considered first-line therapy for
mild acne. Oral antibiotics are used in mild acne where there is
inadequate response to topical agents and as first-line therapy in more
severe acne. Caution must be used to avoid tetracycline in pregnant
females. Oral isotetinoin is used in severe nodular acne, but also must
be used with extreme caution in females who may become pregnant. Special
registration is required by physicians who use isotetinoin, because of
its teraogenicity.
A 7 year old male with moderately severe atopic dermatitis has been
treated with a variety of moisturizers and topical corticosteroids
preparations over the past year. The results have been less than
satisfactory. Which one of the following topical medications is
appropriate at this time?

a) Mupirocin (Bactroban)
b) Terbinafine (Lamisil)
c) Penciclovir (Denavir)
d) Hydroquinone (Eldopaque, Eldoquin)
e) Tacrolimus (Protopic)
The Correct answer is E

Explanation
Tacrolimus is an immunomodulator indicated for the treatment of atopic
dermatitis when corticosteroids and other conventional remedies are
inadvisable, ineffective, or not tolerated. It is approved for use in
patients over 2 years of age.
A 10 year old girl is referred to the clinic by the school nurse for
evaluation of scoliosis. The girl's scoliosis was detected during a
routine screening examination at the school, and it appears to be mild
(curve less than 10 degrees). She is athletic and is otherwise in good
health. During the physical examination, particular attention should be
given to which of the following?

a) Arm length
b) Blood pressure
c) Body weight
d) Cardiac examination
e) Stage of pubertal development
The Correct answer is E

Explanation
The treatment of scoliosis is dependent on the age of the patient and
curve progression. Premenarchal females have a greater chance of curve
progression then females one to two years after menarche with similar
curves. Curves of less than 25 degrees are observed and reevaluated
every four to six months. The stage of pubertal development is important
to note because a patient who has attained menarche will only have a
small amount of additional growth; therefore, scoliosis will not progress.
A 3 year old girl has had a low-grade fever, "raspy" cough, and clear
rhinorrhea for 3 days. She is brought to the emergency room when she
begins to develop difficulty breathing. On physical examination her
vital signs include a temperature of 39.7°C, a pulse of 160 beats per
minute, and respirations of 36 breaths per minute. Auscultation reveals
bilateral rhonchi, wheezing, and some mild stridor. Which one of the
following is the most likely diagnosis’

a) Asthma
b) Epiglottitis
c) Laryngotracheobronchitis
d) Tonsillitis
e) Pneumonia
The Correct answer is C
Explanation
Croup (Laryngotracheobronchitis) is acute inflammation of the upper and
lower respiratory tracts caused most commonly by parainfluenza virus
type 1 infection.

It is characterized by a barking cough and inspiratory stridor.


Diagnosis is usually obvious clinically but can be made by
anteroposterior neck x-ray.

Treatment is antipyretics, hydration, nebulized racemic epinephrine, and


corticosteroids. Prognosis is excellent.
You are asked to evaluate a newborn at 1 minute of life. The infant is
blue, with slow, irregular respirations and a heart rate of 80. There is
some flexion of the extremities, and the infant grimaces when you
suction the nares. The 1-minute Apgar score of this infant is:

a) 2
b) 4
c) 6
d) 8
e) 10
The Correct answer is B

Explanation
The Apgar score is a useful tool in determining the need for infant
resuscitation at both 1 minute and 5 minutes. It is not, however, a good
tool to determine long term outcome. The five categories that the Apgar
score evaluates are: heart rate, respiratory effort, muscle tone, reflex
irritability, and color. 0, 1, or 2 points are awarded for each
category, for a maximum score of 10. This infant scores 1 for heart
rate, 1 for respiratory effort, 1 for muscle tone, 1 for reflex, and 0
for color, for a total score of 4 at 1 minute.

A. An Apgar score of 2 would be a blue limp infant, with no response to


stimuli and a heart rate of less than 100 with minimal breathing effort
(or the same with a heart rate over 100 and no breathing effort).
C. Infants with this Apgar score may need some stimulation and
resuscitation efforts.
D. Infants with this Apgar score are usually vigorous and require no
significant resuscitation efforts.
E. This would be a vigorous infant, with pink extremities, vigorous
tone, respiration, heart rate, and good reflex. Most infants only score
a 9 at best at 5 minutes.
A one year old girl presents to the ER. Her mother has been treating her
with Tylenol, and although the child appears flushed and ill when the
fever is high, she is her usual self when the fever is down. Her mother
is concerned because the child has had a fever once before and it was an
ear infection that required antibiotics. The child has otherwise been
healthy and has received all her immunizations including MMR vaccine one
week ago.

On examination, her temperature is 40 degrees Celsius rectally. Her


tympanic membranes are normal. Her throat is mildly erythematous, with
no exudate. Her lungs are clear, respiratory rate is 30/min, and there
are no extra heart sounds. Abdomen is soft. She has a diaper rash.

What causes of fever must you consider in this case?

a) Viral infection
b) Vaccine reaction
c) Meningitis
d) Bacterial infection
The Correct answer is D

Explanation
This child has an acute bacterial infection, most likely either
bacteremia or a urinary tract infection. Appropriate investigations
include a urinalysis (with culture) and blood culture and a complete
blood count to assess her white blood cell level (sign of infection).
During a sports physical examination, a 14 year old boy expresses
concern about his height. He was in the 15th percentile for height
throughout childhood and now is just above the 10th percentile. His
sexual maturation rating is Tanner stage 2 for both genitalia and pubic
hair. He should be told which of the following?

a) He is near his final height


b) He probably has a slight deficiency of growth hormone
c) He should increase his daily caloric intake
d) He will grow several more inches
e) He will need testosterone injections for several months
The Correct answer is D

Explanation
Tanner staging reveals information about pubertal development.
Testicular enlargement is usually the first sign of pubertal
development. Most boys reach adult height during the latter half of
puberty (Tanner stage 4). Since this boy’s rating is Tanner stage 2,
there is evidence that he will probably grow several more inches in
height. Since this is the case, there is no indication that he is near
his final height has a deficiency in growth hormone, should increase his
daily caloric intake or that he will need testosterone injections.
Which of the following is true about congenital heart block in neonatal
lupus erythematosus’

a) It is associated with maternal anti-Ku autoantibodies


b) It is transient
c) The majority of patients will require a pacemaker
d) There is no increased risk of connective tissue disease in adulthood
e) The risk of mortality is small
The Correct answer is C

Explanation
In severe cases, surgical implantation of a pacemaker, along with the
correction of structural abnormalities in the heart, may be necessary.
Congenital heart block, an important manifestation of neonatal lupus
syndrome (NLE) that carries a poor prognosis, may merit preventive
therapy in pregnancy during fetal cardiac development. It should be
considered in pregnant women with systemic lupus erythematosus who are
anti-SSA/Ro antibody positive and have previous children with congenital
heart block.

A general management plan of pregnancy in mothers with systemic lupus


erythematosus includes treatment of disease flares using drugs that are
effective but also safe for the fetus. Such an approach may diminish or
reduce the prevalence of complete heart block associated with NLE.
Corticosteroids and some immunosuppressive drugs are sometimes used, but
long-term outcome data in children exposed to immunosuppressive drugs in
utero is lacking.
The most appropriate initial treatment for scabies in an 8-year-old male is

a) 0.5% malathion lotion (Ovide)


b) 5% permethrin cream (Elimite)
c) 5% precipitated sulfur in petroleum
d) Trimethoprim/sulfamethoxazole (Bactrim, Septra) orally for 10 days
The Correct answer is B

Explanation
In adults and children over 5 years of age, 5% permethrin cream is
standard therapy for scabies. This agent is highly effective, minimally
absorbed, and minimally toxic.

A 17 year old high school student presents to the office for emergency
contraception. Last night, she had unprotected sex with her boyfriend
and does not want to risk unwanted pregnancy. Her last menstrual period
was 17 days ago. Physical exam is unremarkable. What is the most
appropriate next step of management of this patient?

a) Emergency contraception would be too late at this point.


b) Reassure and send her home, since the risk of pregnancy is too low.
c) Prescribe ethinyl estradiol and levonorgestrel to be taken now and
after 12 hours
d) Prescribe Progesterone only pills
e) Prescribe single IM injection of medroxyprogesterone
The Correct answer is C

Explanation
Emergency or postcoital contraception has become necessary since around
50% of the pregnancies in Canada are unplanned. It is highly effective
with a success rate of 99%.

A combination of estrogen (ethinyl estradiol) and progesterone


(levonorgestrel) is usually prescribed. 2 tablets should be taken as
soon as possible (within 72 hours of the intercourse) and 2 others
12-hours later.

It is not too late because emergency contraception is effective if given


within 72 hours (3days) of the sexual intercourse.
Period between 10 and 18 days of the cycle is an ?unsafe period?; the
risk of pregnancy in this patient is significant and a postcoital
contraception should be administered.
A young boy presents with frequent episodes of rhinitis with purulent
discharge and fever, from a maxillary sinus infection. What is the most
likely complication if untreated?

a) Purulent meningitis
b) Ethmoidal sinusitis
c) Orbital cellulitis
d) Frontal sinusitis
The Correct answer is C

Explanation

Orbital cellulitis (postseptal cellulitis) is infection of the orbital


tissues posterior to the orbital septum. Either can be caused by an
external focus of infection (eg, a wound), infection that extends from
the nasal sinuses or teeth, or metastatic spread from infection elsewhere.

Orbital cellulitis is most often caused by extension of infection from


adjacent sinuses (ethmoid, maxillary), it is less commonly caused by
direct infection accompanying local trauma (eg, insect or animal bite,
penetrating eyelid injuries) or contiguous spread of infection from the
face.

Symptoms include eyelid pain, discoloration, and swelling. Orbital


cellulitis also causes fever, malaise, exophthalmos, impaired eye
mobility, and impaired vision. Diagnosis is based on history,
examination, and neuroimaging. Treatment is with antibiotics and
sometimes surgical drainage.
A 5 year old boy is brought to the office by his mother because of
recurrence of bed-wetting at night. He has a 3 month old sister who is
healthy. Physical examination is normal. Urinalysis shows:
Specific gravity 1.010
Glucose Negative
Protein Negative
Microscopic 0-1 WBC/hpf, 0 RBC/hpf

Which of the following is the most important information to share with


his parents’

a) This condition will cease if they reprimand him for deliberately


wetting the bed
b) The condition is self-limiting, and they should take care to lessen
the emotional impact on their child
c) This is a potentially serious problem and could represent chronic
inflammation of the kidneys
d) This may be a precursor of diabetes mellitus
e) This signifies a serious underlying emotional disorder
The Correct answer is B

Explanation
In the absence of an organic etiology, emotional stress (possibly
arising from the arrival of a new sibling) is the most likely etiology
of this child’s secondary enuresis. Complete urinalysis is essential in
eliminating disorders such as urinary tract infections, diabetes
mellitus, and diabetes insipidus. Most episodes of nocturnal enuresis
are self-limited, and may not require additional therapy.

The timing of the boy’s bed-wetting is significant. He has just suffered


a major disruption to his world, the birth of a sibling, and may be
regressing in reaction to this event. Certainly this behavior is likely
to refocus his parent’s attention on him, which may be what he is
seeking at an unconscious level. At any rate, the most logical advice
from the physician should be reassurance that the bed-wetting will go
away, especially if the parents reassure the boy of their continuing
love for him.

An asymptomatic 3-year-old male presents for a routine check-up. On


examination you notice a systolic heart murmur. It is heard best in the
lower precordium and has a low, short tone similar to a plucked string
or kazoo. It does not radiate to the axillae or the back and seems to
decrease with inspiration. The remainder of the examination is normal.
Which one of the following is the most likely diagnosis’

a) Eisenmenger’s syndrome
b) Mitral stenosis
c) Peripheral pulmonic stenosis
d) Still’s murmur
e) Venous hum
The Correct answer is D

Explanation
There are several benign murmurs of childhood that have no association
with physiologic or anatomic abnormalities. Of these, Still’s murmur
best fits the murmur described. The cause of Still’s murmur is unknown,
but it may be due to vibrations in the chordae tendinae, semilunar
valves, or ventricular wall. A venous hum consists of a continuous
low-pitched murmur caused by collapse of the jugular veins and their
subsequent fluttering, and it worsens with inspiration or diastole. The
murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by
physiologic changes in the newborn’s pulmonary vessels. PPPS is a
systolic murmur heard loudest in the axillae bilaterally that usually
disappears by 9 months of age. Mitral stenosis causes a diastolic
murmur, and Eisenmenger’s syndrome involves multiple abnormalities of
the heart that cause significant signs and symptoms, including shortness
of breath, cyanosis, and organomegaly, which should become apparent from
a routine history and examination.
Which of the following is NOT a cause of proportionate short stature?

a) Malnutrition
b) Rickets
c) Teratogen exposure in utero
d) Turner's syndrome
e) Constitutional growth delay
The Correct answer is B

Explanation
Rickets is a cause of disproportionate short stature. This condition
predominantly affects the long bones and results in disproportionate
growth of the extremities compared with the trunk.

A. Malnutrition is commonly associated with proportionate short stature.


C. Teratogen exposure, intrauterine growth retardation, and placental
dysfunction are prenatal causes of proportionate short stature.
D. Turner’s syndrome and trisomy 21 are chromosomal causes of
proportionate short stature.
E. Constitutional delay is one of the most common causes of
proportionate short stature.
In newborns all the following are increasing risk factors for deafness,
except

a) Family history
b) Use of gentamicin
c) History of CMV infection
d) Delayed speaking
The Correct answer is D

Explanation
Prior to the implementation of hearing screen programs, it was customary
to test those newborns who have known significant risk factors for
hearing loss. This group includes infants whose mothers suffered from
illness during pregnancy, those who had a family history of hearing
loss, or those who were exposed to drugs known to affect hearing (eg
aminoglycosides).

In addition, infants with the following conditions were included for


hearing screening: low birth weight and/or prematurity, or oxygen
deprivation or breathing difficulties at birth, high bilirubin levels,
abnormal head or face structures, infections such as cytomegalovirus,
syphilis, herpes or toxoplasmosis and low Apgar scores.
Which one of the following would be the most typical presentation of
spondylolysis or spondylolisthesis in a 15-year-old football player?

a) Low back pain radiating to one buttock


b) Radicular pain with paresthesia over the dorsal foot
c) Difficulty initiating urination
d) Loss of bowel control with coughing
The Correct answer is A

Explanation
The most common presentation of spondylolysis or spondylolisthesis in an
adolescent is low back pain with radiation limited to the buttock or
posterior thigh. More advanced radicular symptoms or bowel or bladder
dysfunction are unusual, and are typically seen in advanced cases.

The emergency room nurse pages you to come examine a 2 year old girl.
Her father states that his daughter fell down the stairs earlier in the
evening, but he does not think that she hit her head during the fall.
The only abnormality detected was on examination of her eyes. There are
multiple scattered retinal hemorrhages visible in the retinal periphery
of each eye. The most likely diagnosis in this case is

a) Acute myelogenous leukemia


b) Diabetic retinopathy
c) Childhood hypertensive retinopathy
d) Child abuse (shaken baby syndrome)
e) Retinal edema
The Correct answer is D

Explanation
When a baby is vigorously shaken, the head moves back and forth. This
sudden whiplash motion can cause bleeding inside the head and increased
pressure on the brain, causing the brain to pull apart and resulting in
injury to the baby. This is known as Shaken Baby Syndrome, and is one of
the leading forms of fatal child abuse. A baby's head and neck are
susceptible to head trauma because his or her muscles are not fully
developed and the brain tissue is exceptionally fragile. Head trauma is
the leading cause of disability among abused infants and children.

Shaken Baby Syndrome occurs most frequently in infants younger than six
months old, yet can occur up to the age of three. Often there are no
obvious outward signs if inside injury, particularly in the head or
behind the eyes. In reality, shaking a baby, if only for a few seconds,
can injure the baby for life. These injuries can include brain swelling
and damage; cerebral palsy; mental retardation; developmental delays;
blindness; hearing loss; paralysis and death. When a child is shaken in
anger and frustration, the force is multiplied five or 10 times than it
would be if the child had simply tripped and fallen.
A 6 year old male is brought in for evaluation by his mother, who is
concerned that he may have asthma. She reports that he coughs about 3
days out of the week and has a nighttime cough approximately 1 night per
week. There is a family history of eczema and allergic rhinitis.

Which one of the following would be the preferred initial treatment for
this patient?

a) A leukotriene receptor antagonist such as montelukast (Singulair)


b) A low-dose inhaled corticosteroid such as budesonide (Pulmicort
Turbuhaler)
c) A long-acting beta-agonist such as salmeterol (Serevent)
d) A mast-cell stabilizer such as cromolyn sodium (Intal)
The Correct answer is B

Explanation
Treatment is based on asthma classification. This child meets the
criteria for mild persistent asthma: daytime symptoms of asthma more
than twice weekly but less then once daily, and nocturnal symptoms of
asthma 3-4 times per month, peak expiratory flow (PEF) or FEV1 ? 80% of
predicted, and a PEF variability of 20%-30%.

Asthma controller medications are recommended for all patients with


persistent asthma, and the preferred long-term controller treatment in
mild persistent asthma is a low-dose inhaled corticosteroid. Cromolyn,
leukotriene modifiers, nedrocromil, and sustained-release theophylline
are alternatives, but are not preferred initial agents. Quick. acting,
quick-relief agents such as short-acting beta-agonists are appropriate
for prompt reversal of acute airflow obstruction.

You are working in the emergency department of a large urban hospital


when a 4-month-old boy is brought in with a soft swelling on the right
side of the head. The boy’s mother says that the baby has been eating
and acting normally. She is unaware of any head trauma. The baby appears
happy and playful, and there are no old bruises or scars. A CT scan of
the head reveals no intracranial hemorrhage, but a linear skull fracture
of the right parietal bone is seen by the radiologist. What would you do
next?

a) Tell the mother you are going to call the police and have her
arrested for child abuse
b) Explain to the mother that linear skull fractures are dangerous and
are often associated with permanent brain damage
c) Admit the child to the pediatric intensive care unit for careful
monitoring of neurological and respiratory status
d) Start a workup for suspected non-accidental trauma, including
radiographic studies to look for new and old fractures
e) Report the case to Child Protective Services, the discharge the baby
to home
The Correct answer is D

Explanation
A workup for suspected nonaccidental trauma should include a careful
history to determine if the explanation is consistent with the nature
and degree of the injury and consistent with the developmental age of
the child. Skeletal radiographs to look for old and new fractures are
important. Retinal hemorrhages may be associated with shaken baby
syndrome. Clotting disorders should be ruled out in children with bruising.

A. A confrontational approach may cause the mother to flee the emergency


department with the baby. It is important to remain calm and carry out
the evaluation in a professional manner.
B. Unless associated with intracranial hemorrhage, linear skill
fractures are generally not associated with severe brain damage.
C. This child does not have a medical condition that warrants admission
to an intensive care unit. In fact, if a safe home environment can be
assured, hospital admission may not be necessary.
E. In cases of suspected child abuse, the baby should not be sent home
until the Child Protective Services agency has completed an evaluation
and determined the home setting to be safe.
A previously well 8 month old infant is admitted to hospital following a
12-hour history of intermittent periods of screaming and vomiting. On
physical examination, he appears quite ill, he is pale and slightly
dehydrated. There is a questionable right upper quadrant mass. The most
likely diagnosis is

a) Volvulus
b) Acute intussusception
c) Hydropyonephrosis
d) Malrotation
e) Hirschsprung enterocolitis
The Correct answer is B

Explanation
Intussusception is telescoping of one portion of the intestine into an
adjacent segment, causing intestinal obstruction and sometimes
intestinal ischemia.

The initial symptoms are recurrent colicky abdominal pain that occurs q
15 to 20 min, often with vomiting. The child appears relatively well
between episodes. Later, as intestinal ischemia develops, pain becomes
steady, the child becomes lethargic, and mucosal hemorrhage causes
heme-positive stool on rectal examination and sometimes spontaneous
passage of a ?currant jelly? stool. A palpable abdominal mass, described
as sausage-shaped, is sometimes present.
Little League elbow refers to a problem located over the

a) medial epicondyle
b) lateral epicondyle
c) olecranon
d) capitellum
e) ulnar groove
The Correct answer is A

Explanation
Little League elbow is an apophysitis of the medial epicondyle of the
elbow. It occurs in throwing athletes between 9 and 12 years of age, and
causes elbow pain during throwing. It may also affect velocity and
control. It may cause pain and swelling in the arm and/or elbow, but the
diagnosis should be considered in throwing athletes with elbow pain even
if symptoms are minimal.
A healthy 4 year old girl presents with the following symptoms: rapidly
progressing respiratory distress, high fever, muffled voice, and
drooling. Which one of the following measures is most appropriate in the
initial management of this problem?

a) Endotracheal intubation
b) Ribavirin aerosol
c) Bronchodilators
d) Racemic epinephrine aerosol
e) High doses of intravenous steroids
The Correct answer is A

Explanation
Epiglottitis is a rapidly progressive bacterial infection of the
epiglottis and surrounding tissues that may lead to sudden respiratory
obstruction and death. Symptoms include severe sore throat, dysphagia,
high fever, drooling, and inspiratory stridor.

Diagnosis requires direct visualization of the supraglottic structures,


which is not to be performed until full respiratory support is
available. Treatment includes prompt airway protection via intubation
and antibiotics.
In a premature infant who is suspected of having necrotizing
enterocolitis (NEC), each of the following is correct, except

a) Septicemia is associated with an increased risk of NEC


b) NEC is thought to be caused by systemic hypertension
c) The finding of air in the portal vein indicates severe illness
d) Respiratory distress increases the risk of NEC
e) Apgar scores inversely correlate with the risk of NEC
The Correct answer is B

Explanation
Necrotizing enterocolitis is an acquired disease, primarily of preterm
or sick neonates, characterized by mucosal or even deeper intestinal
necrosis. Signs and symptoms include feeding intolerance, lethargy,
temperature instability, ileus, bloating, bilious emesis, hematochezia,
reducing substances in the stool, apnea, and sometimes signs of sepsis.

In infants who develop NEC, 3 intestinal factors are usually present: a


preceding ischemic insult, bacterial colonization, and intraluminal
substrate (ie, enteral feedings).

Etiology is believed that an ischemic insult damages the intestinal


lining, leading to increased intestinal permeability and leaving the
intestine susceptible to bacterial invasion. Once feedings are begun,
ample substrate is present for proliferation of luminal bacteria, which
can penetrate the damaged intestinal wall, producing hydrogen gas. The
gas may collect within the intestinal wall (pneumatosis intestinalis) or
enter the portal veins.

Diagnosis is clinical and is confirmed by imaging studies. Treatment is


primarily supportive and includes nasogastric suction, parenteral
fluids, TPN, antibiotics, isolation in cases of infection, and, often,
surgery.
You are seeing a previously healthy 4 year old girl with a 5-day history
of fever, itching truncal rash, and bilateral foot pain. Her fever has
been as high as 39.5C. The rash is described by her mother as “feeling
rough”. She complains of pain in her feet when she is wearing shoes, and
has refused to walk today. She has not had any recent URI symptoms and
there has been no emesis or diarrhea. There have been no known ill
contacts; however, she is in daycare. Physical examination is
significant for a mildly dehydrated female who appears ill, but not
toxic. Her temperature is 38.5C. There is bilateral bulbar and
conjunctival injection without exudates. Her lips are dry and cracked.
Her tongue is erythematous and without lesions. There are no palatal
petechia and her posterior pharynx is benign without exudates. She has
tender anterior cervical lymph nodes measuring 2-3 cm. Lungs are clear.
There are no murmurs, and extremities are well perfused. Examination of
the skin reveals a fine mildly erythematous sandpaper-like truncal rash
with areas of excoriation. Both hands and feet are edematous. A rapid
strep test is negative. The most appropriate next step would be:

a) Obtain a CBC, blood culture, and give an IM dose of a broad spectrum


antibiotic with plans to reexamine her in the morning
b) Send a throat swab for culture and hold antibiotics pending results
c) Treat her empirically for step throat and await the culture results
d) Admit her, obtain basic laboratory studies including a CXR and
consult a pediatric cardiologist
e) Admit her for rehydration therapy and observation
The Correct answer is D

Explanation
This child has Kawasaki disease, as characterized by the nonexudate
conjunctival injection, polymorphous nonvesicular rash, mucosal
involvement, edema of the hands and feet, and cervical lymphadenopathy.
Due to the cardiac complications (coronary aneurysms), it is essential
to consult a cardiologist to evaluate for myocarditis and possible
aneurysm development.

A. This patient should be admitted for a complete evaluation.


B. This treatment plan is incomplete.
C. Although streptococcal pharyngitis and scarlet fever are in the
differential, this plan does not address other diagnostic possibilities.
E. Cardiology should be notified and involved as early as possible when
Kawaski’s disease is suspected, to assist with diagnosis, treatment, and
long-term follow-up.
A 4-year-old presents with a dry scaling rash which recurs
intermittently. The family history is positive for asthma, allergy, and
eczema. Treatment of eczema includes which of the following?

a) Keeping the skin scrupulously clean with baths twice daily


b) Allergy testing and allergy shots
c) A strict elimination diet
d) Steroid cream and moisturizing lotion
e) Prednisone (oral steroid)
The Correct answer is D

Explanation
Moisturizing skin and anti-inflammatory creams are the mainstay of
treatment to minimize the drying and itching, which cause the rash.

A. Bathing dries the skin and worsens eczema.


B. Allergy tests correlate poorly with eczema and allergy shots have not
been proven in the treatment of eczema.
C. This type of dietary restriction is not helpful and may result in
nutritional deficiencies.
E. Oral steroids will clear the rash, but the result is only temporary,
and long-term use would risk steroid dependency and immune suppression.
A 5 year old boy is found to have unusual cravings for dirt and ice. He
has also been seen eating paint chips of the walls. What is the most
likely condition to be found in this child?

a) Lead poisoning
b) Iron overload
c) Copper toxicity
d) Inhalant exposure
The Correct answer is A

Explanation
Pica, is the term used to describe craving for and eating nonnutritious
things such as dirt and ice.

Pica is often diagnosed in a hospital emergency room, when the child or


adolescent develops symptoms of lead poisoning, bowel perforation, or
other medical complications caused by the nonfood items that have been
swallowed.

Most commonly, young children get lead poisoning from lead-based paint,
which was used in many old homes. That's why kids who live in older
homes are at a greater risk for lead poisoning.

These children are found to have unsafe levels of lead in their blood,
which can lead to a wide range of symptoms, from headaches and stomach
pain to behavioral problems and anemia. Lead can also affect a child's
developing brain.
You are called to evaluate a term newborn in the delivery room. The
pregnancy and delivery were uneventful, but the baby has remained
cyanotic despite routine delivery room care. A hyperoxia test is
performed; the results of which are printed below:

FiO_2 = 0.21 FiO_2 = 1.00


PaO_2 = 30 PaO_2 = 40

Which statement is the correct interpretation of the test results above?

a) The test results suggest that the baby has a cardiac defect
involving restricted pulmonary blood flow or a separate circulation
b) The baby has a normal PaO_2 for a newborn
c) The test results suggest that the baby has underlying neurologic disease
d) The test results suggest that the baby has a cardiac defect
involving complete mixing without restricted pulmonary blood flow
The Correct answer is A

Explanation
The hyperoxia test is used as an early tool to evaluate the cyanotic
neonate to determine if the etiology of the cyanosis is cardiac or
non-cardiac in origin. A right radial artery (preductal) blood gas is
performed with the child inspiring room air and 100% oxygen. The change
in PaO_2 with the administration of oxygen issued as a guide to
determine the etiology of the cyanosis. A PaO_2 of less than 150 with
the administration of 100% oxygen suggests a cardiac lesion. The cardiac
lesions may be further classified based upon the absolute value of the
PaO_2 . A PaO_2 of less than 50 on 100% oxygen suggests a cardiac
disorder, in which there is restricted pulmonary blood flow or a
separate venous and arterial circulation, whereas a PaO_2 between 50 and
150 on 100% oxygen suggests that there is no restriction of pulmonary
blood flow in the presence of complete mixing of oxygenated and
deoxygenated blood. In this case, the PaO_2 on 100% oxygen was less than
50, suggesting restricting pulmonary blood flow or a separate circulation.
An otherwise healthy 1 year old white male has a screening hemoglobin
level of 10.5 g/dL (N 11.3-14.1), a mean corpuscular volume of 68 fL (N
71-84), and an undetected serum lead level. What should be your next step?

a) A therapeutic trial of iron for 1 month


b) A serum ferritin level
c) An erythrocyte protoporphyrin level
d) Hemoglobin electrophoresis
e) Bone marrow examination
The Correct answer is A
Explanation
It is important to screen for anemia during late infancy. Iron
deficiency is the most common cause of anemia in this age group. There
is evidence that persistent iron deficiency in childhood may have a
negative impact on cognitive development. A therapeutic trial of iron is
the best approach to the treatment of iron deficiency in late infancy.
If the anemia fails to respond, investigating other causes of anemia is
indicated.
A 12 year old girl has had repetitive urinary tract infections. On
presentation her temp is 38.5. An intravenous pyelogram (IVP) is normal.
What is the most appropriate next step?

a) Urine culture
b) Ultrasound and voiding cystography
c) Blood culture
d) Cystoscopy
The Correct answer is B

Explanation
Recurrent UTIs are sometimes seen in conjunction with conditions, such
as: vesico-ureteral reflux (VUR) and hydronephrosis.

VUR which is found in 30% to 50% of children diagnosed with a UTI and is
a congenital condition in which urine flows backward from the bladder to
the ureters and sometimes reaches the kidneys. If the urine in the
bladder is infected with bacteria, VUR can lead to pyelonephritis.

Hydronephrosis, which is an enlargement of one or both kidneys due to


backup or blockage of urine flow and is usually caused by severe VUR or
a blocked ureter. Children with hydronephrosis are sometimes at risk of
recurrent UTIs and may need to take daily low doses of antibiotics to
prevent UTIs.

Diagnostic workup should include ultrasound and voiding cystourethrogram.

A 40 year old woman delivers a newborn male. Her pregnancy was normal
except that she noted decreased fetal movement compared to her previous
pregnancies. She declined an amniocentesis offered by her obstetrician.
Physical examination of the newborn reveals an infant with facial
features suggestive of Down Syndrome. The infant then has bilious
vomiting. An x-ray film showing the kidneys, ureters, and bladder (KUB)
is performed, which shows a "double bubble" sign. Which of the following
is the most likely cause of the abdominal signs and symptoms’

a) Duodenal atresia
b) Hirschsprung Disease
c) Malrotation
d) Meconium ileus
e) Pyloric stenosis
The Correct answer is A
Explanation
The "double bubble" sign is pathognomonic for duodenal atresia, which is
a congenital anomaly associated with Down Syndrome. Two large gas
collections, one in the stomach and one in the proximal duodenum are the
only radiographic lucencies visible in the GI tract. The hallmark of
duodenal obstruction is bilious vomiting without abdominal distention.
Children with Down Syndrome can also have esophageal atresia,
imperforate anus, endocardial cushion defects and hypotonia.

A child has developed a scaling yellowish rash over scalp and face. See
picture:

What is the most likely diagnosis’

a) Atopic dermatitis
b) Psoriasis
c) Seborrheic dermatitis
d) Eczema
The Correct answer is C

Explanation
Seborrhoeic dermatitis primarily affects the scalp and intertriginous
areas. It is most common in the first 6 weeks of life, but can occur in
children up to 12 months of age. Involvement of the scalp is frequently
termed "cradle cap", and manifests as greasy, yellow plaques on the
scalp. Other commonly affected areas include the forehead and eyebrows
(as in the photo), nasolabial folds, and external ears. Involvement of
skin creases, such as the nappy area, can lead to secondary Candidal
infection and maceration.

The etiology is unknown. Treatment includes the use of a mild tar


shampoo, oatmeal baths, and avoidance of soaps. Occasionally, a mild
topical steroid may be indicated.
A 6-month-old child is hospitalized with multiple bruises. Child abuse
is suspected. As part of her evaluation, an ophthalmology consult is
obtained. Which of the following ocular findings is most consistent with
child abuse?
a) Retinal hemorrhage
b) Conjunctivitis
c) Strabismus
d) Leukocoria
e) Dacryocystitis
The Correct answer is A

Explanation
Retinal hemorrhages may indicate shaken baby syndrome and, in some
cases, may be the only verifiable sign of child abuse.

B. Conjunctivitis is the result of an infection, allergy, or contact


irritation and is not typical of abuse.
C. Strabismus is not a typical early finding in an abuse case.
D. May be seen as a late finding if an abused child has suffered severe
trauma or retinal detachment, but would not coexist with new bruises.
E. Dacryocystitis results from infection of the lacrimal duct and is not
associated with trauma.
A 13 year old boy complains of having six loose bowel movements with
blood associated with abdominal cramps on a daily basis for the past 3
months. He has one bowel movement during the night. Which one of the
following is the most likely diagnosis’

a) Ulcerative colitis
b) Salmonella gastroenteritis
c) Giardiasis
d) Colonic polyp
e) Campylobacter gastroenteritis
The Correct answer is A

Explanation
Ulcerative colitis is a chronic disease in which the large intestine
becomes inflamed and ulcerated (pitted or eroded), leading to flare-ups
(bouts or attacks) of bloody diarrhea, abdominal cramps, and fever. The
long-term risk of colon cancer is increased. Ulcerative colitis may
start at any age but usually begins between the ages of 15 and 30. A
small group of people have their first attack between the ages of 50 and 70.

The symptoms of ulcerative colitis occur in flare-ups. A flare-up may be


sudden and severe, producing violent diarrhea (typically bloody), high
fever, abdominal pain, and peritonitis (inflammation of the lining of
the abdominal cavity). During such flare-ups, the person is profoundly
ill. More often, a flare-up begins gradually, and the person has an
urgency to have a bowel movement (defecate), mild cramps in the lower
abdomen, and visible blood and mucus in the stool. A flare-up can last
days or weeks and can recur at any time.

If the disease extends farther up the large intestine, the stool is


looser, and the person may have as many as 10 to 20 bowel movements a
day. Often, the person has severe abdominal cramps and distressing,
painful spasms that accompany the urge to defecate. There is no relief
at night. The stool may be watery and contain pus, blood, and mucus.
Frequently, the stool consists almost entirely of blood and pus. The
person also may have a fever and a poor appetite and may lose weight.
The hospital nursery reports that a 24 hour old male has developed
“acne” confined to his nose and cheeks. Your examination confirms the
presence of acneiform lesions, including papules. Which one of the
following would be most appropriate?

a) Benzoyl peroxide, half-strength


b) Clindamycin (Celocin-T) topically
c) An emollient lotion
d) Boric acid rinses
e) No treatment
The Correct answer is E

Explanation
Acneiform lesions confined to the nose and cheeks may be present at
birth or may develop in early infancy. The lesions clear without
treatment, as large sebaceous glands stimulated by maternal androgens
become smaller and less active.
In early February, you receive a call from your office nurse. Her
5-month-old daughter has been ill for several days. What started as a
mild upper respiratory infection has progressed and she now has profuse
rhinorrhea, a temperature of 100.2 F (37.9 C), and audible wheezing. In
spite of an almost nonstop cough, she does not appear acutely ill.

The organism responsible for this child’s illness is most likely to be

a) Group B Streptococcus
b) Mycoplasma pneumoniae
c) Bordetella pertussis
d) Parainfluenza virus 3
e) Respiratory syncytial virus
The Correct answer is E

Explanation
The most common cause of pneumonia in children age 4 months to 4 years
is respiratory syncytial virus. Other viruses may cause pneumonia as
well. The peak incidence of respiratory syncytial virus is between 2 and
7 months of age. Wheezing and profuse rhinorrhea are characteristic and
the disease typically occurs in mid-winter or early spring epidemics.
Parainfluenza 3 typically affects older infants and is not common in
winter. Mycoplasma tends to affect older children and children with
bacterial illnesses; those infected with this organism generally appear
more acutely ill.
A 7 year old girl has a blood pressure of 130/90 mmHg. She has had
recurrent urinary tract infections in the past. She has proteinuria.
Which one of the following would be the most appropriate investigation?

a) Renal ultrasound
b) Renal scan
c) Plasma renin activity
d) Computerized tomography of abdomen
e) Digital angiography of renal vessels
The Correct answer is A

Explanation
Urinary tract infections (UTIs) are among the most common bacterial
infections encountered by primary care physicians. Although UTIs do not
occur with as great a frequency in children as in adults, they can be a
source of significant morbidity in children.

For reasons that are not yet completely understood, a minority of UTIs
in children progress to renal scarring, hypertension and renal
insufficiency. The diagnostic work-up should be tailored to uncover
functional and structural abnormalities such as dysfunctional voiding,
vesicoureteral reflux and obstructive uropathy.

A more aggressive work-up, including renal ultrasound and voiding


cystourethrography, is recommended for patients at greater risk for
pyelonephritis and renal scarring, including infants less than one year
of age and all children who have systemic signs of infection concomitant
with a UTI.
A 9 year old child is studying in kindergarten, is unable to read, write
or even to color a picture. He becomes happy when he answers simple
questions. What is the most likely diagnosis’

a) Autism
b) Mental retardation
c) Specific learning disability
d) Normal child
The Correct answer is B

Explanation
Kindergarden is usually for children aged 4-6. So a 9 year old in
kindergarden would not be considered normal. Also the fact that this
child is unable to advance into a higher grade more appropriate for his
age suggests that he has a global learning disability rather than a
specific one for say math, reading or drawing/coloring. We now turn our
attention to a) autism vs b) mental retardation.

a) Autism is a disorder in which a young child cannot develop normal


social relationships, uses language abnormally or not at all, behaves in
compulsive and ritualistic ways, and may fail to develop normal
intelligence. Autistic children develop symptoms in at least 3 of the
following areas: social relationships, language, behavior, and sometimes
intelligence.

About 50% of autistic children never learn to speak. Those who learn do
so much later than normal and use words in an unusual way. These
children rarely have an interactive dialogue with others. Autistic
children often speak with an unusual rhythm and pitch. About 70% of
children with autism have some degree of mental retardation (an IQ less
than 70). Their performance is uneven, they usually do better on tests
of motor and spatial skills than on verbal tests.
b) Mental retardation is characterized by significantly subaverage
intellectual functioning (often expressed as an intelligence quotient <
70 to 75) combined with limitations of > 2 of the following:
communication, self-direction, social skills, self-care, use of
community resources, and maintenance of personal safety.

Delayed development is usually apparent by preschool age. Among older


children, hallmark features are a low IQ combined with limitations in
adaptive behavior skills. Although developmental patterns may vary, it
is much more common for children with MR to experience slow progress
than developmental arrest.

Behavioral disorders include lack of socially responsible behavior,


impaired ability to communicate, and discomfort from coexisting physical
problems and mental health disorders such as depression or anxiety.

In comparing autism and mental retardation, the question best fits the
latter.
A 34-year-old gravida 3 para 1 woman with Class D diabetes mellitus is
36 weeks pregnant. You appropriately refer her for a level II
ultrasound. All of the following abnormalities may be seen EXCEPT:

a) Caudal regression syndrome


b) Large size for gestational age
c) Congenital heart defect
d) Omphalocele
e) Neural tube defects
The Correct answer is D

Explanation
Although the spectrum of congenital anomalies seen in infants of
diabetic mothers (IDM) is broad, abdominal wall defects are not
typically seen. Diabetic embryopathy is the most common teratogenic
disorder and occurs secondary to persistent hyperglycemia in maternal
insulin depedent diabetes mellitus (IDDM). Congenital anomalies are seen
in 10% of exposed infants, compared to 2-5% of the general population.

A. Sacral agenesis with lumbar vertebral anomalies, poor growth of the


caudal region, distal spinal cord disruption, and other anomalies are
common in IDM.
B. IDM infants are often large for gestational age, with increased body
size and visceromegaly.
C. Congenital heart disease is very common among IDM infants and
includes transient hypertrophic subaortic stenosis, transposition of the
great vessels, ASD, VSD, and aortic coarctation.
E. Other midline defects, including CNS anomalies such as anencephaly,
myelomeningocele, hydrocephalus, and microcephaly, are also common in IDM.

A 5 year old girl complains of a sore throat and fever for 2 weeks.
There is cervical adenopathy and a sand paper like rash on physical
exam. A diagnosis of Scarlet fever is made. What investigation will be
useful in differentiating this from a viral etiology?
a) Throat swab
b) Antistreptolysin O test
c) PCR
d) CBC
The Correct answer is A

Explanation
Scarlet fever is an illness that brings on a rash covering most of the
body, a strawberry-like appearance of the tongue and usually a high
fever. The most common source of scarlet fever is one form of a common
bacterial infection known as strep throat.

Common symptoms are: Red rash that looks like a sunburn and feels like
sandpaper. Strawberry-like red and bumpy appearance of the tongue. Fever
of 101 degrees Fahrenheit or higher, often with chills. Very sore and
red throat, sometimes with white or yellowish patches. Enlarged glands
in the neck (lymph nodes) that are tender.

A bacterium called Streptococcus pyogenes, or group A beta-hemolytic


streptococcus causes scarlet fever. Throat culture remains the criterion
standard for confirmation of group A streptococcal upper respiratory
infection.

Streptococcal antibody tests are used to confirm previous group A


streptococcal infection. The most commonly available streptococcal
antibody test is the antistreptolysin O test (ASO). Currently,
streptococcal antibody tests are not indicated during acute illness.

Possible complications include rheumatic fever, and poststreptococcal


glomerulonephritis. Treatment is with antibiotics such as penicillin and
amoxicillin.
A 3-year-old male is brought to your office the day after he was stung
by a honeybee. He has developed a significant local reaction, with
redness and swelling around the site of the sting on his forearm, and
also has had some swelling of his lips for ?a couple of hours’. His
mother removed the stinger and gave him some oral diphenhydramine
(Benadryl). The local reaction has now almost resolved and he has not
had any hives or respiratory distress.

Which one of the following is true concerning this situation?

a) The child is at high risk for a systemic reaction if he is stung


again in the future
b) An antibiotic that covers Streptococcus pyogenes and Staphylococcus
aureus should be administered
c) Systemic corticosteroids would be the initial treatment of choice if
the child develops respiratory distress with his next sting
d) Skin tests are not helpful in confirming the presence of insect
sting allergy
e) If venom immunotherapy is begun, it should be stopped after 2 years
of treatment
The Correct answer is A
Explanation
Children generally have a benign course after insect stings, but those
with moderate to severe systemic reactions have a high risk of future
reaction. Local reactions may initially look like cellulites, but
antibiotic therapy is not needed.

The treatment of choice for anaphylaxis subsequent to an insect sting is


systemic epinephrine. Corticosteroids may be given as adjunctive
treatment. Skin test using insect venom are used to confirm the presence
of allergy in a patient who has had a clinical reaction to a sting, and
to identify the specific insect(s) to which the patient is allergic.
Screening in a patient who has not had a reaction is not indicated.
Immunotherapy may induce cellular suppression after 4 or 5 years.

Patients who stop venom immunotherapy after 1 or 2 years continue to be


at Moderate risk of systemic reaction to future stings.

In assessing the nutritional status of an infant it is useful to know


that birth weight is expected to be regained within

a) 5 days
b) 14 days
c) 21 days
d) 28 days
The Correct answer is B

Explanation
A helpful guideline for assessing normal growth in the very young infant
is that birth weight should be regained by the 14th day.

A 1 year old infant is brought to the health center by his mother


because of eight watery bowel movements during the past 24 hours. On
physical examination the infant is lethargic and somnolent. The mucous
membranes are dry and the skin turgor is poor with minimal capillary
refill. The anterior fontanel is sunken. At his last visit 2 weeks ago,
he weighed 10 kg (22 lb); today his weight is 9 kg (20 lb). His
temperature is 37.2C (99.0F), pulse is 170/min and blood pressure is
100/60 mm Hg. Which of the following is the most appropriate next step
in management of this infant?

a) Begin intravenous hydration with isotonic saline solution


b) Educate the mother on how to recognize dehydration and worsening
clinical symptoms in her infant
c) Obtain serum electrolyte concentrations and begin oral rehydration
therapy
d) Obtain a stool culture and begin amoxicillin therapy
e) Tell the mother to stop breast-feeding and have her give the infant
a soy-based formula
The Correct answer is A

Explanation
Patients with severe volume depletion should receive intravenous
isotonic fluids in 20- to 60-mL/kg fluid boluses.1 In children with
difficult peripheral access, perform intraosseous or central access
promptly. Fluid boluses should be repeated until vital signs, perfusion,
and capillary refill have normalized. If a patient reaches 60-80 mL/kg
in isotonic crystalloid boluses and is not significantly improved,
consider other causes of shock (eg, sepsis, hemorrhage, cardiac disease)
and consider vasopressors and advanced monitoring such as with a bladder
catheter, central venous pressure, and measuring mixed venous oxygen
saturation.

The following table highlights the physical findings seen with different
levels of pediatric dehydration. (Of these, the most accurate in
identifying the level of dehydration are capillary refill, skin turgor,
and breathing. The least accurate are mental status, heart rate, and
fontanelle appearance)
A 10 year old white male is brought to your office with a chief
complaint of ?head congestion? associated with moderate malaise and a
low-grade fever for 7 days. He has had a thick discolored nasal
discharge for the last 2 days. Which one of the following is correct
regarding his management?

a) Amoxicillin should be prescribed


b) Erythromycin should be prescribed
c) No antibiotics should be used at this time
d) Sinus radiographs should be ordered, and the decision to use
antibiotics should be based on the findings
The Correct answer is C

Explanation
Clinical diagnosis of bacterial sinusitis requires the following:
prolonged nonspecific upper respiratory signs and symptoms (i.e.,
rhinosinusitis and cough without improvement for > 10-14 days), or more
severe upper respiratory tract signs and symptoms (i.e., fever 39°C,
facial swelling, and facial pain). This individual does not meet these
criteria, so antibiotics should not be used at this time. Although some
believe that mucopurulent rhinitis (thick, opaque, or discolored nasal
discharge) indicates the presence of bacterial sinusitis, this sign
should be recognized as part of the natural course of a nonspecific,
uncomplicated viral upper respiratory infection (URI). Sinus radiographs
can demonstrate thickened mucosa, infundibular occlusion, and occasional
air-fluid levels in uncomplicated viral URI.
An 8-month-old child with known tetralogy of Fallot becomes agitated and
develops cyanosis. Which of the following treatments is not appropriate
for this “spell”?

a) Administration of crystalloid
b) Morphine sulfate
c) Neo-synephrine
d) Nitroglycerin
e) Placing the child in a knee to chest position
The Correct answer is D

Explanation
?Tet spells’ are caused by an increase in right ventricular outflow
resistance leading to an increase in right-to-left shunting of blood,
resulting in worsening cyanosis. These spells may resolve spontaneously,
but may require treatment if they are sustained. The treatment of the
spells is to diminish right-to-left shunting by increasing systemic
vascular resistance (with the administration of neo-synephrine or the
knee-to-chest maneuver), or decreasing pulmonary vascular resistance
(with the administration of morphine sulfate). Volume is usually given
concomitantly to increase the systemic blood pressure, which will also
minimize right-to-left shunting. The administration of nitroglycerin
would be expected to worsen a ?tet spell?, as its vasodilator effects
would lead to a decrease in systemic blood pressure and worsening
right-to-left shunt.
Which one of the following is true regarding prenatal risk assessment
for trisomy 21 (Down syndrome)?

a) The majority of pregnant women with a positive ?triple screen? on


maternal serum screening have a fetus with trisomy 21
b) Maternal serum screening should be regarded as an alternative to
amniocentesis in women over the age of 35
c) Amniocentesis is performed at an earlier gestational age than
chorionic villus sampling
d) An elevated second-trimester maternal serum alpha-fetoprotein level
indicates increased risk for trisomy 21
e) Seventy percent of trisomy 21 pregnancies occur in women older than
35 years of age
The Correct answer is E

Explanation
Women older than 35 years of age give birth to 70% of infants with Down
syndrome. Chorionic villus sampling is performed at an earlier
gestational age (10-12 weeks) than early amniocentesis (12-15 weeks).
With trisomy 21, second-trimester maternal serum alpha-fetoprotein and
unconjugated estriol levels are about 25% lower than normal levels, and
hCG levels are approximately two times higher than normal. The
likelihood of a fetus having trisomy 21 in a patient with positive
triple test is 2%. The triple test fails to detect trisomy 21 in the
fetus in 10%-15% of pregnant women over the age of 35, and thus should
not be regarded as an equivalent alternative to amniocentesis in these
women.
An 8-year-old boy presents with a 2- to 3-day history of diarrhea, fever
of 102-103?F, and vomiting. He is having stools more than 10 times
daily. The stools are watery with tenesmus and flecked with gross blood.
He is 5-6% dehydrated. The most likely diagnosis is:

a) Intussusception
b) Viral gastroenteritis
c) Shigella gastroenteritis
d) Ulcerative colitis
e) Meckel's diverticulum
The Correct answer is C

Explanation
Shigella gastroenteritis is characterized by blood in the stools, high
fever, watery diarrhea, a high stool volume, elevated white blood cell
count, and bandemia.

A. Intussusception occurs more commonly in younger patients.


B. Acute onset of severe, bloody diarrhea is not typical of viral
gastroenteritis.
D. Ulcerative colitis is uncommon in this age group and may have a more
chronic course.
E. Diarrhea and fever are not characteristic of Meckel’s diverticulum,
and abdominal pain is usually present.
A previously well 13 year old boy experiences a sudden onset of pain in
the right testicle with accompanying nausea and vomiting. On examination
8 hours after the onset of pain, the testicle is located high in the
scrotum and is swollen and exquisitely tender. The overlying epididymis
cannot be separately palpated. The most likely diagnosis is

a) Acute epididymitis
b) Torsion of the spermatic cord
c) Incarcerated inguinal hernia
d) Testicular tumor
The Correct answer is B

Explanation
Testicular torsion is an emergency condition due to rotation of the
testis and consequent strangulation of its blood supply. Symptoms are
acute scrotal pain and swelling, nausea, and vomiting. Diagnosis is
based on physical examination and confirmed by color Doppler. Treatment
is immediate manual detorsion followed by surgical intervention.
Which of the following statements about sickle cell disease is true?

a) All patients with sickle cell disease have a homozygous HbSS genotype
b) Sickle cell disease causes a severe chronic anemia that is not
routinely transfusion dependent
c) Patients have increased susceptibility to infection by
nonencapsulated organisms
d) Patients usually present with sickle cell crises within one month of age
e) Splenic dysfunction usually does not occur until the child enters
his/her teens
The Correct answer is B

Explanation
Sickle cell anemia is chronic hemolytic anemia occurring almost
exclusively in blacks, caused by homozygous inheritance of Hb S.
Sickle-shaped RBCs clog capillaries, causing organ ischemia. Acute pain
(crises) may develop frequently. Infection, bone marrow aplasia, or lung
involvement (acute chest syndrome) can develop acutely and be fatal.
Normocytic hemolytic anemia is characteristic.

Diagnosis requires Hb electrophoresis and demonstration of sickling in


RBCs on an unstained drop of blood. Crises are treated with analgesics
and other supportive measures. Transfusions are occasionally required.
Vaccines against bacterial infections, prophylactic antibiotics, and
aggressive treatment of infections prolong survival. Hydroxyurea
decreases the frequency of crises.
A 2 year old boy has developed grade 2 vesicoureteral reflux. What is
the most appropriate management?

a) Intermittent prophylactic antibiotic


b) Continuous prophylactic antibiotic
c) Observation
d) Surgery
The Correct answer is B

Explanation
Vesicoureteral reflux (VUR) is the backup of urine from the organ that
stores urine (bladder) into the tube that carries urine from the kidney
to the bladder (ureter) during urination. VUR may result in urine reflux
into the renal pelvis, causing distention (hydronephrosis) and kidney
damage. In children, this condition is usually caused by an abnormality
that is present at birth (congenital) and is often diagnosed during
prenatal ultrasound.

Reflux is graded according to its severity:

Grade I results in urine reflux into the ureter only.


Grade II results in urine reflux into the ureter and the renal pelvis,
without distention (hydronephrosis). See picture below:
Grade III results in urine reflux into the ureter and the renal pelvis,
causing mild hydronephrosis.
Grade IV results in moderate hydronephrosis.
Grade V results in severe hydronephrosis and twisting of the ureter.

Since many children will outgrow their reflux, they can be followed
carefully, with their reflux monitored at intervals by tests such as
VCUG, renal ultrasound, or nuclear voiding cystogram. All children aged
1-5 years with reflux grades I-IV should be treated initially with
continuous prophylactic antibiotics.
A 12-year-old female has a cough and slight shortness of breath on a
daily basis. She is awakened by the cough at least 3 nights per week.
Which one of the following would be the most appropriate daily
prophylactic treatment for this patient?

a) Inhaled corticosteroids daily


b) An oral leukotriene inhibitor as needed
c) Oral prednisone daily
d) A short-acting Beta-agonist daily
e) A long-acting Beta-agonist daily
The Correct answer is A

Explanation
This patient has moderate persistent asthma. The preferred and most
effective treatment is daily inhaled corticosteroids.

-A leukotriene inhibitor would be less effective.


-Oral prednisone daily is not recommended because of the risk of
inducing adrenal insufficiency.
-Short- and long-acting beta-agonists are not recommended as daily
therapy because either can cause tachyphylaxis. They are considered
rescue medications rather than preventive treatments.
A 10 year old female presents with a mildly itchy rash of 10 days’
duration. She had streptococcal pharyngitis 2 weeks ago. A red, papular
rash with scaling is present on the trunk and proximal extremities. The
lesions are 1-3 cm in diameter. This presentation is most consistent with

a) Scarlet fever
b) Guttate psoriasis
c) Atopic dermatitis
d) Scabies
e) Erythema marginatum
The Correct answer is B

Explanation
Guttate psoriasis occurs predominantly in children and is characterized
by small oval lesions on the trunk and proximal extremities. The onset
frequently follows a streptococcal respiratory infection. Scarlet fever
usually accompanies streptococcal paryngitis and the rash is red,
punctate, and often felt more readily than seen.

Atopic dermatitis is characterized by chronic dry skin which is pruitic.


Scabies is not related to streptococcal infection and is a popular,
itchy rash seen on the finger webs, axillae, belt line, and genital
areas. Erythema marginatum is a manifestation of rheumatic fever and is
a nonspecific macular lesion of the trunk with central blanching that
appears serpiginous.
A very obese 12 year old boy is brought in because he has developed a
limp when he walks. He also complains of some hip pain. What is the most
likely diagnosis’
a) Osgood-Schlatter
b) Avascular necrosis of femoral head
c) Slipped capital femoral epiphysis
d) Legg calve perthes disease
The Correct answer is C

Explanation
Slipped capital femoral epiphysis (SCFE) usually occurs in early
adolescence and preferentially affects boys. Obesity is a significant
risk factor. Genetic factors also contribute. Exact cause is unknown but
probably relates to weakening of the physis (growth plate), which can
result from trauma, hormonal changes, inflammation, or increased
shearing forces due to obesity.

Onset is usually insidious, and symptoms are associated with stage of


slippage. The 1st symptom may be hip stiffness that abates with rest; it
is followed by a limp, then hip pain that radiates down the anteromedial
thigh to the knee. Up to 15% of patients present with knee or thigh
pain, and the true problem (hip) may be missed until slippage worsens.
Early hip examination may detect neither pain nor limitation of
movement. In more advanced stages, findings may include pain during
movement of the affected hip, with limited flexion, abduction, and
medial rotation; knee pain without specific knee abnormalities; and a
limp. The affected leg is externally rotated. If blood supply to the
area is compromised, avascular necrosis and collapse of the epiphysis
may occur.

Because treatment of advanced slippage is difficult, early diagnosis is


vital. Anteroposterior and frog-leg lateral x-rays of both hips are
taken. X-rays show widening of the epiphyseal line or apparent posterior
and inferior displacement of the femoral head.

SCFE usually progresses; it requires surgery as soon as it is diagnosed.


Patients should not bear weight on the affected leg until SCFE has been
ruled out or treated. Surgical treatment consists of screw fixation
through the epiphysis.
A child who lives in an old building with is found to have microcytic
anemia. He also has symptoms of nausea, vomiting, anorexia and
constipation, sleep disturbances and irritability. What is the most
likely diagnosis’

a) Thalassemia
b) Iron deficiency
c) Lead poisoning
d) Vitamin A poisoning
The Correct answer is C

Explanation
Lead paint was commonly used until 1960, used to some degree until the
early 1970s, and mostly eliminated in 1978; thus, for a significant
number of older housing units, leaded paint still poses some hazard.
Lead poisoning is usually caused by direct ingestion of leaded paint
chips (from cracked, peeling paint).
Lead poisoning is most often a chronic disorder and may not cause acute
symptoms. With or without acute symptoms, poisoning eventually has
irreversible effects (eg, cognitive deficits, peripheral neuropathy,
progressive renal dysfunction).

Risk of cognitive deficits increases when the whole blood lead level is
>10 mg/dL (> 0.48 mmol/L) for an extended period, although the cutoff
may be even lower. Other symptoms (eg, abdominal cramping, constipation,
tremors, mood changes) may occur if lead is > 50 mg/dL (> 2.4 mmol/L).
Encephalopathy is likely if lead is > 100 mg/dL (> 4.8 mmol/L).

Lead poisoning will show a microcytic anemia with an MCV < 80.
A mother brings her 2 year old toddler to you because he does not eat.
Pregnancy and delivery were normal and his birth weight was 4 kg. He was
breastfed up to 6 months of age. He is now drinking 1.5 L of milk a day,
and loves juices. His height (91 cm) is in the 90th percentile and his
weight 16.5 kg) is over the 97th percentile for his age. Which one of
the following measures is most appropriate in the initial management of
this problem?

a) Admit the child to hospital for adrenal, pituitary and thyroid


function tests
b) Refer the mother and her son to a child psychiatrist
c) Plan an appropriate diet for his age
d) Reassure the mother and check his weight in 3 months
e) Add vitamin supplements to his regular diet
The Correct answer is C

Explanation
This child’s birth weight was normal and now he is in the 97th
percentile for weight. This suggests that he is being overfed by a
mother who will need proper counseling with regard to her toddlers diet.

A 16 year old white female is brought to your office because she has
been “passing out”. She tells you that on several occasions while
playing in the high-school band at the end of the half-time show she has
“blacked out”. She describes feeling lightheaded with spots before her
eyes and tunnel vision just prior to falling. Friends in the band have
told her that she appears to be pale and sweaty when these episodes
occur. No seizure activity has ever been observed. In each instance she
regains consciousness almost immediately; there is no postictal state.
She has been seen in the emergency department for this on two occasions
with normal vital signs, physical findings, and neurologic findings. A
CBC, a metabolic profile, and an EKG are also normal. Which one of the
following tests is most likely to yield the correct diagnosis’

a) A sleep-deprived EEG
b) 24-hour Holter monitoring
c) A pulmonary/cardiac stress test
d) An echocardiogram
e) Tilt table testing
The Correct answer is E

Explanation
Reflex syncope is a strong diagnostic consideration for episodes of
syncope associated with a characteristic precipitating factor. The major
categories of syncope include carotid sinus hypersensitivity, and
neurally mediated and situational syncopes. The most common and benign
forms of syncope are neurally mediated or vasovagal types with sudden
hypotension, frequently accompanied by bradycardia. Other terms for this
include neurocardiogenic, vasomotor, neurovascular, or vasodepressive
syncope. Most patients are young and otherwise healthy. The mechanism of
the syncope seems to be a period of high sympathetic tone (often induced
by pain or fear), followed by sudden sympathetic withdrawal, which then
triggers a paradoxical vasodilation and hypotension. Attacks occur with
upright posture, often accompanied by a feeling of warmth or cold
sweating, lightheadedness, yawning, or dimming of vision. If the patient
does not lie down quickly he or she will fall, with the horizontal
position allowing a rapid restoration of central profusion. Recovery is
rapid, with no focal neurologic sense of confusion or headache. The
event can be duplicated with tilt testing, demonstrating hypotension and
bradycardia.
A 14 year old male presents to your office complaining of recent growth
of his breasts. He has a history of cardiac disease and is currently
taking digoxin and hydrochlorothiazide. On examination your patient is
slim, his blood pressure is 160/96 mmHg, and he has bilateral non-tender
gynecomastia. The remainder of his physical examination is within age
normal limits.

The patient asks you why his breasts are growing and you site which of
the following reasons as a possible cause?

a) His slender body habitus


b) Digitalis
c) His elevated blood pressure
d) Hydrochlorothiazide
e) His underlying cardiac disease
The Correct answer is B

Explanation
Certain medications can promote breast growth. They interact with the
natural levels of testosterone and estrogen, and upset the balance in
some manner. Gynecomastia is a common consequence of estrogen treatment
in patients with prostate cancer. Drugs that may cause gynecomastia
include: Hormones (androgens, anabolic steroids, estrogen agonists),
antiandrogens or androgen-synthesis inhibitors, antibiotics (isoniazid,
ketoconazole, metronidazole), anti-ulcer medications such as cimetidine,
cancer chemotherapeutics, especially alkylating agents and
cardiovascular drugs, such as captopril and digoxin (digitalis).

A 3 year old girl presents with generalized edema shortly after recovery
from an upper respiratory infection. Laboratory studies revealed marked
albuminuria as well as hypoalbuminemia and hyperlipidemia. Which one of
the following is the most likely diagnosis’

a) Minimal change disease


b) Focal and segmental glomerulosclerosis
c) Membranous glomerulonephritis
d) Poststreptococcal glomerulonephritis
e) Rapidly progressive glomerulonephritis
The Correct answer is A

Explanation
Minimal change disease (Lipoid Nephrosis, Nil Disease) causes abrupt
onset of edema and heavy proteinuria, mostly in children. Renal function
is typically normal.

Minimal change disease (MCD) is the most common cause of nephrotic


syndrome (NS) in children 4 to 8 years, but it also occurs in adults.
The cause is almost always unknown, although rare cases may occur
secondary to drug use (especially NSAIDs) and hematologic malignancies.

Albumin is lost in the urine of patients with MCD more so than larger
serum proteins, probably because MCD causes changes in the charge
barrier rather than the size barrier in the glomerular capillary wall.
Lipiduria and hyperlipidemia will also be present.

Diagnosis is made empirically or by renal biopsy. Prognosis is


excellent. Treatment is with corticosteroids or, in patients who do not
respond, cyclophosphamide or cyclosporine.
A 14 year old male presents to your office complaining of recent growth
of his breasts. He has a history of cardiac disease and is currently
taking digoxin and hydrochlorothiazide. On examination your patient is
slim, his blood pressure is 160/96 mmHg, and he has bilateral non-tender
gynecomastia. The remainder of his physical examination is within age
normal limits.

Your patient desires more information about breast enlargement in males.


Which of the following information should *not* be given?

a) Gynecomastia is very uncommon and he needs to have his breast tissue


biopsied as
soon as possible to exclude breast carcinoma

b) Asymptomatic palpable breast tissue can be seen in normal males,


particularly in
neonates, at puberty and with increasing age above 45 years

c) Avoid heavy alcohol abuse since it may be lead to gynecomastia


d) Gynecomastia results from an increased estrogen to testosterone ratio
e) Gynecomastia is common among elderly men, particularly when there is
associated weight gain.
The Correct answer is A
Explanation
Gynecomastia is an abnormal enlargement of one or both breasts in men.
Milk production may or may not be present. Gynecomastia is fairly
common. It is a physiologic phenomenon that occurs during puberty, when
at least half of males experience enlargement of one or both breasts.
Pubertal hypertrophy is characterized by a tender discoid enlargement of
the breast tissue beneath the areola and usually subsides spontaneously
within a year.

Gynecomastia also is common among elderly men, particularly when there


is associated weight gain. This condition is usually temporary and
benign. It may be caused by hormonal imbalance, medication with
estrogens or steroidal compounds, or failure of the liver to inactivate
circulating estrogen, as in alcoholic cirrhosis.

The causes of gynecomastia are multiple. A search for a common mechanism


has not been successful. A number of researchers believe that in many
cases (but not all), an altered androgen/estrogen ratio causes changes
in cellular elements in breast tissue. This could be due to: decrease in
production of androgen, increase in estrogen formation and a decrease in
sensitivity of breast tissue to androgens

A 15 year old girl presents with a 2 day history of pain and swelling in
her left knee. She plays soccer regularly on her school team. There is
no history of trauma. On physical examination, there is marked swelling
and tenderness over her anterior tibial tuberosity. A radiograph of her
left knee reveals irregularities of the tubercle contour and haziness of
the adjacent metaphyseal border. Which of the following is the most
likely explanation for her symptoms’

a) Avascular necrosis of the hip


b) Legg-Calve-Perthes disease
c) Osgood-Schlatter disease
d) Septic arthritis
e) Slipped capital femoral epiphysis
The Correct answer is C

Explanation
Osgood-Schlatter disease is a common cause of anterior knee pain in the
adolescent. It is a stress reaction of the insertion of the patella
tendon into the tibia tubercle. The condition previously was more common
in adolescent boys near the time of their growth spurt; however, girls
are being seen more frequently with this diagnosis owing to more active
sports participation. There can be some fragmentation of the ossicles of
the developing tibia tubercle or soft tissue involvement of the patella
tendon insertion without obvious bony changes. Often there is only a
tendonitis of the patella tendon insertion and inflammation of the deep
infrapatellar bursa. Clinically, a young teenager who is quite active in
sports will complain of pain and swelling over the tibial tubercle. The
condition may be unilateral or bilateral.

On examination, there is an obviously swollen, tender, and occasionally


warm area over the tibia tubercle. The radiograph can be normal or show
fragmentation of the area of patella tendon insertion. The natural
history of untreated Osgood-Schlatter disease is relatively benign, if
allowed to heal and complications are avoided. Since unusual stress at a
time of rapid growth is occurring, limiting the offending sports
activity is usually sufficient to relieve the symptoms. Kneeling and
squatting should be limited. Physical therapy is occasionally used if
there is unusual hamstring tightness.
Which of the following is not used in the treatment of juvenile
rheumatoid arthritis’

a) Methotrexate
b) Steroids
c) Physiotherapy
d) Multivitamins
e) Analgesics
The Correct answer is D

Explanation
Juvenile rheumatoid arthritis pain can develop in kids aged 1-16 years
of age. Common presentations include swelling, red and warm joints. The
knee and wrist joints are the most commonly affected. Initial lab workup
involves: CBC, ESR, RF and ANA.
Treatment is with a combination of medication, physical therapy, and
exercise. Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen
are used most commonly.

Except for severe systemic disease, systemic corticosteroids can usually


be avoided. When necessary, the lowest possible dose is used (eg, oral
prednisone)

Methotrexate and hydroxychloroquine are useful DMARDs for polyarticular


disease. Physical therapy, exercises, splints, and other supportive
measures help prevent flexion contractures.
A 5-month-old infant is brought to your office by his mother, who states
that he has experienced 2 days of nasal congestion and cough. The child
is in no distress. After a thorough history and examination you arrive
at the diagnosis of viral upper respiratory infection.

Which one of the following is recommended as both safe and effective for
patients this age?

a) Amoxicillin
b) Azithromycin (Zithromax)
c) Dextromethorphan
d) Nasal bulb suction
e) Pseudoephedrine
The Correct answer is D

Explanation
Prescribing antibiotics for viral upper respiratory infections is
inappropriate and is discouraged by all evidence-based recommendations.
Over-the-counter medications have often been recommended as an
alternative to antibiotics, but recently concerns have been raised about
their use in young children. Early in 2007 the Centers for Disease
Control (CDC) released a report about the use of over-the-counter cold
medications in children less than 2 years of age. The report reminds
practitioners that the Food and Drug Administration (FDA) has not
approved any dosing regimens for these medications in young children,
since their effectiveness has not been proven and the risks for toxicity
are not adequately known in this age group. It was reported that 1519
children were treated in emergency departments in 2005 for adverse
events related to these medications, including some overdoses and at
least three deaths.

The 2007 report adds to similar warnings on the use of over-the-counter


cold medications in young children from the Academy of Pediatrics and
the College of Chest Physicians. As an alternative, parents and other
caregivers are encouraged to use rubber suction bulbs, saline nose
drops, and cool-mist humidifiers.
Which of the following statements is true regarding this patient’s
condition?
a) This condition is autosomal dominant
b) This condition cannot be detected prenatally
c) This condition is usually caused by a missing chromosome
d) Affected individuals are usually females while males die in utero
e) This condition has an extremely poor prognosis for survival past one month of
age
The Correct answer is E

Explanation
This photograph shows a scalp defect, or cutis aplasia, a common feature
of trisomy 13 syndrome (Patau syndrome). This condition is associated
with an extremely poor prognosis for survival. Thirty percent of
patients die by one month of age, and 90% die by one year. The few who
survive beyond that age are severely mentally retarded.

A. Trisomy 13 is a chromosome disorder, not a single gene disorder.


B. Trisomy 13 may be easily diagnosed prenatally by either amniocentesis
or chorionic villus sampling (CVS).
C. Trisomy 13 is usually caused by an extra copy of chromosome 13.
Usually this occurs de novo by nondisjunction, but one-fourth of cases
are familial, due to a parenteral chromosome translocation.
D. Both males and females are eq
A mother meets you in the emergency department with her 3-week-old
infant. The infant was delivered at term, with an uneventful prenatal
and postnatal course to this point. The mother reports that the infant
stopped breathing for 20-25 seconds, and that his lips and tongue
appeared bluish. There was no coughing, choking, or congestion, but the
child seemed ?limp?. The episode ended when the mother vigorously
stimulated her child and he started crying. On examination, the child
appears normal.

Which one of the following would be most appropriate in this situation?

a) The mother should be reassured and the infant should be discharged


to home
b) The infant should be released with a home apnea monitor
c) The infant should be admitted to the hospital for observation
d) A referral to child protective services is mandatory
e) Direct laryngoscopy to rule out a foreign body is routinely indicated
The Correct answer is C

Explanation
Some experts recommend inpatient observation for all children with
apparent life-threatening events such as this. It is generally advised,
however, that for a short, self-correcting episode associated with
feeding, hospital admission is not always necessary. Otherwise, the
child should be admitted for observation and evaluation. Although child
abuse is a concern, referral to child protective services is not
mandatory. Laryngoscopy would not be routine, but might be appropriate
depending on the history and physical examination. Many groups recommend
home apnea monitoring after discharge for those with more severe or
undiagnosed cases.
A 1 week old white male is brought to your office because of
“irritability”. The physical examination is normal except for a
suprapubic mass. When the mother is questioned, she tells you that the
infant has a dribbling urinary stream. The most likely diagnosis is

a) Wilms’ tumor
b) Posterior urethral valves
c) Urinary tract infection
d) Spina bifida occulta involving the sacral plexus
e) Horseshoe kidney
The Correct answer is B

Explanation
Lower urinary tract obstruction in a newborn or young boy should be
assumed to be caused by posterior urethral valves until proven
otherwise. These valves consist of folds of mucosa obstructing the
urethra at the prostatic level. The diagnosis can be confirmed by
voiding cystourethography or by endoscopy of the urethra. The prognosis
depend on the extent of renal damage at the time of diagnosis.
What is the most suggestive sign of selective mutism in a child?

a) Child who does not speak in comfortable settings (eg home)


b) Child who does not speak with teachers and classmates
c) Unlikely to have anxiety
d) Has a communication disorder (eg stuttering)
The Correct answer is B

Explanation
Selective Mutism (SM) is a complex childhood anxiety disorder
characterized by a child’s inability to speak in select social settings,
such as school. These children understand language and are able to talk
normally in settings where they are comfortable, secure and relaxed.

Over 90% of children with SM also have social phobia or social anxiety,
and some experts view SM as a symptom of social anxiety. What is clear
is that children and adolescents with SM have an actual fear of speaking
and of social interactions where there is an expectation to talk.

A child meets the criteria for selective mutism if the following are true:

1. The child does not speak in “select” places such as school or other
social events.
2. But, he or she can speak normally in at least one environment;
usually this is in the home environment but a small percentage of
children with SM are mute at home.
3. The child's inability to speak interferes with his or her ability to
function in educational and/or social settings.
4. The mutism has persisted for at least one month.
5. The mutism is not caused by a communication disorder (such as
stuttering) and does not occur as part of other mental disorders (such
as autism).
A 2-week-old female is brought to the office for a well child visit. The
physical examination is completely normal except for a clunking
sensation and feeling of movement when adducting the hip and applying
posterior pressure. Which one of the following would be the most
appropriate next step?

a) Referral for orthopedic consultation


b) Reassurance that the problem resolves spontaneously in 90% of cases,
and follow-up in 2 weeks
c) Triple diapering and follow-up in 2 weeks
d) A radiograph of the pelvis
The Correct answer is A

Explanation
Developmental dysplasia of the hip encompasses both subluxation and
dislocation of the newborn hip, as well as anatomic abnormalities. It is
more common in firstborns, females, breech presentations,
oligohydramnios, and patients with a family history of developmental
dysplasia.

Experts are divided with regard to whether hip subluxation can be merely
observed during the newborn period, but if there is any question of a
hip problem on examination by 2 weeks of age, the recommendation is to
refer to a specialist for further testing and treatment. Studies show
that these problems disappear by 1 week of age in 60% of cases, and by 2
months of age in 90% of cases. Triple diapering should not be used
because it puts the hip joint in the wrong position and may aggravate
the problem. Plain radiographs may be helpful after 4?6 months of age,
but prior to that time the ossification centers are too immature to be
seen.

Because the condition can be difficult to diagnose, and can result in


significant problems, the current recommendation is to treat all
children with developmental dysplasia of the hip. Closed reduction and
immobilization in a Pavlik harness, with ultrasonography of the hip to
ensure proper positioning, is the treatment of choice until 6 months of
age. The current guidelines recommend ultrasound screening at 6 weeks
for breech girls, breech boys (optional), and girls with a positive
family history of developmental dysplasia of the hip. Other countries
have recommended universal screening, but a review of the literature has
not shown that the benefits of early diagnosis through universal
screening outweigh the risks and potential problems of overtreating.

A 10 year old boy who was out playing in the cold weather develops frost
bit on his fingers. The most appropriate treatment for this is

a) Put hands in warm water for 30 minutes


b) IV antibiotics
c) Escharectomy
d) Debridment
e) Fasciotomy
The Correct answer is A

Explanation
When exposed to very cold temperatures, skin and underlying tissues may
freeze, resulting in frostbite. The areas most likely to be affected by
frostbite are the hands, feet, nose and ears. You can identify frostbite
by the hard, pale and cold quality of skin that has been exposed to the
cold. As the area thaws, the flesh becomes red and painful.

If fingers, ears or other areas suffer frostbite: warm your hands by


tucking them under your arms. If your nose, ears or face is frostbitten,
warm the area by covering it with dry, gloved hands.

If there's any chance of refreezing, don't thaw out the affected areas.
If they're already thawed out, wrap them up so they don't refreeze.

Get emergency medical help if numbness remains during warming. If you


can't get help immediately, warm severely frostbitten hands or feet in
warm, not hot, water. You can warm other frostbitten areas, such as your
nose, cheeks or ears, by covering them with your warm hands or by
applying warm cloths.
A 6-year-old boy is seen in the office for a well visit. During the
exam, strabismus is noted. You are concerned that he may be at risk for
amblyopia. Of the following, which is a TRUE statement concerning amblyopia?

a) Strabismus is the most common cause of amblyopia


b) Amblyopia may result from watching too much TV
c) Amblyopia is successfully treated at any age
d) Treatment of amblyopia includes occlusion of the “bad” eye
e) There are no clear risk factors for amblyopia
The Correct answer is A

Explanation
Successful treatment depends on early recognition and referral for
occlusion therapy.

B. It is important to monitor the amount of television exposure but his


alone is not a root cause of amblyopia.
C. Although recent reports show there may be some small benefit even
from late treatment, corrective therapy is most successful prior to 8
years of age.
D. Treatment of amblyopia may include occlusion of the ?good eye?,
forcing the child to use the “bad” or lazy eye.
E. Some of the known risk factors for amblyopia include strabismus,
myopia, muscle weakness, cataract.
A 24 year old mother is discharged from the hospital with her baby 24
hours after an uncomplicated labor and delivery. The baby was delivered
at term, and this is her first child. You receive a call from the mother
the next day because she is concerned that the baby ?looks a little
orange?. Which one of the following bilirubin levels would prompt
phototherapy?

a) 6 mg/dL at 30 hours
b) 12 mg/dL at 48 hours
c) 21 mg/dL at 72 hours
d) 15 mg/dL at 96 hours
The Correct answer is C

Explanation
Jaundice attributable to physiological immaturity usually appears
between 24-72 hours of age, peaks by 4-5 days in term and 7th day in
preterm neonates and disappears by 10-14 days of life. It is
predominantly unconjugated and levels usually do not exceed 15 mg/dl.
This pattern of physiological jaundice has been described in
predominantly artificially fed babies. Based on recent recommendations
of AAP, bilirubin levels upto 17-18 mg/dl may be accepted as normal in
term healthy newborns1. Safe bilirubin levels in preterms vary according
to gestational age.
Anything out of this range is considered pathological jaundice.

At 36 hours of age a full-term infant has not yet passed meconium.


Physical examination reveals jaundice and abdominal distention.
Radiographs of the abdomen show dilated loops of bowel and
calcifications in the scrotum. A meconium plug is passed after rectal
examination. Which of the following would be the most definitive
diagnostic test to order

a) Barium enema
b) Sweat chloride test
c) Ultrasound of the abdomen
d) Urine calcium excretion
e) Voiding cystourethrogram
The Correct answer is B

Explanation
Cystic fibrosis (CF) is an inherited disease of the exocrine glands
affecting primarily the GI and respiratory systems. It leads to COPD,
exocrine pancreatic insufficiency, and abnormally high sweat
electrolytes. Diagnosis is by sweat test or identification of 2 cystic
fibrosis mutations in patients with characteristic symptoms. Treatment
is supportive through aggressive interdisciplinary care.

Meconium ileus due to obstruction of the ileum by viscid meconium may be


the earliest sign and is present in 15 to 20% of affected neonates. It
is often associated with volvulus, perforation, or atresia and, with
rare exceptions, is followed by other CF signs. CF also may be
associated with delayed neonatal passage of meconium and with the
meconium plug syndrome (a transient form of distal intestinal
obstruction secondary to one or more plugs of inspissated meconium in
the anus or colon).
A 10-year-old boy comes to the office for evaluation of short stature.
His height and weight are below the 5th percentile for his age, but his
growth velocity is normal. The child has otherwise been healthy.
Physical exam reveals an immature male with no evidence of pubertal
development and his bone age is that of a 6-year-old male. What is the
most likely diagnosis’

a) Constitutional growth delay


b) Familial short stature
c) Primary hypothyroidism
d) Growth hormone deficiency
e) Chronic systemic disease
The Correct answer is A

Explanation
Children with constitutional delay grow and develop at or below the
fifth percentile, but have normal growth velocities. Puberty is
significantly delayed, which results in delayed skeletal maturation and
a delayed bone age. There is often a family history of short stature in
childhood and delayed puberty.

B. Children with familial short stature have a normal bone age and
puberty is not delayed.
C. Primary hypothyroidism results in a diminished growth velocity.
D. Children with growth hormone deficiency will have a delayed bone age
and will show growth well below the third percentile. These children
will also have a diminished growth velocity.
E. Children with chronic systemic diseases may develop short stature
either from a lack of calorie absorption or from calorie depletion from
increased metabolic demands. Their growth velocity is abnormal, and
there is marked retardation of bone age and pubertal delay.
A 2 year old child presents with fever, prostration, and nuchal
rigidity. He has received his primary immunizations but not the
pneumococcal conjugate vaccine. The cerebrospinal fluid (CSF) is cloudy,
and microscopic examination reveals innumerable neutrophils. The CSF
protein is increased, and glucose is decreased. Which one of the
following is the most likely etiologic agent?

a) Escherichia coli
b) Haemophilus influenzae
c) Neisseria meningitidis
d) Streptococcus pneumoniae
e) Staphylococcus aureus
The Correct answer is D

Explanation
Meningitis in newborns usually results from an infection of the
bloodstream (sepsis). The infection is typically caused by bacteria
acquired from the birth canal, most commonly group B streptococci,
Escherichia coli, and Listeria monocytogenes. Older infants and children
usually develop infection through contact with respiratory secretions
from infected people. Bacteria that infect older infants and children
include Streptococcus pneumoniae and Neisseria meningitidis. Haemophilus
influenzae type b was the most common cause of meningitis, but
widespread vaccination against that organism has now made it a rare cause.

Older children and adolescents with meningitis typically have a few days
of increasing fever, headache, confusion, and a stiff neck. They may
have an upper respiratory tract infection that is unrelated to the
meningitis. Newborns and infants rarely develop a stiff neck and are
unable to communicate specific discomfort. These younger children become
fussy and irritable (particularly when they are held) and stop feeding,
important signs that should alert parents to a possibly serious problem.
Sometimes newborns and infants have fever, vomiting, or a skin rash. One
third have seizures.
You see a 20-month-old male approximately 1 hour after he had a
generalized seizure that lasted 2-3 minutes according to his mother. His
past medical history is unremarkable except for two episodes of otitis
media. On examination his temperature is 38.9°C (102.0°F), and he is
awake, interactive, and consolable, with obvious otitis media of the
left ear. A neurologic examination is unremarkable, and there are no
meningeal signs. Which one of the following would be most appropriate at
this point?

a) Lumbar puncture
b) Electroencephalography
c) Neuroimaging studies
d) Serum levels of electrolytes, calcium, phosphate, and magnesium,
plus a blood glucose level and a CBC
e) No diagnostic studies at this time
The Correct answer is E

Explanation
This patient had a classic simple febrile seizure and no additional
diagnostic studies are recommended. A lumbar puncture following a
seizure is not routinely recommended in a child over 18 months of age,
since by that age a patient with meningitis would be expected to
demonstrate meningeal signs and symptoms or clinical findings suggesting
an intracranial infection. There is no evidence to suggest that routine
blood tests or neuroimaging studies are useful in a patient following a
first simple febrile seizure, and it has not been shown that
electroencephalography performed either at the time of presentation or
within the following month will predict the likelihood of recurrence.

A 3-week-old Caucasian male is brought to your clinic by his parents for


a red growth on his face. He was a healthy term baby weighing 3650 g. He
was seen previously in your office at 3 days of age and had no skin
findings at that time. There is a 1 1/2 cm x 2 cm bright red, raised
lesion on the left temple. It is soft and nontender to palpation without
blanching. The parents are very concerned. You advise them:

a) The lesion is highly concerning and a punch biopsy should be


performed immediately
b) This lesion is consistent with a benign condition and will disappear
before 1 year of age
c) The lesion is consistent with a benign condition that will likely
increase in size over the first year, then begin to fade and disappear
entirely by school age without treatment
d) The lesion should be injected with steroids to produce the best
cosmetic result
e) This is an infectious lesion and should be treated with high dose IV
antibiotics
The Correct answer is C

Explanation
This presentation is consistent with a capillary hemangioma, which is
not uncommon in infants. They often develop shortly after birth,
increase in size over the first year of life, then involute over several
years. They usually disappear by age 8-10 years. They should be treated
only if they are excessively large or in vital areas (eyelid, airway,
vaginal). Treatments include excision, steroids, laser treatment, or
interferon.

A. Punch biopsy is unnecessary and could be dangerous due to heavy bleeding.


B. These lesions are benign but usually grow larger over the first year,
then gradually involute.
D. Steroid injection is not necessary in most cases.
E. This is not an infectious lesion and antibiotics would be unhelpful.

A 5-year-old female presents with a lesion on her forearm. It began as a


red macule, turned into a small vesicle that easily ruptured, then dried
into a 1-cm honey-colored, crusted lesion seen now. Which one of the
following would be the most appropriate therapy?

a) Oral penicillin V
b) Oral erythromycin
c) Topical disinfectant (e.g., hydrogen peroxide)
d) Topical bacitracin
e) Topical mupirocin (Bactroban)
The Correct answer is E
Explanation
Topical mupirocin is as effective as cephalexin or
amoxicillin/clavulanate in the treatment of impetigo. Oral penicillin V,
oral erythromycin, and topical bacitracin are less effective than
mupirocin. Topical disinfectants such as hydrogen peroxide are no more
effective than placebo.
An infant is delivered at full term by a spontaneous vaginal delivery to
a 30 year old primigravida. At delivery, the infant is noted to have
subcostal retractions and cyanosis despite good respiratory effort. The
abdomen is scaphoid. On bag and mask ventilation, auscultation of the
lungs reveals decreased breath sounds on the left, with heart sounds
louder on the right. Which of the following is the most likely diagnosis’

a) Dextrocardia with situs inversus


b) Diaphragmatic hernia
c) Pneumonia
d) Pulmonary hypoplasia
e) Spontaneous pneumothorax
The Correct answer is B

Explanation
Congenital diaphragmatic hernia is often seen on prenatal ultrasound. A
diaphragmatic hernia is a defect in the hemidiaphragm that allows the
abdominal contents into the thorax. It has the findings of respiratory
distress, cyanosis, and scaphoid abdomen. Auscultation will show
decreased breath sounds on the affected side. It occurs more often on
the left side than the right.
A 12-year-old male presents to your office with a history of reactive
disease since he was 6 years old. He wheezes throughout the day and
requires a short and long-acting beta2-agonist daily. At night he
complains of waking up frequently with cough and wheezing. He is
currently taking a high-dose-inhaled steroid, a leukotriene inhibitor,
and has just completed a 2-week oral steroid burst. His last peak
expiratory flow (PEF) was <60% of predicted. How would you classify his
asthma?

a) Mild intermittent
b) Mild persistent
c) Moderate persistent
d) Severe persistent
The Correct answer is D

Explanation
This patient has continual daytime and frequent nighttime symptoms
despite good medical therapy. His PEF is <60%, which classifies him as
severe persistent. He may benefit from addition of low dose daily or
every other day oral steroids to try and control his symptoms.

A. Mild intermittent has daily symptoms <2x/week and nighttime symptoms


<2x/month. Their PEF is >80%.
B. Mild persistent has daytime symptoms 3-6x/week and nighttime symptoms
3-4x/month. Their PEF is >80%.
C. Moderate persistent has daily daytime symptoms with nighttime
symptoms occurring >5x/month. Their PEF is >60% and <80%.
A 2 year old with fever is seen in hospital following a generalized
seizure. He also has foul smelling, blood-tinged diarrhea. The culture
of the stool is most likely to grow

a) Campylobacter species
b) E. coli
c) Entamoeba histolytica
d) Giardia
e) Shigella species

The Correct answer is E

Explanation
Shigellosis is infection with species of the gram-negative bacillus
Shigella, which results in dysentery that is characterized by frequent
watery stools, often with mucus and blood, pain, fever, and dehydration.

Fever is frequently present and may reach 106° F. Some children develop
seizures. It is not known if these seizures occur simply from the high
fever or as a specific complication of shigellosis.

Which one of the following is true concerning control of mild persistent


asthma in the pediatric population?

a) Cromolyn sodium (Intal) should not be used for chronic control of


asthma in children under 5 years of age
b) Inhaled anticholinergic agents, such as ipratropium bromide
(Atrovent), should be added if inhaled Beta-adrenergic agents do not
maintain chronic control of asthma
c) A long-acting Beta-agonist should be added if a short-acting
Beta-agonist is ineffective

d) Inhaled Beta-adrenergic agents may be used every 2 hours to maintain


chronic control of asthma
e) Inhaled anti-inflammatory agents, such as glucocorticoids or
cromolyn sodium, should be used initially to maintain chronic control of
asthma
The Correct answer is E

Explanation
Initial medications for the control of mild persistent asthma in
children should include an anti-inflammatory agent, such as
glucocorticoids or comolyn. Cromolyn may be used safely in any pediatric
age group, including infants.
Ipatropium bromide is useful in the treatment of COPD but has very
limited use for asthma. Inhaled Beta-adrenergic agents should be used
every 4 hours if needed. Overuse of these agents has been associated
with an increased mortality rate.
A 7-year-old was admitted to PICU for altered mental status and
suspected meningitis. During your exam, the patient developed a
generalized tonic-clonic seizure. You promptly administer
benzodiazepines, fluids, and ceftriaxone and vacomycin. Despite
anticonvulsants, the seizure persists. Which complication of meningitis
is most likely to cause a seizure that is refractory to the above
treatments’

a) Brain abscess
b) Subdural empyema
c) Hyponatremia from SIADH
d) Elevated intracranial pressure (ICP)
e) Complex febrile seizure
The Correct answer is C

Explanation
Hyponatremia from the syndrome of inappropriate secretion of ADH (SIADH)
is a common complication of bacterial meningitis. Hyponatremic seizures
are notoriously resistant to anticonvulsants and need to be treated with
appropriate saline solutions.

A. A brain abscess is a complication that may cause seizures, but


usually is not one of the presenting signs. This complication may need
neurosurgical care.
B. Again, subdural empyema is not a presenting sign, but seizures
resulting from irritation from an empyema usually respond well to therapy.
D. Increased ICP is a possible complication from meningitis and may
cause seizures. Medical therapy is usually not sufficient.
E. This child is too old to make a diagnosis of a febrile seizure. Given
the presenting signs and symptoms one should always consider bacterial
infection first.
All of the following are true with regard to post infectious
glomerulonephritis, except

a) Normal C3, C4
b) Red blood cell casts
c) Increased ASO
d) Edema
The Correct answer is A

Explanation
Post-streptococcal glomerulonephritis (PSGN) is a disorder of the
kidneys that occurs after infection with certain strains of
Streptococcus bacteria. The infection causes the tiny blood vessels
called glomeruli in the kidneys to become inflamed, making the kidneys
less able to filter and remove wastes.

Post-streptococcal glomerulonephritis is uncommon these days because


infections that can lead to the disorder are commonly treated with
antibiotics. The disorder may develop 1 - 2 weeks after an untreated
throat infection, or 3 - 4 weeks after a skin infection.

Symptoms include cough, with sputum, decreased urine output, edema


(swelling), rust-colored urine and visible blood in the urine.

Diagnostic tests can show blood pressure is often high, serum ASO may be
raised, serum complement levels usually decrease, urinalysis shows
protein and blood in the urine with red blood cell casts.
A high-school gymnast presents to your office with a history of back
pain for the past 3?4 weeks. She reports that symptoms are worse with
any hyperextension activity. Examination demonstrates a hyperlordotic
posture with mild tenderness in the lower lumbar spine. Radiographs
demonstrate the classic ‘scotty dog with a collar? appearance of
spondylolysis.

Which one of the following statements about this diagnosis is true?

a) Most athletes can resume full activity in 4-6 weeks


b) Spondylolisthesis >25% requires referral to a spine surgeon
c) Inadequate treatment can lead to complete fracture and
spondylolisthesis with
prolonged disability
d) Adolescents should be followed with serial CT every 6 months until
they reach
skeletal maturity
The Correct answer is C

Explanation
Complete fracture and spondylolisthesis with prolonged disability may
occur if spondylolysis is not diagnosed early and treated appropriately.
Most athletes respond to conservative management and return to full
activity approximately 6 months after diagnosis. Treatment for low-grade
spondylolisthesis (up to 50% slippage) is similar to treatment for
spondylolysis. Patients should be followed with serial radiographs at
6-month intervals until they reach skeletal maturity. Patients with a
high-grade slippage (>50%) may need to be comanaged by an orthopedic or
spine surgeon to guide treatment and assist in return-to-play decisions.
An 11-year-old boy with an underlying seizure disorder presents to the
emergency department in status epilepticus. Which of the following
interventions would NOT be indicated urgently?

a) Administration of rectal diazepam


b) Urgent CT scan of the head
c) IV administration of lorazepam
d) IV loading dose of phenytoin
e) Correction of any abnormalities of the airway, breathing, and
circulation
The Correct answer is B

Explanation
Status epilepticus is a dangerous condition which may lead to hypoxia
and brain damage if not treated expeditiously. The airway, breathing,
and circulation should be evaluated and any abnormalities corrected.
Intravenous or rectal administration of a benzodiazpine is very
effective in breaking the seizure cycle. A loading dose of phenytoin is
usually administered to prevent recurrences. Neuroimaging tests should
not be done until the seizure activity is under control and may not be
necessary in a patient with a chronic seizure disorder. A thorough
evaluation should be performed after the prolonged seizure is controlled
and then the need for neuroimaging tests may be determined.
A woman brings in her 5 year old son to your office for well child
checks. You notice on each visit that the child is very unkept, dirty,
does not speak proper sentences, and seems malnourished on physical
exam. You have mentioned your concerns to the mother in the past. What
is the most appropriate next step at this time?

a) Call the child’s teacher


b) Counsel the mother again
c) Child protection service
d) Call the police
The Correct answer is C

Explanation
Child protection service (CPS) or children’s aid society (CAS) is a
service physicians or the general public can contact and report
suspected cases of child neglect or abuse.

CPS agencies generally perform a series of functions as follows:

They receive reports of child maltreatment allegations. Then they


determine if a received report's allegations meet statutory definitions
for child maltreatment.

If a received report is accepted, then CPS "investigates" or "assesses"


the allegations through contacts with the family and pertinent
collateral-information providers.

If the child-maltreatment allegations prove sufficiently credible and/or


if the family is in need of services to prevent future maltreatment,
they are generally provided.

If the child's remaining in the home creates an imminent or significant


long-term risk to the child's safety, then arrangement for the child's
placement outside of the home is made either with the family's consent
or through the courts.

A 7 year old patient with family history of urticaria, presents for


consultation. His investigation reveals C1 esterase inhibitor
deficiency. What is the diagnosis’

a) Hives
b) Hereditary angioedema
c) Normal allergic response
d) Immunodeficiency
The Correct answer is B

Explanation
Hereditary angioedema is caused by deficiency (type 1; in 85%) or
dysfunction (type 2; in 15%) of C1 inhibitor, a protein that regulates
the classical complement activation pathway.
Inheritance is autosomal dominant. C1 inhibitor deficiency may also
develop when complement is consumed in neoplastic disorders or when C1
inhibitor autoantibody is produced in monoclonal gammopathy (acquired
deficiency). Attacks are precipitated by trauma or viral illness and
aggravated by emotional stress.

Symptoms and signs are similar to those of angioedema except that edema
progresses until complement components have been consumed; the GI tract
is often involved, causing nausea, vomiting, colic, and signs of
intestinal obstruction.

Diagnosis is by detection of low levels C1 inhibitor. Treatment is


attenuated androgens to stimulate hepatic C1 inhibitor synthesis.
The parents of a 2 year old girl bring her to the Emergency Room. They
state that she has been suffering from a cold for five days. They became
concerned when she developed a barking cough and noisy breathing.
Examination reveals a listless child with a mild fever, inspiratory
stridor and diminished breath sounds. Which one of the following is the
most likely pathogen?

a) Bordetella pertussis
b) Streptococcus pneumoniae
c) Parainfluenza virus
d) Respiratory syncytial virus
e) Hemophilus influenzae
The Correct answer is C

Explanation
Croup is acute inflammation of the upper and lower respiratory tracts
caused most commonly by parainfluenza virus type 1 infection. It is
characterized by a barking cough and inspiratory stridor. Diagnosis is
usually obvious clinically but can be made by anteroposterior neck
x-ray. Treatment is antipyretics, hydration, nebulized racemic
epinephrine, and corticosteroids. Prognosis is excellent.
A 15 year old boy presents to the clinic with a 2 month history of
bulky, floating, foul smelling stools. He also complains of weight loss,
fatigue and bone pain.

Physical exam reveals loss of muscle bulk and pallor. The lab tests show
that the patient is anemic (Hct of 30%) and the serum ferritin is 30
ng/mL. Which of the following is most likely to be associated with this
condition?

a) Anti-centromere antibodies
b) Anti-endomysial antibodies
c) Anti-mitochodial antibodies
d) Anti-smith antibodies
e) C-ANCA antibodies
The Correct answer is B

Explanation
Celiac disease should be suspected in any patient presenting with
malabsorption and iron deficiency anemia. Our patient presents with
symptoms and signs of malabsorption, which includes characteristically
bulky, foul smelling, and floating stool (because of the high fat loss),
loss of muscle mass or subcutaneous fat, pallor due to iron deficiency
anemia and bone pain caused by osteomalacia. Celiac disease is
associated with anti-endomysial antibodies.

C-ANCA antibodies are associated with Wegener’s granulomatosis.

Anti-Mitochondrial antibodies are associated with primary biliary cirrhosis.

Anti-Centromere antibodies are associated with limited Scleroderma


(CREST syndrome)

Anti-Smith antibodies are highly specific for SLE.

Celiac disease is frequently tested! Know every detail about this


disease! Always remember the young patient with osteomalacia and do not
forget the associated pruritc rash (dermatitis herpetiformis).

The latest time after the onset of GABHS (group A beta hemolytic strep)
pharyngitis that initiation of penicillin therapy can be expected to
prevent acute rheumatic fever is

a) 24 hrs
b) 48 hrs
c) 96 hrs
d) 9 days
e) 2 weeks
The Correct answer is D

Explanation
Rheumatic fever is a nonsuppurative, acute inflammatory complication of
group A streptococcal infection, causing combinations of arthritis,
carditis, subcutaneous nodules, erythema marginatum, and chorea.
Diagnosis is based on applying the Jones criteria to information from
history, examination, and laboratory testing. Rheumatic fever can be
prevented in a case of strep pharyngitis by giving penicillin. Even when
started as late as 9 days after the onset of pharyngitis, penicillin
effectively prevents primary attacks of acute rheumatic fever.
A 6 week old male infant develops recurrent episodes of vomiting with
dehydration. Each of the following would be consistent with a diagnosis
of congenital hypertrophic pyloric stenosis, except

a) Non-bile stained vomitus after feeding


b) A metabolic acidosis and hyperkalemia
c) A history of increasing constipation
d) Good appetite
e) Visible epigastric peristaltic waves
The Correct answer is B

Explanation
Hypertrophic pyloric stenosis can cause almost complete gastric outlet
obstruction. Symptoms develop between 2 and 6 weeks of life. Projectile
vomiting (without bile) occurs shortly after eating. Until dehydration
sets in, the child feeds avidly and otherwise appears well, unlike many
of those with vomiting due to systemic illness.

Diagnosis is by abdominal ultrasonography showing increased thickness of


the pylorus (typically to = 4 mm; normal, < 2 mm). The classic
electrolyte pattern of an infant with pyloric stenosis is that of
hypochloremic, hypokalemic, metabolic alkalosis.

Initial treatment is directed at hydration and correcting electrolyte


abnormalities. Definitive treatment is a longitudinal pyloromyotomy,
which leaves the mucosa intact and separates the incised muscle fibers.
Which of the following statements about precocious puberty is true?

a) The cause is never found in most cases


b) The children are always shorter than average
c) The incidence is the same for males and females
d) Ketoconazole is the treatment of choice for females
e) All girls with breast development before age 10 require karyotyping
for Turner syndrome
The Correct answer is A

Explanation
Precocious puberty is onset of sexual maturation before age 8 in girls
or age 9 in boys. The onset of puberty is normally triggered by the
hypothalamus (the area of the brain that helps control pituitary gland
function). It signals the pituitary gland (a pea-sized gland near the
base of the brain) to release hormones that stimulate the ovaries (in
girls) or testicles (in boys) to make sex hormones.

Sometimes, precocious puberty stems from a structural problem in the


brain (such as a tumor), brain injury due to head trauma, an infection
(such as meningitis), or a problem in the ovaries or thyroid gland that
triggers the onset of puberty ahead of schedule - but this usually isn't
the case.

For the majority of girls, there's no underlying medical problem - they


simply start puberty too early for no known reason. In boys, the
condition is less common, and more likely to be associated with an
underlying medical problem than it is in girls.

In about 5% of boys, precocious puberty is inherited. Starting puberty


early can be passed to the son from the father or to the son from the
maternal grandfather through the mother (who will not be affected by the
disorder). But less than 1% of girls affected by precocious puberty have
inherited the condition.
You see a 6-year-old male who has had a sore throat since yesterday. He
has not had a fever and is currently afebrile. He complains of a slight
runny nose and cough. On examination you note a tonsillar exudate and
anterior cervical lymphadenopathy. A rapid antigen detection test for
group A ß-hemolytic streptococci is negative.
The most appropriate course of action at this point is to

a) perform no further tests and treat symptomatically


b) obtain a throat culture and base antibiotic treatment on the results
c) obtain a throat culture and begin empiric antibiotics at this visit
d) perform no further testing and treat empirically with antibiotics
e) test for mononucleosis and treat symptomatically
The Correct answer is B

Explanation
A rapid antigen detection test (RADT) was performed in this patient
because he exhibited two criteria for streptococcal pharyngitis. In
children and adolescents, a backup throat culture is still recommended
because the sensitivity of the RADT is only in the 80%-90% range.
Guidelines do not recommend empiric treatment for pediatric patients,
but do recommend bacteriologic confirmation of group A ß-hemolytic
streptococcal pharyngitis by rapid antigen detection testing or throat
culture prior to initiation of treatment.
A 7 day old breastfed infant born at term has had decreased appetite,
irritability, and vomiting for 24 hours. On physical examination, the
infant appears listless. Respiratory rate is 40/min; heart rate,
160/min; and blood pressure, 68/38 mm Hg. The skin and sclerae are
icteric but no other abnormalities are noted. Laboratory studies reveal:
hemoglobin 120 g/L; total bilirubin, 270 umol/L; and direct bilirubin,
135 umol/L. Urinalysis is negative for reducing substances. Which of the
following is the most likely diagnosis

a) Bacterial sepsis
b) Blood group incompatibility
c) Breast milk jaundice
d) Hypothyroidism
e) Intrauterine infection
The Correct answer is A

Explanation
Neonatal sepsis is invasive bacterial infection occurring in the 1st 90
days of life. Signs are multiple and include diminished spontaneous
activity, less vigorous sucking, apnea, bradycardia, temperature
instability, respiratory distress, vomiting, diarrhea, abdominal
distention, jitteriness, seizures, and jaundice. Diagnosis is clinical,
with extensive laboratory testing. Treatment is initially with
ampicillin plus either gentamicin or cefotaxime, narrowed to
organism-specific drugs as soon as possible.
A 10 year old child presents to the ER with his mother complaining of
frequent vomiting and abdominal cramps.

The symptoms suddenly started after he ate fried chicken with


mayonnaise, french fries and salad at a local restaurant two hours ago.
He has had around five episodes of vomiting over the last 2 hours. The
patient denies diarrhea, fever or other complaints. He is not taking any
medication and his medical history is otherwise unremarkable.

His vital signs are within normal limits. The abdomen is supple and the
exam is non-contributory. Which of the following pathogens is the most
likely cause of the child’s symptoms’

a) Campylobacter jejuni
b) Clostridium botulinum
c) Clostridium difficile
d) Enterotoxigenic E. coli
e) Staphylococcus aureus
The Correct answer is E

Explanation
Sudden onset nausea and vomiting is most likely due to a toxin mediated
illness. Staphylococcus aureus toxin is a preformed toxin; thus symptoms
are rapid in onset (within 1-4 hours) and usually with absent lower GI
symptoms. It may be present in many foods such as mayonnaise, salad, meats’

The most common cause of acute diarrhea in Canada is attributed to C.


jejuni; lower GI symptoms are predominant and begin at least 12-48h
after eating.

Although rare in Canada, enterotoxigenic E. coli is the most common


cause of traveler’s diarrhea.

C. diff causes pseudomembraneous colitis and is associated with recent


antibiotic use.

C. botulinum usually presents with weakness and paralysis that begin in


the eyes and go downward.
A 10 year old boy develops an itchy, red rash on his legs after walking
in the forest. He has had this before during the summer months. The rash
is composed of blisters arranged in lines. In this condition, which one
of the following is true?

a) Antibodies have been formed


b) A cell mediated response is responsible
c) This is a type I allergic response
d) Antibodies are directed against skin basement membrane
e) The antigen is bound to a cell surface protein
The Correct answer is B

Explanation
Type IV reactions (delayed hypersensitivity) are T cell?mediated. These
cells, sensitized after contact with a specific antigen, are activated
by reexposure to the antigen; they damage tissue by direct toxic effects
or through release of cytokines, which activate eosinophils, monocytes
and macrophages, neutrophils, or killer cells depending on type.

Disorders involving type IV reactions include contact dermatitis (eg,


poison ivy), hypersensitivity pneumonitis, allograft rejection,
tuberculosis, and many forms of drug hypersensitivity.
All of the following are features of kawasaki disease, except

a) Fever for 1 day


b) Conjunctivitis
c) Skin rash
d) Fissured lips
e) Strawberry tongue
The Correct answer is A

Explanation
Kawasaki disease is a vasculitis, sometimes involving the coronary
arteries, that tends to occur in infants and children between ages 1 and
8 years. It is characterized by prolonged fever, exanthem,
conjunctivitis, mucous membrane inflammation, and lymphadenopathy.
Coronary artery aneurysms may develop and rupture or cause MI. The
illness tends to progress in stages, beginning with fever lasting at
least 5 days. Associated signs include erythematous macular rash,
fissured lips and a red strawberry tongue.

Diagnosis is by clinical criteria, once the disease is diagnosed,


echocardiography is performed. Treatment is aspirin and IV immune
globulin. Coronary thrombosis may require fibrinolysis or percutaneous
interventions.
A baby just after delivery, has a HR 140/min, is breathing well, crying
and moving well, with pink body and blue extremities. Grimace is absent.
What is the Apgar score?

a) 5
b) 7
c) 9
d) 10
The Correct answer is B

Explanation The following table shows how to calculate Apgar scores:

This baby would have an APGAR score of 7.


Which approach is most appropriate when examining the abdomen and
genitals of a ticklish child?

a) Divert the child’s attention to a picture in the examining room

b) Place the child’s hands on top of yours for the duration of the
examination

c) Apply increased pressure to the abdomen until the ticklish sensation


abates

d) Ask the child’s parent to hold the child still for the duration of
the examination

e) Ask your office assistant to hold the child still for the duration
of the examination
The Correct answer is B

Explanation A helpful technique when examining any young child is to


place the child’s hand on top of the physician’s hand during the
abdominal exam. This can help divert the child’s attention if she is
ticklish and give the child a sense of control.

A. Diversion attempts are often unsuccessful with a ticklish child.


C. Applying increased pressure may only make the exam more painful to
the patient and thus more difficult.
D. Restraining the child by anyone will make the exam much more
difficult and potentially more traumatic to the child.
E. Restraining the child by anyone will make the exam much more
difficult and potentially more traumatic to the child.
Children typically manifest anxiety toward strangers at what age?

a) 3 months
b) 9 months
c) 18 months
d) 24 months
e) 30 months
The Correct answer is B

Explanation
At 3 - 4 months of age, a normal term baby will smile at almost anyone.
By 9 months of age, there is a developmentally normal anxiety over
separation from the mother (Or primary care giver), as well as anxiety
at the sight of an unfamiliar face. Coincident with the increased
mobility gained by walking (usually at 12-15 months of age), these
anxieties normally abate.
A 3 year old white female is brought to your office because she is
complaining of pain in her right arm. Her mother tells you the pain
began after she pulled her daughter by the arm while the girl was
fighting with her brother. You examine the child and diagnose
“nursemaid’s elbow”. You recommend which one of the following?

a) Manipulation of the forearm to reduce radial head subluxation


b) Long arm cast immobilization
c) Use of a sling for arm rest
d) A cock-up wrist splint
The Correct answer is A

Explanation
Subluxation of the radial head (nursemaid’s elbow) is a common childhood
orthopedic problem. There is conflicting information in various
textbooks on the proper technique to reduce the subluxed radial head.
However, a study comparing hyperpronation to supination/flexion found
that hyperpronation had a higher success rate. If a fracture is
diagnosed, then a sling would be helpful. Neither a wrist splint nor a
long arm cast is helpful in this situation.
You see a healthy 7 year old male who was bitten on the cheek 1 hour ago
by a neighbor’s dog. On examination you find a jagged laceration about 2
cm long that extends into the fatty tissue. Which one of the following
would be appropriate in the management of this injury?

a) Copiously irrigate the wound with normal saline and suture


b) Allow healing by secondary intention
c) Suture the wound before cleaning
d) Give metronidazole (Flagyl) prophylactically
e) Have the animal killed and the brain tissue analyzed
The Correct answer is A

Explanation
Dog bites are a common medical problem. Timely and copious irrigation
with normal saline or Ringer’s lactate will reduce the rate of infection
markedly. Recent wounds and wounds on the faces are usually closed
primarily. Cultures are usually not helpful unless the wound appears
infected. Amoxicilllin/clavulanate is the antibiotic of choice for a dog
bite. Since this is a neighbor’s dog, it can be observed at home for 10
days if the rabies vaccination is current, or at a veterinarian’s office
if vaccination status is unknown.
What is the most common complication of juvenile rheumatoid arthritis’

a) Iridocyclitis
b) Hepatitis
c) Nephritis
d) Vasculitis
The Correct answer is A

Explanation
Juvenile rheumatoid arthritis (JRA) is a rheumatic disease that begins
at or before age 16. Arthritis, fever, rash, adenopathy, splenomegaly,
and iridocyclitis are typical of some forms.

Patients with JRA can have joint stiffness, swelling, effusion, pain,
and tenderness. JRA may interfere with growth and development.
Micrognathia (receded chin) due to early closure of mandibular epiphyses
may occur. Iridocyclitis may develop, which may cause conjunctival
injection, pain, and photophobia but can be asymptomatic; scarring and
glaucoma with band keratopathy can result.

Diagnosis is clinical. Treatment involves NSAIDs and often


disease-modifying antirheumatic drugs.
A mother gives her 3 year old child a cookie whenever he starts to
whine. In behavioral terms, she is using

a) Positive reinforcement
b) Negative reinforcement
c) Extinction
d) Bonding
The Correct answer is A

Explanation
This situation illustrates a common problem in the behavioral management
of children, namely positive reinforcement or reward for a negative or
undesirable behavior. By giving the child a cookie, the mother is
actually increasing the likelihood that the child will whine. Putting a
child in time-out for whining would be an example of negative
reinforcement. Letting the child continue to whine by ignoring the
behavior is termed extinction. Bonding is not a term used in behavioral
management, but it describes that affectionate relationship between
parents and infants. Bonding occurs rapidly and shortly after birth and
reflects the feelings of the parents toward a newborn (unidirectional).
A 4 year old female presents with ulcers on her tongue and oral mucosa.
The patient refuses to eat due to pain in her mouth. Her temperature is
38.3C (101F). A maculopapular, vesicular rash is also noted on the
hands, feet, and buttocks. The patient is diagnosed with
hand-foot-and-mouth disease. This common disease of children is caused by:

a) Paramyxovirus
b) Rubella virus
c) Herpes virus 6
d) Parvovirus B-19
e) Coxsackie A viruses
The Correct answer is E

Explanation
Hand-foot-and-mouth disease is caused by coxsackie A viruses. As with
most viral exanthems, the treatment is supportive care. Anorexia may
develop due to the painful ulcers in the mouth. Fluids are encouraged to
maintain hydration. Some physicians recommend a mouthwash made with
Maalox or Kaopectate with diphenhyramine to control the pain before
meals. Acetaminophen or ibuprofen may be used to treat the fever, which
usually lasts about 2-3 days.
A. Paramyxovirus causes measles.
B. Rubella virus causes rubella.
C. Herpes virus 6 is associated with roseola infantum.
D. Erythema infectiosum, or fifth disease, is caused by parvovirus B-19.

In males, the initiation sequence of sexual development is:

a) Pubic hair, height growth spurt, penile enlargement, testicular


enlargement
b) Penile enlargement, testicular enlargement, height growth spurt,
pubic hair
c) Pubic hair, testicular enlargement, penile enlargement, height
growth spurt
d) Testicular enlargement, penile enlargement, pubic hair, height
growth spurt,
The Correct answer is D

Explanation
This is the correct order of sexual maturation in males.

A. This is the reverse order.


B. Penile enlargement occurs after testicular enlargement.
C. Pubic hair growth is the last step of sexual maturation.

In boys, sexual changes begin with growth of the scrotum and testes,
followed by lengthening of the penis and growth of the seminal vesicles
and prostate. Next, pubic hair appears. Axillary and facial hair appears
about 2 yr after pubic hair. The growth spurt usually begins a year
after the testes start growing. The median age for 1st ejaculation
(between 121/2 and 14 yr) is affected by psychologic, cultural, and
biologic factors. First ejaculation takes place about 1 yr after penis
growth accelerates. Gynecomastia, usually in the form of breast buds, is
common in young adolescent boys and usually resolves within several years.

A newborn term male infant at 2 hours of age is noted by the nurse to be


mildly jaundiced. Which one of the following causes of jaundice can be
ruled out because of the infant’s age?

a) Sepsis
b) Erythroblastosis fetalis
c) Congenital toxoplasmosis
d) Concealed hemorrhage
e) Physiologic jaundice (icterus neonatorum)
The Correct answer is E

Explanation
In physiologic jaundice (icterus neonatorum), the level of
indirect-reacting bilirubin in umbilical cord serum is 1-3 mg/dL and
rises at a rate of less than 5 mg/dL/24 hours. As a result, physiologic
jaundice first becomes apparent on the second or third day of life.
Jaundice appearing on the first day of life may be due to
erythroblastosis fetalis, sepsis, concealed hemorrhage, cytomegalic
inclusion disease, rubella, or congenital toxoplasmosis.
A baby presents to your office with a rash in the diaper area. The rash
has 5-10 mm sized fragile blisters which break easily, leaving a red
base crusting and a fine collarette of white skin. There is no history
of fever or any other signs of systemic illness. Your choice of
treatment would be:

a) Neosporin ointment
b) Mycolog (Nystatin/Triamcinolone) cream
c) Mupirocin ointment
d) Desitin
e) Amoxicillin orally
The Correct answer is C

Explanation
This rash is bullous impetigo caused by Staphylococcus aureus. It is
effectively treated with a topical antibiotic which includes coverage
for Staphylococcus.

A. Neosporin may be sensitizing due to the neomycin component.


B. The rash is not candidal and steroids are not indicated.
D. Desitin is indicated for contact (irritant) diaper dermatitis and its
prevention.
E. Amoxicillin does not have good staphylococcal coverage and systemic
treatment is probably not necessary.
Which one of the following therapeutic interventions is useful in the
treatment of croup, but is not an accepted treatment for bronchiolitis’

a) Oral dexamethasone
b) Nebulized racemic epinephrine
c) Nebulized ribavirin
d) Oxygen via the blow-by method
e) Extracorporeal membrane oxygenation
The Correct answer is A

Explanation
Oral or intramuscular dexamethasone at a dosage of 0.15-0.6 mg/kg has
been found useful in the treatment of croup. Nebulized budesonide in a
2-mg dose has also been found to be beneficial. Their use if restricted
to cases in which asthma is a strong diagnostic possibility.

Nebulized racemic epinephrine has been beneficial in both croup and


bronchiolitis. L-epinephrine is a useful substitute if racemic
epinephrine is not available. Oxygen treatment by a technique which does
not stress the infant is acceptable in croup and bronchiolitis.
Nebulized ribavarin is rarely useful in severe bronchiolitis in infants
with congenital heart disease, bronchopulmonary dysplasia, or other
severe underlying cardiopulmonary disease. Extracorporeal membrane
oxygenation has been lifesaving in cases of severe bronchiolitis. It has
not been extensively studied in croup.
On physical examination of a 3 month old child you detect a thrill and a
machinery-type murmur at the left upper sternal border. A widened
systemic pulse pressure and bounding peripheral pulses are also noted.
Based on these findings, which one of the following is the most likely
diagnosis’

a) Familial hypercholesterolemia
b) Patent ductus arteriosus
c) Tetralogy of Fallot
d) Marfan's syndrome
e) Aortic stenosis

The Correct answer is B

Explanation
Patent ductus arteriosus (PDA) is a persistence of the fetal connection
(ductus arteriosus) between the aorta and pulmonary artery after birth,
resulting in a left-to-right shunt. Symptoms may include failure to
thrive, poor feeding, tachycardia, and tachypnea. A continuous
machine-like murmur in the upper left sternal border is common.
Diagnosis is by echocardiography.

Administration of indomethacin with or without fluid restriction may be


tried in premature infants with a significant shunt but not in term
infants with PDA. If the connection persists, surgical or catheter-based
correction is indicated. Endocarditis prophylaxis is recommended before
and for 6 to 12 months after correction.
A 20 month old white female is brought to your office with a 2-day
history of poor appetite, fever, and cough. She was born at term, has no
history of previous illness, and is up-to-date on her immunizations. On
examination she has a low-grade fever, clear rhinorrhea, mild tachypnea
with bilateral wheezes and rhonchi, and a pulse oximetry reading of 90%.

You send the child to the hospital for laboratory studies, a chest film,
and observation. The laboratory reports a positive rapid diagnostic
assay for respiratory syncytial virus (RSV) from a nasopharyngeal specimen.

Based on the most likely diagnosis, which one of the following treatment
options is indicated?

a) Amoxicillin
b) Methylprednisolone (Medrol)
c) Oxygen
d) Palivizumab (Synagis)
The Correct answer is C

Explanation
Respiratory syncytial virus (RSV) causes acute respiratory tract illness
in patients of all ages. In infants and young children, RSV is the most
important cause of bronchiolitis and pneumonia. Rapid diagnostic assays,
including immunofluorescent and enzyme immunoassay techniques for
detection of viral antigen in nasopharyngeal specimens, are available
commercially and are generally reliable.

Unless there is evidence of a suppurative complication, such as otitis


media, the treatment of RSV bronchiolitis is supportive (e.g., with
hydration and supplemental oxygen). It is currently unclear whether
there is a direct relationship between RSV bronchiolitis and a
predisposition to asthma. In hospitalized infants with RSV
bronchiolitis, corticosteroids are not effective and are not indicated.

Antimicrobial agents such as amoxicillin are rarely indicated because


bacterial lung infection and bacteremia are uncommon in children
hospitalized with RSV bronchiolitis. Antimicrobial agents may be
indicated with a suppurative complication.

Palivizumab, a humanized mouse monoclonal antibody administered


intramuscularly, is available to reduce the risk of RSV hospitalization
in high-risk children. This medication is not indicated in this case
because of a negative past history. It is indicated for prophylaxis only
in selected infants and children with chronic lung disease (CLD,
formerly called bronchopulmonary dysplasia) of prematurity, a history of
preterm birth (<35 weeks gestation), or congenital heart disease.
Palivizumab is administered every 30 days, beginning in early November,
with 4 subsequent monthly doses.

An obese 11 year old boy with diabetes mellitus is admitted to the


hospital because of severe ketoacidosis and cardiovascular collapse.
Initial management consists of cardiac monitoring and intravenous
administration of fluids, electrolytes and insulin. Because of the
difficulty in obtaining satisfactory peripheral venous access, the left
femoral vein is catheterized percutaneously. Six hours later, his mental
status is improved, blood pressure is 120/70 mm Hg and serum glucose
concentration is 250 mg/dL. Physical examination at that time shows a
cold left foot with diminished pulses compared with those of the right
foot. The most likely explanation for the diminished pulses is

a) Paradoxical embolus from the femoral vein


b) Diabetic arteriopathy
c) Inadvertent injury of the femoral artery
d) Intense arteriolar constriction induced by hyperosmolality
e) Thrombosis of the catheterized femoral vein
The Correct answer is C

Explanation
During percutaneous placement of central venous lines, many
complications are possible. Depending on the site of placement, the most
serious complications vary. For all line placements however, injury to
the accompanying artery poses a serious risk. In this case, the presence
of a cold foot without pulses on the side ipsilateral to the line
placement strongly suggests damage to the femoral artery.

Which of the following genetic diseases is incorrectly linked with its


transmission pattern

a) Duchenne muscular dystrophy = sex-linked recessive


b) Achondroplasia = autosomal dominant
c) Cystic fibrosis = autosomal recessive
d) Hemophilia = sex-linked dominant
The Correct answer is D

Explanation
Hemophilia A (factor VIII deficiency), which affects about 80% of
hemophilic patients, and hemophilia B (factor IX deficiency) have
identical clinical manifestations, screening test abnormalities, and
X-linked recessive genetic transmission.

A 9 month old white male is brought to your office for a well-child


visit. You note that the child’s weight gain has been flat over the last
several months. He has fallen from the 75th percentile to the 15th for
weight, and his percentile for length is beginning to decline as well.
The mother states that the child began to have diarrhea as soon as she
began giving him various grain cereals and baby foods 5 months ago. The
remainder of a review of systems and a social and family history is
unremarkable. Physical examination reveals an undernourished infant with
mild abdominal distention. A check of the infant’s hemoglobin shows a
microcytic anemia with a low serum ferritin level. Which one of the
following is the most likely diagnosis’

a) Thalassemia
b) Celiac sprue
c) Cystic fibrosis
d) Congenital megacolon (Hirschsprung’s disease)
e) Inborn error of metabolism
The Correct answer is B

Explanation
Celiac sprue is a condition of acquired malabsorption that resolves when
the patient is exposed to a gluten-free diet. Gluten is a substance
found in wheat, rye, and barley, but not in corn or rice products.
Children with this sensitivity will develop inflammation and destruction
of the microvilli in the small intestine as a result of an immune
response to gluten. Patients with celiac sprue often present as this
child has, between 4 and 24 months of age with impaired growth,
diarrhea, and abdominal distention. An iron deficiency anemia can occur
with impairment of iron absorption from the small intestine. Lesser
cases of malabsorption are common, and this condition often goes
unrecognized into adolescence or adulthood. Serologic tests, and
ultimately a biopsy of the small intestine, can confirm the diagnosis.

An 8 year old boy with sickle cell disease presents with left leg pain
and a high fever. He has been refusing to walk since yesterday. On
physical examination, his temperature is 39.8 C (103.6 F), blood
pressure is 122/68 mm Hg, pulse is 102/min, and respirations are 20/min.
His left femur is tender to palpation 3 cm above the left knee, and
there is marked soft tissue swelling. A plain film of his left leg is
normal. A bone scan shows increased uptake around the metaphysis of the
left femur. Which of the following is the most likely pathogen?
a) Escherichia coli
b) Haemophilus influenzae
c) Salmonella
d) Staphylococcus aureus
e) Streptococcus pneumoniae
The Correct answer is D

Explanation
Osteomyelitis is a pyogenic infection of the bone. The pathogenesis of
the disease is similar to septic arthritis, with the origin of infection
occurring from hematogenous spread, direct extension of a local
infection, or direct inoculation of bone either from trauma (e. g. ,
puncture wound or open fracture) or surgical manipulation. In children,
the most frequent presentation is acute hematogenous spread. The most
common location of osteomyelitis is the metaphysis of the distal femur
and proximal tibia. The most prevalent pathogens are the same as those
seen in septic arthritis. Staphylococcus aureus is the most common
pathogen, with group A beta-hemolytic streptococci a distant second.
Neonates are at risk for group B beta-hemolytic streptococci.

Patients with sickle cell disease are at risk for infection by


Salmonella and other gram-negative bacteria, and patients in the 18- to
48-month age range are at increased risk for acute recurrent Salmonella
osteomyelitis. Salmonella osteomyelitis frequently involves multiple
sites and creates punched-out destructive lesions of the metaphysis and
diaphysis. However, even in patients with sickle cell disease,
Staphylococcus aureus is still the most common pathogen for osteomyelitis.
She has short stature, no sexual development, no pubic hair, no breast
development. What is the most appropriate test to order?

a) Karyotype
b) FSH and LH
c) TSH and GH
d) CT of head
The Correct answer is A

Explanation
This is a classic presentation for Turner syndrome. In Turner syndrome
(gonadal dysgenesis), girls are born with one of the two X chromosomes
partially or completely missing. A karyotype will reveal her chromosome
profile to be 45,X.

Girls with Turner syndrome have a webbed neck, a low hairline at the
back of the neck, a broad chest with wide-spaced nipples, and poorly
developed nails.

As a girl with Turner syndrome gets older, she has no menstrual periods
(amenorrhea), and the breasts, vagina, and labia remain childlike rather
than undergoing the changes of puberty. A girl or woman with Turner
syndrome is virtually always short; obesity is common.
An intraventricular hemorrhage with ventricular dilatation is considered
what grade based on the Papile Grading System in neonates’

a) Grade 1
b) Grade 2
c) Grade 3
d) Grade 4
e) None of the above
The Correct answer is C

Explanation
An intraventricular hemorrhage with ventricular dilatation is a grade 3
hemorrhage.

A. Grade 1 is an isolated subependymal hemorrhage. Most are asymptomatic.


B. Grade 2 is an intraventricular hemorrhage without ventricular dilatation.
D. Grade 4 is an intraventricular hemorrhage with parenchymal extension
and has the worst overall prognosis.
A 26-month-old child presents for follow-up of suspected iron deficiency
anemia. Routine screening 8 weeks ago reveals a hypochromic, microcytic
anemia (hemoglobin 9.0 g/dl and MCV 65 fl). The patient was empirically
started on oral iron at that time. The child eats a well-balanced diet
and drinks about 10 oz of milk daily from a cup. The patient’s family is
originally from the Middle East and a brother also has mild anemia with
microcytosis. The child has never missed a well-child checkup and is
completely immunized. On physical examination, the child appears normal
aside from pale conjunctiva. A repeat blood count is unchanged from the
previous values. The next appropriate step in management is:

a) Advise the patient to drink less milk and eat more iron containing foods
b) Order a hemoglobin electrophoresis to evaluate for thalassemia
c) Reassure the parents that anemia from poor eating is common in
2-year-olds
d) Order a transfusion of packed red blood cells
e) Order an injection of iron and report the family to Child Protective
Services
The Correct answer is B

Explanation
Thalassemia trait is often confused with iron deficiency because both
conditions are associated with microcytic anemia. In heterozygous beta
thalassemia, the hemoglobin electrophoresis will show elevations of
hemoglobin A2 and hemoglobin F. No treatment is needed, but genetic
counseling is recommended.

A. The child’s diet does not have excess milk ingestion to suggest a
dietary cause of iron deficiency anemia and there is nothing in the
history to suggest blood loss. Iron deficiency would also be expected to
improve significantly after a month of treatment.
C. Anemia is never normal in 2-year-old children.
D. A transfusion is necessary when anemic children have signs of cardiac
decompensation. This child has no such symptoms.
E. Poor compliance with oral iron therapy is common and could explain
the lack of imprvovement in hemoglobin level in this patient. If
compliance is being questioned, a serum ferritin level to check body
iron stores would be valuable. The ferritin would be low in iron
deficiency, but normal in homozygous thalassemia.
Which of the following is usually an acute cause rather than chronic
cause of diarrhea in a child

a) Infectious diarrhea
b) Inflammatory bowel disease
c) Cystic fibrosis
d) Celiac disease
The Correct answer is A

Explanation
Acute diarrhea is most likely infectious, especially if onset is sudden
or accompanied by vomiting, bloody stools, fever, anorexia, or
listlessness. Diagnosis is clinical, and treatment is supportive until
the condition resolves spontaneously.

Chronic diarrhea is usually more significant. Causes include


gluten-induced enteropathy (celiac disease), cystic fibrosis, sugar
malabsorption, and allergic gastroenteropathy. Inflammatory bowel
disease and some infections (eg, with Giardia) can also cause chronic
diarrhea.
A 3 week old white male presents with a history of several days of
projectile vomiting after feeding, and documented weight loss despite a
good appetite. There is a questionable history of a paternal uncle
having surgery for a similar problem when he was an infant. Which one of
the following findings is a characteristic sign of this disease?

a) Hypochloremic alkalosis
b) Pneumonia
c) Generalized abdominal distension
d) Currant jelly stool
e) Direct hyperbilirubinemia
The Correct answer is A

Explanation
Hypertrophic pyloric stenosis is the most likely diagnosis in this case.
If it is allowed to progress untreated, there may be signs of
malnutrition, constipation, oliguria, and profound hypchloremic
metabolic alkalosis. The latter is a characteristic sign of pyloric
obstruction. As the child vomits chloride and hydrogen-rich gastric
contents, hypochloremic alkalosis sets in. Pneumonia is not a common
problem with pylori stenosis, as it can be with congenital
tracheoesophageal fistulae for example. After feeding, there may be a
visible peristaltic wave that progresses across the abdomen. However,
since the point of obstruction is proximal to the small and large
intestines and affected infants lose weight, the abdomen is usually flat
rather than distended, especially in the malnourished infant. Currant
jelly stool is a common clinical manifestation of intussusception. Mild
jaundice with elevated indirect bilirubin is seen in about 5% of infants
with pyloric stenosis, but is not a characteristic sign.

A six year old boy presently undergoing treatment for Wilm's tumor,
visits the oncology clinic regarding a sudden loss of vision in his
right eye of one day's duration. His vision in the right eye is
restricted to light perception only. His vision in the left eye is
20/20. Pupils are 4 mm in size each eye, pupillary reactions are
sluggish right eye, but brisk with a normal consensual reaction when the
light is shown to the left eye. Swinging the flashlight from left to
right eye, the right pupil dilates. Swinging the flashlight from right
to left eye, the left pupil constricts.

The pupillary reactions demonstrated represent

a) Metastasis to the right optic nerve


b) Orbital tumor
c) Hemorrhage within the right optic nerve sheath
d) Retinal detachment
e) Increased Intracranial Pressure
The Correct answer is A

Explanation
Marcus Gunn pupil is a medical sign observed during the
swinging-flashlight test whereupon the patient's pupils constrict less
(therefore appearing to dilate) when the light swings from the
unaffected "good" eye to the affected "bad" eye. There is no anisocoria,
and the "bad eye" still senses light and produces pupillary constriction
to some degree, albeit reduced. The commonest cause of Marcus Gunn pupil
is a lesion of the optic nerve (before the optic chiasm) or severe
retinal disease.
An 11 year old patient presents with petechiae and mucosal bleeding. His
initial labs show a low platelet count. He is eventually diagnosed with
idiopathic thrombocytopenic purpura (ITP). What is the most appropriate
treatment?

a) Steroids
b) Antibiotics
c) IV fluids
d) Surgery
The Correct answer is A
Explanation
Idiopathic thrombocytopenic purpura is a bleeding disorder caused by
thrombocytopenia not associated with a systemic disease. Typically, it
is chronic in adults but is usually acute and self-limited in children.
Spleen size is normal. Diagnosis requires that other disorders be
excluded through selective tests. Treatment includes corticosteroids,
splenectomy, and, for life-threatening bleeding, platelet transfusions,
and IV immune globulin.
A 12 month old child is brought by the father with 2nd degree burns on
both hands. He tells you that the child dipped his hands in very hot
bathtub water. There is a clear distinction line on the burn with no
splash burns. The most likely diagnoses is

a) Child abuse
b) Scalded skin syndrome
c) ITP
d) Accidental burning
The Correct answer is A

Explanation
This is most likely a case of child abuse. Common signs of such include:

Bruises on uncommonly injured body surfaces, blunt-instrument marks or


burns, human hand marks or bite marks, multiple injuries at different
stages of healing, evidence of poor care or failure to thrive,
circumferential immersion burns, burn (scalding) marks, seen when a
child is placed in hot water as a punishment, particularly "glove" or
"sock" burn patterns, unexplained retinal hemorrhages.

Scald marks on the hands, feet or buttocks with a glove, sock or


circular appearance are almost always caused by deliberate immersion.

A pediatrician's office gets a phone call from a frantic mother. Her 6


year old daughter was playing under the sink and accidentally spilled a
drain cleaner all over her arms and legs. The nurse on the phone can
hear the girl screaming in the background. Which of the following are
the most appropriate instructions to give the mother?

a) Cover the burned areas with triple antibiotic ointment until the
girl can be seen at the office
b) Get the girl into the shower right away and keep the water running
over her for 30 minutes before bringing her to the emergency department
c) Get the girl to the emergency department as soon as possible
d) Wash the burned areas with diluted vinegar and bring the girl to the
office
e) Wrap the burned areas in sterile dressings before bringing the girl
to the emergency department
The Correct answer is B

Explanation
By far the most important thing that can be done for caustic chemical
burns is to wash away the caustic agent as soon as possible, and the
best way to do that is with massive irrigation. Any answer that allows
the chemical agent to stay in touch with the skin, whether mixed with
antibiotic ointment, wrapped in bandages, or with no specific additional
instructions will result in continued burning for the time that it will
take to get to the emergency department or physicians' office.

An infant child develops abdominal obstruction. His history includes no


passing of meconium on the first day of life. You suspect hirschsprung's
disease. What is the method for definitive diagnosis’

a) Barium enema
b) Colonic transit time with radio opaque markers
c) X-ray
d) Rectal biopsy
The Correct answer is D

Explanation
In Hirschsprung's disease (congenital megacolon), a section of the large
intestine is missing the nerve network that controls the intestine's
rhythmic contractions.

At the time of birth, newborns should pass a dark green fecal material
(meconium). Delayed passage of meconium raises the suspicion of
Hirschsprung's disease. Later in infancy, children with Hirschsprung's
disease can have symptoms that suggest intestinal obstruction,
bile-stained vomit, a swollen abdomen, and refusal to eat.

Rectal biopsy and measurement of the pressure inside the rectum


(manometry) are the only tests that can reliably be used to diagnose
Hirschsprung's disease. A barium enema may also be performed. During a
barium enema, the doctor instills barium and air into the child's rectum
and then takes x-rays.
A concerned father calls your office because his three week old son has
a fever of 39.5 degrees Celsius (103.1 F) measured axially. He was born
at term and had no complications after a spontaneous vaginal delivery.
He was breast-feeding well until yesterday. Since then he has been
sleeping more. He has a two-year-old brother who has a cold. What is the
best advice to give the parents’

a) Treat the fever with Tylenol, bring the baby to the office if fever
lasts over 48 hours
b) Bring baby to the office for further evaluation sometime later today
c) Take baby to the emergency room for hospital admission
d) Make a house call
e) Make appointment for the baby with a pediatrician
The Correct answer is C

Explanation
Febrile neonates (up to 28 days old) are at particularly high risk for
bacterial infections. An immature immunologic system makes them
vulnerable to more virulent bacteria as well as viral infections.

The routine workup for febrile neonates must be more aggressive than in
other age groups because of the greater probability of a serious
bacterial infection and our inability to predict which neonates have
serious infections.

All febrile neonates should have a blood culture drawn, a lumbar


puncture for cerebrospinal fluid culture and studies, and urine obtained
by catheterization for urinalysis and culture. Chest films should be
taken when respiratory symptoms are present. Stool leukocytes and
culture are indicated in neonates with diarrhea. A white blood cell
(WBC) count is usually obtained also.

All febrile neonates should be hospitalized and receive intravenous


antibiotics, even when laboratory screening tests are normal. Treatment
should include IV gentamicin (2.5 mg/kg) or a third-generation
cephalosporin such as cefotaxime (50 or 100 mg/kg if meningitis is
suspected).
The mother of a 5 day old white male brings the infant to your office
because of profuse bleeding from his circumcision site. A plastic bell
technique was used, and the bell is partially on. The mother reports
that there was some scrotal bruising after the procedure. The remainder
of the pre- and post-natal history is unremarkable. The infant appears
healthy and vigorous. There is no heart murmur. Capillary refill is
good. There is no bruising and no petechiae.

Laboratory Findings

Hematocrit ---------------------------54% (N 41-65)


Hemoglobin ---------------------------18.0 g/dL (N 13.4-19.8)
WBCs ---------------------------14,000/mm3 (N 6000-17,500)
Platelets ---------------------------278,000/mm3 (N 150,000-400,000)
Prothrombin time ---------------------------12 sec (N 10-16)
Activated partial thromboplastin time ---------------------------87 sec (N 31-54)

Which one of the following additional tests will most likely help you to
make the correct diagnosis’

a) Factor VIII levels


b) Hemoglobin electrophoresis
c) Antithrombin level
d) Protein S and protein C levels
e) Testing for factor V Leiden
The Correct answer is A

Explanation
Hemophilia is X-linked and occurs in approximately 1 in 5000 male
births, with 85% having factor VIII deficiency (hemophilia A) and the
remaining 15% having factor IX (hemophilia B) and factor XI (hemophilia
C) deficiency. Because factor VIII does not cross the placenta, bleeding
symptoms may be present from birth, with the most dreaded manifestation
being intracranial hemorrhage. About 30% of affected male infants will
bleed from the circumcision site.

The only ?routine? laboratory test that is affected by a reduced level


of factor VIII is the activated partial thromboplastin time. Once
hemophilia is suspected, the specific assay for factor VIII will confirm
the diagnosis. Factor VIII levels in affected persons vary from less
than 1% to approximately 25% of normal activity. Clinical severity of
the disease varies with the degree of deficiency of factor VIII activity.

Recently-developed recombinant factor VIII for treating patients with


hemophilia can help prevent transfusion-related infections. Deficiencies
of antithrombin III, protein S and protein C, and mutations of the gene
for factor V (factor V Leiden) are associated with thrombotic
conditions, not bleeding.
Which of the following is NOT true of congenital cytomegalovirus (CMV)
infection?

a) With acute fulminant infection, CMV may present with


hepatosplenomegaly, petechiae, jaundice, intrauterine growth
retardation, thrombocytopenia, and elevated direct hyperbilirubinemia
b) Periventricular calcifications may be present
c) Child may develop mental retardation
d) There is no evidence of hearing loss
e) Microcephaly may be present at birth
The Correct answer is D

Explanation
Hearing loss is the most common sequela of congenital CMV infections and
should be screened for as soon as the diagnosis is entertained.

A. Acute fulminant CMV infections in the neonate present with multiorgan


involvement. CMV affects the liver presenting with elevated direct
bilirubin and transaminases. It also causes hepatosplenomegaly with
petechiae related to abnormal spleen sequestration and thrombocytopenia.
B. Periventricular calcifications are a classic finding on head
ultrasound or CT of the head with congenital CMV infections, but
calcifications may occur anywhere in the brain.
C. Mental retardation is common and related to both microcephaly,
central nervous system calcifications, and neurologic dysfunction from
primary CMV infection.
E. Microcephaly is not specific for congenital CMV infections but may be
seen in up to 15% of patients.
A 3 year old boy presents to the emergency room with a history of
recurrent cough. A review of his previous records reveals recurrent
episodes of right lower lobe pneumonia. A chest x-ray in the current
admission also confirms a right lower lobe pneumonia. He has no other
major health issues. What is the most likely diagnosis’

a) Cystic fibrosis
b) Croup
c) Chronic granulomatous disease
d) Asthma
e) Bronchiectasis of the lingula
The Correct answer is A

Explanation
Cystic fibrosis is an inherited disease of the exocrine glands affecting
primarily the GI and respiratory systems. It leads to COPD, exocrine
pancreatic insufficiency, and abnormally high sweat electrolytes.

Fifty percent of patients present with pulmonary manifestations, often


beginning in infancy. Recurrent or chronic infections manifested by
cough and wheezing are common. Cough is the most troublesome complaint,
often accompanied by sputum, gagging, vomiting, and disturbed sleep.
Intercostal retractions, use of accessory muscles of respiration, a
barrel-chest deformity, digital clubbing, and cyanosis occur with
disease progression.

Diagnosis is by sweat test or identification of cystic fibrosis


mutations in patients with characteristic symptoms. Treatment is
supportive through aggressive interdisciplinary care.
A 9 month old previously healthy child is brought to the doctor's office
because of sudden onset of lethargy, constipation, generalized weakness
and poor feeding. He has been meeting all development milestones and his
immunization schedule is up to date. On further questioning, his parents
mention that his diet was recently advanced to a homemade formula of
evaporated milk and honey. On physical examination, he has stable vital
signs, clear lungs, normal skin turgor and full fontanelles. Which of
the following is the most likely explanation for the patient's
presentation?

a) Botulism
b) Hirschsprung disease
c) Hypernatremia
d) Hyponatremia
e) Hypothyroidism
The Correct answer is A

Explanation
The clue to this patient's condition is the recent of a honey-containing
formula. Clostridium botulinum spores that are commonly found in honey
germinate in the infant's gastrointestinal tract and produce the
characteristic toxin. Infants younger than 1 year of age should not be
placed on a diet with honey.
A 14 year old boy is concerned about his height. Physical examination
reveals Tanner stage II pubic hair and genital development. Height and
weight are at the 10th percentile for age. Which of the following is the
most accurate statement about his growth?

a) He is taller than the average 14 year old girl


b) He will be taller than his peers by age 16
c) He has not reached his peak height velocity
d) He will stop growing by age 17
e) His adult height will be at the 10th percentile
The Correct answer is C

Explanation
The peak height velocity occurs at a mean of 13.5 years in boys and 11.5
years in girls. Since this boy is only in tanner stage II, he still has
not reached the peak height yet.

A 12 year old girl, who has been undergoing treatment for chronic
juvenile rheumatoid arthritis for the past 3 years, is brought to the
office because of painful swelling of the right knee. She has had three
episodes of painless swelling of her left knee and ankle, which have
subsided spontaneously with rest and aspirin therapy. On physical
examination today there is pronounced redness and warmth around the
right knee, and a large effusion is present. Attempts at active and
passive motion cause severe pain. Which of the following is the most
appropriate step at this time?

a) 99m technetium bone scan


b) Joint aspiration
c) Serum antinuclear antibody titer
d) Serum rheumatoid factor assay
e) X-ray films of the joint
The Correct answer is B

Explanation
Aspiration of the joint should be done in this patient because she has
clinical findings suspicious for septic arthritis. These clinical
findings include redness and warmth around the knee, large effusion, and
pain upon movement of the joint. Diagnostic arthrocentesis should be
performed in all patients in whom the diagnosis of septic arthritis is
considered.

Obtaining a 99mm technetium bone scan may aid in the diagnosis of a


septic joint by demonstrating increased soft tissue uptake in the region
of the joint. However, this is an aid to diagnosis; the ?gold standard?
is the joint aspirate. Obtaining an antinuclear antibody titer would not
be helpful, as we already know that this patient has juvenile rheumatoid
arthritis (JRA), and an ANA depending on the type of JRA may or may not
be positive. The focus should be on determining if the knee is septic,
only the joint aspirate will give us this information.
Which of the following is NOT a major manifestation in the Jones
criteria for diagnosis of rheumatic fever?

a) Fever
b) Chorea
c) Carditis
d) Erythema marginatum
e) Subcutaneous nodules
The Correct answer is A

Explanation
Fever is a minor criterion. The five major criteria are chorea,
carditis, erythema marginatum, subcutaneous nodules, and migratory
polyarthritis. The diagnosis of rheumatic fever requires the presence of
either two major criteria, or one major criterion and two minor
criteria, plus evidence of an antecedent streptococcal infection (throat
culture, rapid antigen test or elevated or increasing streptococcal
antibody test). Minor criteria include fever, arthralgia, prolonged PR
interval, and elevation of acute phase reactants.

B. Sydenham’s chorea occurs in 10-15% of patients with acute rheumatic


fever (ARF).
C. This is the most serious manifestation of ARF characterized by
pancarditis. Endocarditis affecting the aortic and mitral valves can
lead to acute regurgitation and long-term valvular stenosis.
D. Occurs in <3% of patients with ARF. It consists of erythematous
macular lesions with pale centers that are not pruritic. It occurs
primarily on the trunk and extremities, not the face.
E. Occurs in <1% of patients with ARF. Approximately 1 cm nodules may be
palpated along extensor tendon surfaces and correlates with significant
rheumatic heart disease.
Cystic fibrosis may present in the neonatal period or in adults. Which
of the following are possible complications associated with cystic fibrosis’

a) Rectal prolapse
b) Protein-calorie malnutrition
c) Nasal polyps
d) Male infertility
e) All of the above
The Correct answer is E

Explanation
See individual descriptions below.

A. Rectal prolapse occurs in up to 20% of patients with cystic fibrosis.


It is related to the passage of large bulky stools from pancreatic
insufficiency and improves when patients are palced on pancreatic enzyme
replacement.
B. Protein-calorie malnutrition or failure to thrive occurs because of
fat malabsorption and the need for increased caloric intake. Some
patients need 120-140% of daily-recommended caloric intake to grow and
gain weight.
C. Nasal polyps are common in cystic fibrosis patients with chronic
sinopulmonary disease and may be seen in young infants.
D. Almost all post pubertal males are infertile secondary to obstructive
azoospermia.
A 17 year old high school student presents to your clinic complaining of
severe sore throat.

He has been suffering from sore throat for the past week associated with
profound fatigue and malaise. He denies cough or other complaints. He
tried Ibuprofen to relieve the pain but with minimal benefit.

Vital signs are as following: BP is 120/70mm Hg, Temp is 390C, pulse is


105/min and RR: 18/min. HEENT exam reveals enlargement of the tonsils
bilaterally, coated with a thin whitish membrane. Palatal petechiae are
also noted. Cervical lymph node enlargement is detected. Abdominal exam
shows left upper quadrant tenderness with palpable spleen tip. Lab tests
show:

Leukocyte count: 13,000/mm3


Hemoglobin: 14.5 g/dL
Platelet: 200,000/mm3
WBC differential:
Neutrophils: 30%
Lymphocytes: 60%
Atypical lymphocytes: 30

What is the most likely diagnosis of this patient?

a) Acute HIV infection


b) Acute leukemia
c) Infectious mononucleosis
d) Non specific viral pharyngitis
e) Streptococcal tonsillitis
The Correct answer is C

Explanation
Always consider infectious mononucleosis in a young patient presenting
with fever, sore throat, lymphadenopathy and splenomegaly. Physical
examination usually reveals pharyngitis, palatal petchiae along with
tonsillar exudates. Lymphocytosis with the evidence of atypical
lymphocytes would strongly suggest the diagnosis.

Streptococcal tonsillitis is the major differential diagnosis; however


the lymphocytosis and the atypical lymphocytes suggest a viral etiology
of the condition rather than bacterial. Moreover, splenomegaly is not
associated with strep pharyngitis.

Although, acute HIV infection could give similar symptoms and should be
ruled out; it is unlikely, as acute HIV infection would give leucopenia
(not leucocytosis).

Acute leukemia is unlikely in the presence of a normal blood count and


absent blasts.

Non specific viral pharyngitis would present with flu like illness
(coryza) rather than sore throat and lymphadenopathy.
A healthy 8 month old white male has suddenly developed recurrent bouts
of what appears to be severe abdominal pain. He cries inconsolably and
draws up his legs, but does not seem ill between episodes. He has
vomited and on examination has a small amount of bloody mucoid stool in
his diaper and palpable mass in his undistended right upper abdomen. The
most likely diagnosis is

a) Intussusception
b) Pyloric stenosis
c) Duodenal atresia
d) Meckel’s diverticulum
e) Gastroschisis
The Correct answer is A

Explanation
This case presentation is fairly typical for intussusception, the
“telescoping” of a portion of the intestine into itself with obstruction
and crampy pain. it generally occurs between the ages of 6 months and 24
months. A sausage-shaped mass is often palpable as a result of the ileum
being trapped within the colon. The presence of bloody mucus supports
the diagnosis.

Pyloric stenosis generally occurs in the first 4-6 weeks of life


(although it can occur as late as the fifth month) with a striking
first-born male predominance. Emesis is the most prominent feature of
pyloric stenosis; it is usually painless, and there are no bloody
stools. The small pyloric mass, which feels like an olive, may be
palpable at the margin of the right rectus muscle. The onset is more
insidious than with intussuscpetion. Duodenal atresia presents shortly
after birth with vomiting and a “double-bubble” on radiograph,
indicating a gas-filled stomach and proximal duodenum. A Meckel’s
diverticulum may rarely be found at the lead point of an
intussusception, but it usually presents as a cause of recurrent
abdominal pain in later life. Gastroschisis is an antenatal evisceration
through a small paraumbilical defect that is present at birth.

The parents of a 10 month old boy presents with a history of excessive


straining due when trying to have a bowel movement. On physical exam you
clearly see he has developed a rectal prolapse. See picture of rectum
protruding through child’s anus:

What is your next intervention?

a) Surgical consult
b) Sweat chloride test
c) Stool studies
d) Reassurance
e) Prescribe a stool softener
The Correct answer is B

Explanation
Rectal prolapse occurs in 20% of patients with cystic fibrosis who are
aged 6 months to 3 years. The appropriate intervention at this point is
to order a sweat chloride test to see if this child has cystic fibrosis.

What is the most appropriate diagnostic test to diagnose suspected


unilateral renal agenesis’

a) IVP
b) ERCP
c) Renal doppler
d) Abdominal x-ray (KUB)
The Correct answer is C

Explanation
Unilateral renal agenesis is not usually of any major concern, as long
as the other kidney is healthy. The odds of a person being born with
this condition are roughly 1 in 5000. Adults with unilateral renal
agenesis have considerably higher chances of hypertension and high blood
pressure. Most contact sports would be advised against.

Failure to visualize the renal arteries with color renal doppler is the
recommended diagnostic test in suspected cases of both with bilateral
and unilateral agenesis. See picture below:

You attend the cesarean delivery of a full-term male infant with no


prenatal risk factors other than breech position. The infant was
received from the operating team crying and vigorous, with Apgar scores
of 8 at 1 minute and 9 at 5 minutes.

An hour later, the infant has become ashen-blue in color with an oxygen
saturation of 82%. He is alert and tachypneic, with a heart rate of 140
beats/min and a normal temperature. You order supplemental oxygen.

Which one of the following is the most appropriate next step in managing
this patient?

a) Begin bag-mask ventilation with 100% oxygen


b) Perform endotracheal intubation
c) Infuse prostaglandin E1
d) Obtain an EKG
e) Order a chest radiograph and laboratory studies
The Correct answer is E

Explanation
Cynosis and tachypnea may be a sign of transient tachypnea of the
newborn (TTN), or may be the first signs of a more serious health
condition. Many of the severe conditions may be ruled out through the
history (hyaline membrane disease is unlikely in this full-term infant)
and physical examination (choanal atresia may be ruled out at the
bedside). After these initial steps are taken, a chest radiograph and
laboratory studies will help rule out many urgent and life-threatening
conditions, such as pneumothorax, pneumonia, severe anemia, sepsis, etc.
An EKG is less helpful in determining causes since it cannot
differentiate defects that cause cyanotic heart disease. Infusion of
prostaglandin E1 should be started only if the condition is determined
to be ductal dependent; this is not the case in this scenario. Bag and
mask breathing is not warranted in this child, who is alert and
breathing, and has a normal heart rate. At this time, it is reasonable
to start investigations into the cause of the child’s problems before
resorting to more extreme measures such as intubation.

All of the following are true about Turner syndrome, except

a) Short stature
b) Amenorrhea
c) Coarctation of the Aorta
d) Hirsutism
The Correct answer is D

Explanation
In Turner syndrome (gonadal dysgenesis), girls are born with one of the
two X chromosomes partially or completely missing.

Many newborns with Turner syndrome have swelling (lymphedema) on the


backs of their hands and tops of their feet. Swelling or loose folds of
skin are often evident over the back of the neck. Many other
abnormalities often develop, including a webbed neck, a low hairline at
the back of the neck, a broad chest with wide-spaced nipples, and poorly
developed nails.

As a girl with Turner syndrome gets older, she has no menstrual periods
(amenorrhea), and the breasts, vagina, and labia remain childlike rather
than undergoing the changes of puberty. The ovaries usually do not
contain developing eggs. A girl or woman with Turner syndrome is
virtually always short; obesity is common.

Other disorders often develop. Heart defects include narrowing of part


of the aorta (coarctation of the aorta). Kidney and eye defects,
diabetes mellitus, and thyroid diseases are common.
An otherwise healthy 1-year-old male is brought to your office because
of increased respiratory effort, wheezing, and rhinorrhea. He has no
fever. On examination he is found to have an increased respiratory rate
and mild retractions. A chest film shows no foreign body or infiltrates.
Oxygen saturation is 94%.

Management should include which one of the following?

a) A trial of nebulized albuterol


b) Nebulized epinephrine
c) Oxygen
d) Antibiotics
e) Corticosteroids
The Correct answer is A

Explanation
This presentation is consistent with bronchiolitis, which is a response
to a viral respiratory infection. The Academy of Pediatrics guidelines
for the management of bronchiolitis do not recommend routine use of any
treatment, recommending instead that the choice be based on the specific
needs of the child. If the child responds to a trial of albuterol, then
treatment can be continued; otherwise, evidence shows no benefit.
Antibiotics are indicated for signs of bacterial infection. Oxygen is
indicated if the saturation is less than 90%. Corticosteroids have not
been shown to be of benefit.
During the current winter season, a number of infants have been admitted
to the pediatric ward with paroxysms of cough, wheezing, fever up to
38C (100F), and feeding difficulty. Chest radiographs have been
consistently normal or have shown soft findings of peribronchial cuffing.

Which one of the following would be indicated for these infants’

a) Nebulized albuterol (Proventil, Ventolin)


b) Amoxicillin/clavulanate (Augmentin)
c) Azithromycin (Zithromax)
d) Supplemental oxygen
e) Systemic corticosteroids
The Correct answer is D

Explanation
This clinical picture is consistent with respiratory syncytial virus
bronchiolitis, an epidemic respiratory infection prevalent in the winter
months. No treatment has been shown to alter the course of the disease,
so treatment consists of supportive care to prevent hypoxia and
dehydration. Corticosteroids, antibiotics, and bronchodilators have all
been shown to be ineffective.

A neonate develops severe cyanosis that begins within minutes of birth.


Blood drawn one hour after birth shows metabolic acidosis with
respiratory acidosis. A chest x-ray film shows a narrow base to the
great vessels and the heart resembles an egg on its side. ECG is normal.
Which of the following is the most likely diagnosis’

a) Aortic valve stenosis


b) Complete atrioventricular canal defect
c) Tetralogy of Fallot
d) Transposition of the great arteries
e) Underdeveloped (hypoplastic) left ventricle syndrome
The Correct answer is D

Explanation
This is transposition of the great arteries, in which the aorta arises
from the right ventricle and the pulmonary artery arises from the left
ventricle. Approximately 5% of congenital cardiac anomalies have
transposition of the great arteries. Affected babies present within
minutes of birth with severe cyanosis and metabolic acidosis secondary
to inability to oxygenate tissues. The only exchange of blood between
pulmonic and circulatory systems is typically occurring through a patent
ductus arteriosus.

The chest x-ray changes illustrated in the question stem are typical,
and are due to superposition of the great vessels (rather than the
normal side-to-side position). Surgical repair is usually performed
within 7 to 10 days of life.
What is the most common cause of neonatal death in children of mothers
known to have diabetes mellitus before pregnancy?

a) Congenital anomalies
b) Sepsis
c) Hypoglycemia
d) Birth trauma
e) Macrosomia
The Correct answer is A

Explanation
Congenital anomalies are the most common cause of neonatal death in
infants of mothers known to be diabetic prior to pregnancy. The
incidence of congenital anomalies is increased threefold in infants of
diabetic mothers, most notably cardiac and CNS defects. There is good
evidence that tight glycemic control in early pregnancy decreases the
risk of anomalies. The anomaly rate increases as the glycohemoglobin
level increases. In order to improve this, preconception diabetic care
must be strict.

Sepsis, hypoglycemia, birth trauma, and macrosomia are all increased in


infants of diabetic mothers. However, associated congenital anomalies
are more likely to cause perinatal mortality.
A mother brings to you her 5 year old boy for short stature. Both
parents have a history of short stature in childhood, but they are now
of normal height. Features that qualify as main criteria for the
diagnosis of constitutional growth delay include all of the following,
except

a) Height and weight are below the third percentile


b) Normal growth of 5 cm per year
c) The child was normal at birth for height and weight
d) Delayed puberty
e) Bone age is equal to chronologic age
The Correct answer is E

Explanation
This condition describes children who are small for their ages but who
are growing at a normal rate. They usually have a delayed "bone age,"
which means that their skeletal maturation is younger than their age in
years. (A child's bone age is measured by taking an X-ray of a child's
hand and wrist and comparing it to standard X-ray findings seen in
children of the same age.)

These children don't have any signs or symptoms of diseases that affect
growth. They tend to reach puberty later than their peers do, with delay
in the onset of sexual development and the pubertal growth spurt. But
because they continue to grow until an older age, they tend to catch up
to their peers when they reach adult height. One or both parents or
other close relatives of these children often experienced a similar
"late-bloomer" growth pattern.
37 year old G2P2, has just given birth to a term baby at home, and did
not have access to prenatal care during this pregnancy. The mother was
taking levothyroxine during her pregnancy for her Hashimoto’s disease,
but was at times forgetful. The baby showed signs of jaundice within the
first 24 hours of birth. Two weeks later, the jaundice was still
persistent, and the mother was complaining that her infant was not
moving as much. There were times when the infant would start shaking,
although the episode would be brief. Presently the infant is an abnormal
posture, in which the back is severely arched and rigid. What is the
next step in management?

a) Look for ABO or Rh incompatibility

b) Perform CBC, reticulocyte count, and blood smear


c) Initiate phototherapy when direct bilirubin >24mg/dL

d) Initiate exchange transfusion

e) Urinalysis and urine culture, and assess for sepsis


The Correct answer is D

Explanation
This infant has pathological jaundice, and certainly hyperbilirubinemia
as it has persisted for at least 2 weeks. The most feared complication
of jaundice in a newborn is due to elevated indirect (unconjugated)
bilirubin. We fear kernicterus in the newborn, as the bilirubin can
deposit into the basal ganglia and brainstem nuclei. Physicians must be
aware of hypotonia, seizure-like activity, and opisthotonos.
Opisthotonos is a condition in which the body is held in an abnormal
posture, rigidity and severe arching of the back, with the head thrown
backward. Other signs to be aware of is delayed motor skills,
choreoathetosis, and sensorineural hearing loss. We manage these cases
with immediate exchange transfusion.
A 3 year old boy presents to the emergency room following a 40 second
generalized tonic-clonic seizure. The infant has been ill with a high
fever for 24 hours. His history is unremarkable, and physical
examination is normal, CBC and urinalysis are normal. Which one of the
following would be the best initial step?

a) Arrange to have an EEG performed urgently


b) Admit to hospital for an immediate CT scan of the head
c) Carry out blood cultures
d) Reassure the mother and recommend close observation
e) Perform a lumbar puncture
The Correct answer is D

Explanation
Febrile seizures occur in children < 6 years with body temperature >
38°C and no previous afebrile seizures and that have no other
identifiable cause. Diagnosis is clinical after exclusion of other
causes. Treatment of seizures lasting < 15 min is supportive.

Seizures lasting ? 15 min are treated with IV lorazepam and, if


persistent, IV fosphenytoin. Maintenance drug therapy to prevent
recurrent febrile seizures or development of afebrile seizures is
usually not indicated unless multiple or prolonged episodes have occurred.

A 15 year old girl who is at Tanner stage 3 is concerned because she has
still not had her first menses. The most appropriate management at this
time is

a) Examination of the pelvis


b) Chromosome analysis
c) Estrogen and Progesterone level
d) Reassurance
The Correct answer is D

Explanation
Tanner stages are as follows:

Female Breast

Stage 1 no breast tissue with flat areola


Stage 2 breast budding with widening of the areola
Stage 3 larger and more elevated breast extending beyond the areola.
Stage 4 larger and even more elevated breast. Areola and nipple
projecting from the breast contous
Stage 5 Adult size with nipple projecting above areola

Male and female pubic hair

Stage 1 none
Stage 2 small amount of long hair at base of male scrotum or female
labia majora
Stage 3 moderate amount of curly and coarser hair extending outwards
Stage 4 resembles adult hair but does not extend to inner surface of thigh
Stage 5 adult type and quantity extending to the medial thigh surface

Since this patient is developing and has sexual characteristics, she may
need to wait a little longer for menarche. Reassurance is appropriate at
this time. The average age for menarche is 12, but can vary between 9
and 16.
Rectal prolapse in infants is most commonly associated with which one of
the following diseases’

a) Trisomy 21
b) Microcephaly
c) Cystic fibrosis
d) Pyloric stenosis
e) Intussusception
The Correct answer is C

Explanation
Rectal prolapse occurs in 20% of patients with cystic fibrosis who are
aged 6 months to 3 years. The appropriate intervention when encountering
a child with rectal prolapse is to order a sweat chloride test to see if
the child has cystic fibrosis.
The most likely diagnosis in a 3 years old with a abdominal mass, found
to be of renal origin, is

a) Renal cell carcinoma


b) Wilm’s tumor
c) Neuroblastoma
d) Renal stones
e) Polycystic kidney disease
The Correct answer is B

Explanation
Wilms tumor (WT) is the fifth most common pediatric malignancy and the
most common type of renal tumor in children. This neoplasm may present
with renal signs and symptoms, such as hypertension, hematuria and
abdominal pain. Wilms' tumor should be considered in the differential
diagnosis of an abdominal mass in a child. The mean age at diagnosis is
41.5 months for males and 46.9 months for females. Wilms' tumor can
present as an abdominal mass in newborns, and it occasionally develops
in adolescents.

When an abdominal mass is detected in a child, ultrasound examination of


the abdomen should be performed within 24 hours by a radiologist with
pediatric experience. If the ultrasound examination does not clearly
identify the origin of the mass, abdominal CT scanning should be
performed. If the mass is confirmed to be of renal origin, immediate
referral to a pediatric oncologist and a pediatric surgeon is indicated.

Differential Diagnosis of Abdominal Mass in Children


-->Neonates
-Renal
Hydronephrosis
Multidysplastic kidney
Mesoblastic nephroma
Renal vein thrombosis
Polycystic kidney disease
Wilms’ tumor
Rhabdoid tumor
-Pelvic
Ovarian cyst
Hydrocolpos
Hydrometrocolpos
Gastrointestinal duplication

-->Infants and children


-Retroperitoneal
Neuroblastoma
Wilms’ tumor
Lymphoma
-Liver
Hepatoblastoma
Embryonal sarcoma
-Gastrointestinal
Duplication
Meckel’s diverticulum
Fecal mass
-Pelvic
Ovarian cysts
Teratomas
-Other
Omental or mesenteric cyst

A five year old child presents with fever, irritability and sore throat.
Physical exam shows there are numerous small ulcers and vesicles inside
his mouth. See picture:
What is the most likely diagnosis’

a) Herpangina
b) Herpes simplex stomatitis
c) Leukoplakia
d) Erysipelas
The Correct answer is A

Explanation
Herpangina is a febrile disorder caused by numerous group A coxsackie
viruses and occasionally other enteroviruses. Infection produces
oropharyngeal mucosal vesicular and ulcerative lesions.

Herpangina tends to occur in epidemics, most commonly in infants and


children. It is characterized by sudden onset of fever with sore throat,
headache, anorexia, and frequently, neck pain. Infants may vomit. Within
2 days after onset, up to 20 1- to 2-mm diameter grayish papules develop
and become vesicles with erythematous areolae. They occur most
frequently on the tonsillar pillars but also on the soft palate,
tonsils, uvula, or tongue.

Diagnosis is based on symptoms and characteristic oral lesions. It is


best confirmed by isolating the virus from the lesions or by
demonstrating a rise in specific antibody titer, but such testing is not
generally recommended. Treatment of herpangina is symptomatic.

An 8 year old boy presents to the physician for a routine health


maintenance visit. His mother states that he has had difficulty reading
and concentrating in his second-grade class. On examination, seven
café-au-lait spots on his body, as well as two small, soft masses above
his orbit, are seen. He also has axillary freckling. His mother also has
café-au-lait spots on her arms. Which of the following is the most
likely diagnosis’

a) Congenital hypothyroidism
b) Marfan syndrome
c) Neurofibromatosis
d) Osteogenesis imperfecta
e) Tuberous sclerosis
The Correct answer is C

Explanation
Neurofibromatosis is a multisystem genetic disorder. The features of
this condition are more than six café-au-lait spots, two or more
neurofibromas, axillary freckling, optic gliomas, iris hamartomas (Lisch
nodules), and osseous lesions. There is almost always a first-degree
relative with neurofibromatosis.

Congenital hypothyroidism is associated with poor feeding, an enlarged


fontanelle, an enlarged tongue, and an umbilical hernia in the neonatal
period. It would not go undetected until 8 years of age. Marfan syndrome
is a connective tissue disorder characterized by long fingers,
hypermobile joints, subluxation of the lenses, pectus carinatum, and
aortic aneurysms.

Osteogenesis imperfecta is a rare connective tissue disease


characterized by recurrent fractures, blue sclera, thin skin, and
hyperextensibility of ligaments. Tuberous sclerosis is associated with
facial angiofibromas (adenoma sebaceum), retinal hamartomas, seizures,
and mental retardation. Seizures are the most common presenting symptom.
It is an autosomal-dominant inherited disease.
A 3 year old female patient presents with a painless mobile mass in her
right upper quadrant without fever or jaundice. What is the most likely
diagnosis’

a) Tumor of left inferior lobe of the liver


b) Choledochal cyst
c) Tumor of superior pole of the right kidney
d) Liver metastasis
The Correct answer is B

Explanation
In a choledochal cyst the common bile duct of the biliary tree is
structurally abnormal, probably from the time of birth. Usually by the
age of 2 or 3 years the bile begins to collect in the duct. It forms a
sack or cyst which then presses on the bile duct and may prevent bile
from reaching the intestine. Bile can back up into the liver and the
patient becomes jaundiced (yellow).

The classic symptoms of abdominal mass, pain and jaundice is rarely seen
during childhood. Some children may not show symptoms for years. In some
patients, the cyst can be felt by the doctor examining the abdomen.
Blood studies such as a serum amylase and liver function tests may be
drawn during acute episodes of pain. In most patients the diagnosis can
be confirmed by using Ultrasound pictures or by injecting a radioactive
substance and performing a CT scan which gives an "image" of the
abnormal duct.

The abnormal bile duct is removed and a piece of intestine is used to


replace it. In most cases, surgery permanently corrects the disease.
You diagnose sinusitis in a 7 year old male. He has been in good health
otherwise, and has not been seen by a physician since his well care
visit at age 6. Which one of the following is recommended as initial
antibiotic treatment?

a) Azithromycin (Zithromax)
b) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
c) Cefuroxime (Ceftin)
d) Amoxicillin
e) Doxycycline
The Correct answer is D

Explanation
In the absence of any risk factors, approximately 80% of children with
acute bacterial sinusitis will respond to treatment with amoxicillin.
Risk factors for the presence of bacterial species that are likely to be
resistant to amoxicillin include attendance at day care, antimicrobial
treatment within the past 90 days, and age < 2 years .The desire to
continue to use amoxicillin as first-line therapy in patients suspected
of having acute bacterial sinusitis relates to its general
effectiveness, safety, tolerability, low cost, and narrow spectrum.

Which of the following patients with congenital heart disease would be


expected to exhibit cyanosis’

a) A 2-year-old girl with tetralogy of Fallot and concomitant aplastic


anemia with a hemoglobin concentration of 5 g/dl
b) A 6-year-old girl with Turner’s syndrome and coarctation of the aorta
c) A term newborn with truncus arteriosus
d) An 18-month-old boy with a muscular VSD
e) A 10-year-old boy with a congenital ASD
The Correct answer is C

Explanation
Truncus arteriosus is a rare form of congenital heart disease which
presents with moderate cyanosis at birth due to the fact that there is
complete mixing of systemic and pulmonary venous blood.

A. Although tetralogy of Fallot is usually also associated with


cyanosis, there must be at least 5 g/dl of deoxygenated hemoglobin
present in order for cyanosis to be present. Therefore, in severely
anemic states, cyanosis may not be present.
B. Coarctation is not typically a cyanotic lesion. Femoral pulses will
be weak or absent with upper extremity hypertension.
D. VSD is the most common congenital heart disease. A severe lesion may
result in congestive heart failure but without cyanosis.
E. ASD is not a cyanotic lesion, although high flow or secundum lesions
may require SBE prophylaxis.
A 6 month old girl presents with vomiting and diarrhea of acute onset.
Her systolic blood pressure is 40 mm Hg, pulse is 160/minute, she has
poor peripheral circulation and is very lethargic. Her serum sodium
concentration is 158 mmol/L. Which one of the following is the best
initial management?

a) Intravenous 0.9% saline in aliquots of 20 mL/kg


b) Intravenous 5% D/W/0.3% to 0.45% saline solution
c) Oral solution containing 50 mmol sodium per liter
d) Septic workup
e) Hydrocortisone 200 mg intravenously
The Correct answer is A

Explanation
Hypernatremia is plasma Na concentration > 145 mEq/L caused by a deficit
of water relative to solute. A major symptom is thirst; other clinical
manifestations are primarily neurologic (due to an osmotic shift of
water out of cells), including confusion, neuromuscular excitability,
seizures, and coma. Diagnosis is by measuring serum Na.

Severely dehydrated infants must have their circulating blood volume


restored first, usually with 0.9% saline in aliquots of 20 mL/kg IV.
Treatment is then with 5% D/W/0.3% to 0.45% saline solution IV in
volumes equal to the calculated fluid deficit, given over 2 to 3 days to
avoid a rapid fall in serum osmolality, which would cause rapid movement
of water into cells and potentially lead to cerebral edema. Maintenance
fluids should be provided concurrently. The goal of treatment is to
decrease serum Na by about 10 mEq/L/day.

Which of the following statements about a child with short stature is


correct?

a) The bone age is delayed in a child with constitutional growth delay


b) Height crosses a major percentile line on the child’s growth chart
c) Weight is more affected than height in a child with an endocrine
deficiency
d) Karyotyping is part of the routine investigation of all children
with short stature
e) Growth hormone replacement is helpful in a child with familial
growth delay
The Correct answer is A

Explanation
Children with constitutional growth delay (CGD), the most common cause
of short stature and pubertal delay, typically have retarded linear
growth within the first 3 years of life. In this variant of normal
growth, linear growth velocity and weight gain slows beginning as young
as age 3-6 months, resulting in downward crossing of growth percentiles,
which often continues until age 2-3 years. At that time, growth resumes
at a normal rate, and these children grow either along the lower growth
percentiles or beneath the curve but parallel to it for the remainder of
the prepubertal years.

CGD is a global delay in development that affects every organ system.


Delays in growth and sexual development are quantified by skeletal age,
which is determined from bone age radiographic studies of the left hand
and wrist. Growth and development are appropriate for an individual's
biologic age (skeletal age) rather than for their chronologic age.
Timing and tempo of growth and development are delayed in accordance
with the biologic state of maturity.
A 15-month-old male is brought to the emergency department following a
generalized tonic-clonic seizure at home. The parents report that the
seizure lasted 5 minutes, with confusion for the next 15 minutes. This
is the child’s first seizure. There is no family history of seizures.
His medical history is normal except for a 1-day history of a URI.

While initially lethargic in the emergency department, the child is now


awake and playful, with a temperature of 39.5 C (103.2 F) and a normal
examination. Appropriate diagnostic tests are performed, including a
blood glucose level, which is 96 mg/dL.

Which one of the following would be most appropriate to administer at


this point?

a) Phenytoin (Dilantin) intravenously


b) Ceftriaxone (Rocephin) intravenously
c) Acetaminophen orally
d) Carbamazepine (Tegretol) orally
e) Phenobarbital orally
The Correct answer is C

Explanation
This child has had a simple febrile seizure, the most common seizure
disorder of childhood. Treatment includes finding a source for the
fever; this should include a lumbar puncture if meningitis is suspected.
The most common infections associated with febrile seizures include
viral upper respiratory infections, otitis media, and roseola.
Antipyretics are the first-line treatment. Antibiotics are indicated
only for appropriate treatment of underlying infections. Phenytoin and
carbamazepine are ineffective for febrile seizures.

Phenobarbital is sometimes used for prevention of recurrent febrile


seizures, but is not indicated as an initial therapy. Only 30%-50% of
children with an initial febrile seizure will have recurrent seizures.

A 12 year old male middle-school wrestler comes to your office


complaining of a recurrent painful rash on his arm. There appear to be
several dry vesicles. The most likely diagnosis is which of the following?

a) Molluscum contagiosum
b) Human papillomavirus
c) Herpes gladiatorum
d) Tinea corporis
e) Mat burn
The Correct answer is C

Explanation
The most common infection transmitted person-to-person in wrestlers is
herpes gladiatorum caused by the herpes simplex virus. Molluscum
contagiosum causes keratinized plugs. Human papillomavirus causes warts.
Tinea corporis is ringworm, which is manifested by round to oval raised
areas with central clearing. Mat burn is an abrasion.

A 2 year old boy arrives comatose and unresponsive to the emergency


department. The child has dried vomitus on his shirt and pants. The
father indicates that he picked up the child from the grandmother’s
house 60 minutes ago. The grandmother said that she had dropped her
medications on the floor and it was possible that the child ate some
pills, but the father does not know the names of the medications. The
most appropriate first step in the management of this child is which of
the following?

a) Administer syrup of ipecac


b) Send the father back to the grandmother’s house to find out the
names of the medicines
c) Pass a large bore gastric tube and lavage the child’s stomach
d) Establish a secure airway
e) Arrange for admission to the hospital ward to observe the
neurological status carefully
The Correct answer is D

Explanation
The first priority in a comatose, unresponsive, vomiting patient is
management of airway, breathing, and circulation (ABC’s). Establishment
of a secure airway is the first and most important step.

A. Syrup of ipecac should not be used in comatose patients.


B. It will be important to learn what medicines have been ingested, but
this is not the first priority.
C. Gastric lavage is not likely to be beneficial more than 60 minutes
after an ingestion. In order to prevent pulmonary aspiration, gastric
lavage should never be performed in a comatose patient prior to placing
an endotracheal tube.
E. This child will require admission to an intensive care unit after
stabilization.
A previously healthy 10-month-old child of Greek ancestry arrives in the
emergency department with the acute onset of cough, fever, generalized
jaundice, and tea-colored urine. Physical examination reveals scleral
icterus, tachypnea, and crackles over the right lower lung field. The
family history is significant for a maternal uncle who has been
hospitalized for ?anemia?. This child’s chest radiograph demonstrates
right lower lobe pneumonia. The hemoglobin level is 6.2 gm/dl with a
normal red cell size. Examination of the peripheral smear reveals red
cell fragments and Heinz bodies are present. The etiology of this
child’s anemia is:

a) Iron deficiency
b) G6PD deficiency
c) Sickle cell disease
d) Thalassemia trait
e) Foalte deficiency
The Correct answer is B

Explanation
Acute onset of jaundice and abnormal red cell morphology are typical of
hemolytic anemia. Stressors such as infection or certain medications may
trigger hemolysis. G6PD deficiency is transmitted as an X-linked
recessive trait, so males are primarily affected. Children of
Mediterranean and African-American background are at greatest risk.

A. Iron deficiency anemia is associated with microcytic, not normocytic,


anemia.
C. Sickle cell disease is most common in children of African-American
descent. Sickle cells are seen on the peripheral blood smear.
D. Thalassemia trait is associated with microcytic anemia. The
hemoglobin is usually between 9 and 10 g/dl.
E. The mean corpuscular volume is abnormally large in folate deficiency.
A 6 year old girl with an earache has a plugged feeling in her eardrum.
Otoscopy shows middle ear effusion and redness. What is the most
appropriate initial treatment?

a) Oral amoxicillin
b) Topical ear drops (antipyrine/benzocaine)
c) Oral augmentin
d) Symptomatic/supportive therapy
e) Ear irrigation
The Correct answer is A

Explanation
Acute otitis media is a bacterial or viral infection of the middle ear,
usually accompanying a URI. Symptoms include otalgia, often with
systemic symptoms (fever, nausea, vomiting, diarrhea), especially in the
very young.

Diagnosis is based on otoscopy. Treatment is with analgesics and


antibiotics. Amoxicillin is given initially in the oral forms. Augmentin
is reserved for resistant cases.
A 6-year-old white male visits your office with chief complaints of a
recent onset of fever, bilateral knee and ankle pain, colicky abdominal
pain, and rash. On examination, his temperature is 38.3°C (101.0°F), and
there is a prominent palpable reddish-brown rash on the buttocks and
thighs. There is pain on motion of his knees and ankles, and mild
diffuse abdominal tenderness. The stool is positive for occult blood.

Laboratory Findings

Hemoglobin---------------11.0 g/dL (N 11.5 - 13.5)


Hematocrit----------------33% (N 34 - 40)
WBCs----------------------14,500/mm3 (N 5500 - 15,000); 85% segs, 15% lymphs
Platelets-------------------345,000/mm3 (N 150,000 - 400,000)
Prothrombin time-------12 sec (N 11 - 15)

Which one of the following is the most likely diagnosis’


a) Systemic onset juvenile rheumatoid arthritis
b) Rocky Mountain spotted fever
c) Henoch-Schönlein purpura
d) Disseminated anthrax
e) Acute iron ingestion
The Correct answer is C

Explanation
Henoch-Schönlein purpura typically follows an upper respiratory tract
infection, and presents with low-grade fever, fatigue, arthralgia, and
colicky abdominal pain. The hallmark of the disease is the rash which
begins as pink maculopapules, progresses to petechiae or purpura, which
are clinically palpable, and changes in color from red to dusty brown
before fading. Arthritis, usually involving the knees and ankles, is
present in two-thirds of cases, and gastrointestinal tract involvement
results in heme-positive stools in 50% of cases. Laboratory findings are
not specific or diagnostic, and include indications of mild to moderate
thrombocytosis, leukocytosis, and anemia, and an elevated erthrocyte
sedimentation rate. Treatment is typically symptomatic and supportive,
although corticosteroids are indicated in the rare patient with
life-threatening gastrointestinal or central nervous system manifestations.

Systemic juvenile-onset rheumatoid arthritis usually presents with an


evanescent salmon-pink rash. Rocky Mountain spotted fever does not
present with arthritis and the rash begins distally on the legs. Iron
ingestion does not typically cause a rash, fever, or arthritis.
Disseminated anthrax does not present with a rash or joint symptoms.

A mother brings her 3-year-old son to the office for follow-up one day
after his first tonic-clonic seizure. The mother brought the child to
the emergency department directly after the event for evaluation. The
child had not been ill previously, and no fever was present. A CBC,
blood chemistries, non-contrast CT, and spinal tap were normal. In the
office today the child’s medical history is unremarkable, as is his
physical examination, including developmental milestones and a thorough
neurologic examination.

Which one of the following would be most useful in assessing this


patient’s condition?

a) Arterial blood gas levels


b) Urine toxicology screening
c) A chromosomal analysis
d) An EEG
e) MRI of the brain
The Correct answer is D

Explanation
Seizures are a relatively common disorder in children, occurring in
4%-8% of the population by the age of 20.
Your response to a seizure is threefold: 1) reacting to the event
itself; 2) establishing an etiology; and 3) arriving at appropriate
treatment. The patient in this scenario has already been managed for the
acute event. The seizure appears to have been a single, limited event
that has no emergent features such as meningitis or status epilepticus.

When evaluating a patient who has just experienced a seizure, you should
first verify that the patient has normal vital signs and adequate
oxygenation and that there is no further seizure activity. A complete
laboratory evaluation of a child with the new onset of seizures includes
a complete blood count; measurement of blood chemistries, including
glucose, calcium, sodium, potassium, chloride, bicarbonate, urea,
nitrogen, creatinine, magnesium and phosphorus; blood or urine
toxicology screening; analysis of CSF; and EEG and brain imaging (MRI).

Glucose abnormalities and hyponatremia are the most common laboratory


findings associated with seizures.

Electroencephalography (EEG) is recommended for all patients with


new-onset seizures. *Most other patients with a first seizure can
receive EEG testing at a scheduled follow-up visit.* Although EEG within
24 to 48 hours of a seizure is more likely to show an abnormality, some
early abnormalities, such as postictal slowing, may not be significant.

A 6-week-old male infant presents with a history of projectile vomiting


for the past five days. Physical exam reveals a dehydrated, irritable,
afebrile infant. Laboratory evaluation reveals hypochloremic,
hypokalemic metabolic alkalosis. The likely diagnosis is:

a) Normal reflux
b) Hypertrophic pyloric stenosis
c) Viral infection
d) Duodenal atresia
e) Hirschsprung's disease
The Correct answer is B

Explanation
This is the classic presentation of pyloric stenosis. It presents most
commonly in a 6-week to 3-month-old first-born male infant.
Hypochloremic, hypokalemic metabolic alkalosis is seen secondary to the
loss of HCI and a compensatory H+/K+ exchange in the kidneys.

A. Gastroesophageal reflux disease is common, although it generally does


not cause dehydration.
C. In the setting of a viral infection, the infant would likely have
fever and diarrhea.
D. Duodenal atresia presents with vomiting (usually bilious) in the
first few days of life.
E. Hirschsprung’s disease is characterized by constipation.
A 6 month old infant presents in the winter with fever, cough, wheezing,
tachypnea and decreased appetite. A chest radiograph shows hyperaeration
and streaky perihilar infiltrates bilaterally. You diagnose
bronchopneumonia. Which organism would most likely be causing this
child's infection?

a) Chlamydia pneumoniae
b) Mycoplasma pneumoniae
c) Streptococcus pneumoniae
d) Haemophilus influenzae
e) Respiratory syncytial virus
The Correct answer is E

Explanation
Respiratory syncytial virus (RSV) and human metapneumovirus infections
cause seasonal lower respiratory tract disease, particularly in infants
and young children.

The most recognizable clinical syndromes are bronchiolitis and


pneumonia. These illnesses typically begin with upper respiratory
symptoms and fever and then progress over several days to dyspnea,
cough, and wheezing. Apnea may be the initial symptom of RSV in infants
< 6 months. In healthy adults and older children, illness is usually
mild and may be inapparent or manifested only as an afebrile common cold.

Disease may be asymptomatic, mild, or severe, including bronchiolitis


and pneumonia. Although diagnosis is usually clinical, laboratory
diagnosis is readily available. Treatment is supportive.

A 3-year-old female is brought to your office for a health maintenance


examination, and her father expresses concern about her vision. Her
visual acuity is 20/20 bilaterally on a ?tumbling E? visual acuity
chart. With both eyes uncovered during a cover/uncover test, the corneal
light reflex in the right eye is medial to the pupil when focused on a
fixed point, but the light reflex in the left eye is almost centered in
the pupil. When the left eye is covered, the right eye moves quickly
inward to focus on the fixed point, and the corneal light reflex is
centered in the pupil. When the left eye is uncovered, the right eye
returns to its original position. When you cover the right eye, no left
eye movement is noted. Which one of the following is the most likely
diagnosis’

a) Strabismus
b) Amblyopia
c) Cataract
d) Esotropia
e) Heterophoria
The Correct answer is A

Explanation
Strabismus is an ocular misalignment that can be diagnosed on a
cover/uncover test when the corneal light reflex is deviated from its
normal position slightly nasal to mid-pupil. The misaligned eye then
moves to fixate on a held object when the opposite eye is covered. The
eye drifts back to its original position when the opposite eye is
uncovered.
Amblyopia is a visual impairment from abnormal visual development?most
often as a result of strabismus. Cataract is a less frequent cause of
amblyopia. Esotropia is a type of strabismus with an inward or nasal
deviation of the eye that would be evidenced by a corneal light reflex
lateral to its normal position. (The outward eye deviation seen in this
patient is exotropia.) Heterophoria, or latent strabismus, does not
cause eye deviation when both eyes are uncovered.

A 4 year old child returns to your clinic after 3 days of treatment for
acute otitis media. She had been taking amoxicillin, 40 mg/kg/day, and
using acetaminophen and ibuprofen for pain and fever. On examination,
the child still has a bulging red tympanic membrane on the left, with a
flat tympanogram. She has continued to have a fever. Which one of the
following would be contraindicated?

a) Amoxicillin/clavulanate (Augmentin) orally


b) Ceftriaxone (Rocephin) intramuscularly
c) Cefuroxime (Ceftin) orally
d) Ciprofloxacin (Cipro) orally
e) Clindamycin (Cleocin) orally
The Correct answer is D

Explanation
All of these medications listed are indicated for second-line treatment
of acute otitis media. Ciprofloxacin, however, is not approved for
patients under age 18.

All of the following would be treated with immunoglobulin therapy in


children, except...

a) Kawasaki disease
b) Steven Johnson Syndrome
c) Thrombocytopenic Purpura
d) Neonatal sepsis
e) Toxic epidermal necrolysis
The Correct answer is D

Explanation
When neonatal sepsis is suspected, treatment should be initiated
immediately because of the neonate's relative immunosuppression. Begin
antibiotics as soon as diagnostic tests are performed.
Additional therapies have been investigated for the treatment of
neonatal sepsis; however, no substantial clinical trials have shown that
these treatments are beneficial. These additional therapies include
granulocyte transfusion, intravenous immune globulin (IVIG) replacement,
exchange transfusion, and the use of recombinant cytokines.
Which of the following is NOT true of Erb’s palsy?

a) It affects the fourth and fifth cervical spinal nerves


b) It can result from traction on the head, neck, and arms of large
infants during a vaginal delivery
c) The grasp reflex is intact
d) The Moro, biceps, and radial reflexes are absent on the affected side
e) The affected arm is adducted and internally rotated with the elbow
extended, the forearm is in pronation, and the wrist is flexed
The Correct answer is A

Explanation
The fifth and sixth cervical spinal nerves are affected.

B. Frequently seen with large, hypotonic infants that require increased


traction on the head and neck during a vaginal delivery.
C. The grasp reflex is not affected and should be intact.
D. Because of the brachial plexus injury in C5 and C6 spinal nerves, the
Moro, biceps, and radial reflexes are absent on the injured side.
E Because of the brachial plexus injury in C5 and C6 spinal nerves, the
neonate’s arm would be adducted and internally rotated with the elbow
extended, the forearm in pronation, and the wrist in flexion.
A child born at 32 weeks gestation is brought to your office at 2 months
of age for a routine check up. The child has an upper respiratory tract
infection but is afebrile. What decision would you make regarding the
child's first vaccination?

a) Wait until the child is two months older to administer the first
vaccination
b) Wait until the child is clinically well and then vaccinate
c) Administer the first vaccination
d) Consult a pediatrician
The Correct answer is C

Explanation
Acute illness is not a contraindication to immunization. At 2 months of
age this child should receive the following shots:

DTaP: Diphtheria, tetanus, and acellular pertussis vaccine


Hib: Haemophilus influenzae type b vaccine
IPV: Inactivated poliovirus vaccine
PCV: Pneumococcal conjugate vaccine
RV: Rotavirus vaccine, recommended for infants at 2, 4, and 6 months of age
A 5-year-old white male has an itchy lesion on his right foot. He often
plays barefoot in a city park that is subject to frequent flooding. The
lesion is located dorsally between the web of his right third and fourth
toes, and extends toward the ankle. It measures approximately 3 cm in
length, is erythematous, and has a serpiginous track. The remainder of
his examination is within normal limits. Which one of the following is
the most likely cause of these findings’

a) Dog or cat hookworm (Ancylostoma species)


b) Dog or other canid tapeworm (Echinococcus granulosus)
c) Cat protozoa (Toxoplasma gondii)
d) Dog or cat roundworm (Toxocara canis or T. mystax)
The Correct answer is A

Explanation
This patient has cutaneous larva migrans, a common condition caused by
dog and cat hookworms. Fecal matter deposited on soil or sand may
contain hookworm eggs that hatch and release larvae, which are infective
if they penetrate the skin. Walking barefoot on contaminated ground can
lead to infection.

Echinococcosis (hydatid disease) is caused by the cestodes (tapeworms)


Echinococcus granulosus and Echinococcus multilocularis, found in dogs
and other canids. It infects humans who ingest eggs that are shed in the
animal’s feces and results in slow-growing cysts in the liver or lungs,
and occasionally in the brain, bones, or heart. Toxoplasmosis is caused
by the protozoa Toxoplasma gondii, found in cat feces. Humans can
contract it from litter boxes or feces-contaminated soil, or by
consuming infected undercooked meat. It can be asymptomatic, or it may
cause cervical lymphadenopathy, a mononucleosis-like illness; it can
also lead to a serious congenital infection if the mother is infected
during pregnancy, especially during the first trimester. Toxocariasis
due to Toxocara canis and Toxocara cati causes visceral or ocular larva
migrans in children who ingest soil contaminated with animal feces that
contains parasite eggs, often found in areas such as playgrounds and
sandboxes.

While seeing a 6 month old infant for a well-child check, you note that
his height is at the 50th percentile, and his weight is at the 5th
percentile. You are concerned about the possibility of failure to thrive
(FTT). You history and physical examination reveal no obvious cause for
FTT other than inadequate caloric intake due to poor parental
skills. Which one of the following would be the most likely result of
laboratory evaluation of this child?

a) Anemia
b) Hypoglycemia
c) Hypothyroidism
d) Hyponatremia
e) No abnormalities
The Correct answer is E

Explanation
The majority of children with failure to thrive (FTT) have no laboratory
abnormalities. In a classic study of children hospitalized with FTT,
only 1.4% of laboratory tests were of diagnostic significance. A
practical approach is not to order any laboratory tests initially unless
suggested by the history or physical examination. Screening laboratory
studies can be considered in children who fail to respond to nutritional
intervention.
For the past 3 days, an 11 year old white male has had several small,
circular lesions on the left side of his lower forehead and nose,
extending to the tip of his nose. On examination you note grouped
vesicles, several of which are scabbed. The patient also complains of
burning pain in the area of the lesions. He had a sore throat with a
fever 5 days ago, but is now improved. His stepfather reports he is
up-to-date on immunizations, but a specific immunization record is not
available. His history and examination are otherwise unremarkable. The
most likely diagnosis is

a) Herpes zoster
b) Undetected immune deficiency
c) Primary herpes simplex type 1
d) Impetigo
e) Erythema multiforme
The Correct answer is A

Explanation
Clustered circular lesions with accompanying dysesthesia in a dermatone
are cahracteric of herpes zoster, which may occur after a stressful
event or infection in both children and adults. For herpes zoster to
occur, there must be a previous primary varicella infection or
immunization. Herpes zoster is less likely to be associated with
significant post-herpetic neuralgia in children than in adults.
A 1 year old boy is brought to the office by his mother for his routine
health check-up. She informs you that she has just been diagnosed with
hypercholesterolemia. Her fasting serum total cholesterol concentration
was 260 mg/dL and her LDL-cholesterol concentration was 130 mg/dL
(rec<129 mg/dL). A special diet has been recommended for her; however,
she is very concerned about the risk of hypercholesterolemia for her
son. The most appropriate management at this time is to

a) Ask her to reduce the child's fat intake and give him skim milk
instead of whole milk
b) Do nothing until the child is 2 years of age
c) Have the child return for a fasting lipoprotein analysis
d) Obtain a random serum total cholesterol concentration for the child
today
e) Refer the child to a lipid specialist
The Correct answer is B

Explanation
The mother, whose age is unspecified, but is likely less than 60 years
old, has no major risk factors for cardiac disease and her cholesterol
levels are not elevated enough to trigger concern for a familial
hypercholesterolemia. For these reasons, her child does not require any
immediate attention but should wait until roughly two years old when his
diet is free of breast milk and other sources of high fat content that
infants often require.
Cow’s milk should be withheld from a child’s diet until what age?

a) 4 months
b) 6 months
c) 9 months
d) 12 months
e) 15 months
The Correct answer is D

Explanation
Whole cow’s milk does not supply infants with enough vitamin E, iron,
and essential fatty acids, and overburdens their system with too much
protein, sodium, and potassium. Skim and low-fat milk lead to the same
problems as whole milk, and also fail to provide adequate calories for
growth. For these reasons cow’s milk is not recommended for children
under 12 months of age. Human breast milk or iron-fortified formula,
with introduction of certain solid foods and juices after 4?6 months of
age if desired, is appropriate for the first year of life.
A 6 month old white male is brought to your office because he has
“blisters” in his diaper area. You find large bullae filled with cloudy,
yellow fluid. Some of the blisters have ruptured and the bases are
covered with a thin crust. Which one of the following is most
appropriate in the management of this condition?

a) Use of a topical antifungal agent


b) Treating diapers with a vinegar rinse to remove residual ammonia
c) A course of penicillin to prevent acute glomerulonephritis
d) A course of penicillinase-resistant penicillin or a cephalosporin
The Correct answer is D

Explanation
Bullous impetigo is a localized skin infection characterized by large
bullae; it is caused by a group 2 phage type of Staphylococcus aureus.
Cultures of fluid from an intact blister will reveal the causative
agent. Ordinary penicillin is usually effective in streptococcal
impetigo, but early treatment does not appear to lessen the occurrence
of acute glomerulonephritis.
A 4-year-old female has had three urinary tract infections in the past 6
months. She complains of difficulty with urination and on examination is
noted to have labial adhesions that have resulted in near closing of the
introitus.

Which one of the following is the most appropriate management?

a) No treatment at this time


b) Reporting your suspicion of child abuse to the appropriate authorities
c) Application of estrogen cream to the site
d) Gentle insertion of progressively larger dilators over a period of
several days
e) Referral to a gynecologist for surgical correction
The Correct answer is C

Explanation
The etiology of prepubertal labial adhesions is idiopathic. The
adhesions may be partial or complete in some cases only a small pinhole
orifice may be seen that allows urine to exit from the fused labia. This
problem may be asymptomatic, but the patient may also have a pulling
sensation, difficulty with voiding, recurrent urinary tract infections,
or vaginitis. If there is enough labial fusion to interfere with
urination, treatment should be undertaken. The use of topical estrogen
cream twice daily at the point of the midline fusion will usually result
in resolution of the problem.
All of the following are features of chronic non-specific (toddler's)
diarrhea of childhood, except

a) Three to six loose watery stools per day


b) Familial tendency
c) Onset at age 6-30 months
d) Reduced intake of dietary fat
e) Failure to thrive
The Correct answer is E

Explanation
Toddler's diarrhea also known as chronic nonspecific diarrhea of
childhood, this is a perplexing condition for parents and doctors alike.
It is defined as a diarrhea that lasts for more than two weeks, usually
consists of 5-10 watery stools per day (often with undigested food
particles in the stool, in a child between about 6 months to 4 or 5
years old, who is growing and developing normally and otherwise seems
healthy, there is no detectable medical cause for the diarrhea such as
infection, food malabsorption or allergy.

The child's diet must be evaluated. Fluid intake may play a factor.
Studies have shown a link between excessive fluid consumption and
toddlers diarrhea, as well as high carbohydrate, low fat diets. Excess
fruit juice intake - especially apple juice - is often the cause of
mysterious diarrhea (apple juice contains sorbitol, the "active
ingredient" in prunes). If the child is being given any natural remedies
or health foods, these need to be mentioned to the doctor and probably
stopped to see if there is an improvement in the diarrhea.

Treatment is mostly dietary manipulation. Carbohydrates, especially


fruit juices, are reduced and fat increased to 35-40% of the total
calories. High fiber foods such as beans, fruit, breads, and cereals
should be encouraged. Antidiarrheal medications are probably ok for very
short periods of worsening symptoms, but should not be used for very
long, nor very often.
Billy is a 9-year-old boy who comes to your office for a well-child
checkup. He has been healthy and doing well in school, but Billy’s
mother is concerned about his bedwetting. He has never had a prolonged
period of nighttime dryness, and Billy currently wets every night, about
2-3 hours after going to sleep. Billy’s father had enuresis until age
10, but he outgrew the problem without any treatment. The mother has
tried restricting fluids prior to bed, but this has not helped. What
step in management would you do next?

a) Order a urine culture and a voiding cystourethrogram


b) Counsel the mother that enuresis is a self-limited problem that
requires no intervention
c) Start oral medication, either imipramine or desmopressin
d) Counsel Billy and his mother on the use of a buzzer alarm
conditioning device
e) Use negative reinforcement techniques to punish Billy when he has
wet nights
The Correct answer is D

Explanation
Enuresis is a common problem that is usually self-limited, but treatment
with buzzer alarm conditioning devices has been shown to be effective in
about 75% of cases.

A. Unless there is a history of urinary tract infection or an abnormal


urinary stream, cultures and radiographic studies are not necessary.
B. Intervention, when enuresis persists beyond 7-8 years of age, may
decrease stress and embarrassment.
C. While medications may work initially, most children start wetting
again as soon as the medication is stopped. Since desmopressin is very
expensive and imipramine may cause serious side effects if overdosed,
medications should probably not be used as initial cultures and
radiographic studies are not necessary.
E. Punishment and restriction of fluid have not been shown to be
effective treatments for enuresis.
A 5 year old develops difficulty breathing and facial swelling following
subcutaneous injection of an allergen during desensitization therapy.
Which one of the following treatments should be initiated immediately?

a) Discontinuation of subsequent injections for three weeks


b) Application of a tourniquet distal to the injection site
c) Administration of steroids prior to the next injection
d) Administration of aminophylline subcutaneously
e) Administration of epinephrine (1:1000) subcutaneously
The Correct answer is E

Explanation
Anaphylactic reactions are most commonly caused by drugs (such as
penicillin), insect stings, certain foods, and allergy injections
(allergen immunotherapy). But they can be caused by any allergen. Like
other allergic reactions, an anaphylactic reaction does not usually
occur after the first exposure to an allergen but may occur after a
subsequent exposure. However, many people do not recall a first
exposure. Any allergen that causes an anaphylactic reaction in a person
is likely to cause that reaction with subsequent exposures, unless
measures are taken to prevent it.

Anaphylactic reactions begin within 1 to 15 minutes of exposure to the


allergen. Rarely, reactions begin after 1 hour. The heart beats quickly.
The person may feel uneasy and become agitated. Blood pressure may fall,
causing fainting. Other symptoms include tingling (pins-and-needles)
sensations, itchy and flushed skin, throbbing in the ears, coughing,
sneezing, hives, and swelling (angioedema). Breathing may become
difficult and wheezing may occur because the windpipe (upper airway)
constricts or becomes swollen. An anaphylactic reaction may progress so
rapidly that it leads to collapse, cessation of breathing, seizures, and
loss of consciousness within 1 to 2 minutes. The reaction may be fatal
unless emergency treatment is given immediately.

If an anaphylactic reaction occurs, an epinephrine injection should be


given immediately. People who have these reactions should always carry a
self-injecting syringe of epinephrine and antihistamine tablets for
prompt treatment. Usually, this treatment stops the reaction.
Nonetheless, after a severe allergic reaction, such people should go to
the hospital emergency department, where they can be closely monitored
and treatment can be adjusted as needed.
A 3 year old female presents with urinary frequency, dysuria, and fever
to 39.0°C (102.2°F). She denies nausea, vomiting, and flank pain. There
is no prior history of urinary infection and no family history of
urinary tract abnormalities. Urethral catheterization reveals
bacteriuria and a urine culture reveals >100,000 colony-forming units of
Escherichia coli. She is started on appropriate antibiotic therapy.

Evaluation to rule out anatomic abnormalities should include

a) Renal ultrasonography only if she has recurrent infections


b) Renal ultrasonography and voiding cysourethrography (VCUG) only if
she has recurrent infections
c) Renal ultrasonography and cystoscopy only if she has recurrent
infections
d) Renal ultrasonography for this primary episode of infection
e) Renal ultrasonography and VCUG for this primary episode of infection
The Correct answer is E

Explanation
In the first few months of life, the incidence of urinary tract
infection (UTI) in boys is higher than that of girls. However, after
that time period, UTIs are much more common in females, with the peak
incidence in the 2- to 3-year range. The clinical presentation of UTI in
children is similar to that of adults, including dysuria, hematuria,
frequency, incontinence, suprapubic tenderness, and low-grade fever.
Upper tract infection is suggested by high fever, nausea, vomiting,
flank pain, and lethargy.

All children who have a culture-documented UTI should undergo evaluation


of the anatomy of the urinary tract. This is due to the fact that
children who are at most risk for renal parenchymal damage are those
with an anatomic defect. In general, studies to evaluate both the upper
and lower tract are recommended.

Children under the age of 5 years with a UTI, any child with a UTI and a
fever, school-aged girls who have had two or more UTIs, and any boy with
a UTI should have a voiding cystourethrogram (VCUG) to evaluate for
vesiculoureteral reflux and renal ultrasonography to evaluate the
kidneys. Cystoscopy and retrograde pyelography are rarely indicated in
the workup.
A 3-day-old white female is brought to your office for a weight check.
She is breastfed and, based on a recommendation from one of the mother’s
friends, is receiving supplemental sugar water by bottle. The pregnancy
was uneventful, with an uncomplicated labor and delivery at 38 weeks
gestation. The mother’s blood type is A, Rh-positive. The birth weight
was 3000 g (6 lb 10 oz) and the current weight is also 3000 g. You note
that the baby is jaundiced, but the examination is otherwise
unremarkable. Her total bilirubin level is 16 mg/dL with an indirect
(unconjugated) bilirubin level of 14.5 mg/dL. Further testing shows a
hemoglobin level of 20 g/dL (N 14.5?22.5), a normal reticulocyte count
for age, and a negative Coombs test.

Which one of the following is most likely causing the baby’s jaundice?

a) Breastfeeding
b) Spherocytosis
c) Rh incompatibility
d) Biliary atresia
e) Neonatal sepsis
The Correct answer is A

Explanation
Breastfeeding is the most likely cause of this baby’s jaundice. It
usually appears within the first week of life, when breastfed infants
have higher bilirubin levels than do formula-fed infants.
Hyperbilirubinemia (>12 mg/dL) develops in 13% of breastfed infants and
may be due to the dehydration or reduced caloric intake associated with
reduced mild intake. Giving supplemental glucose water to breastfed
infants is associated with higher bilirubin levels, in part because of
reduced intake of breast milk, which has a higher caloric density.
Frequent breastfeeding (>10/24 hr), rooming-in with night feeding, and
discouraging 5% dextrose or water supplementation may reduce the
incidence of early breastfeeding jaundice.

With spherocytosis, the predominant bilirubin is indirect


(unconjugated), but the hemoglobin is low and the reticulocyte count is
increased, with spherocytes seen on the blood smear. Isoimmunization
occurs with an Rh-negative mother and an Rh-positive child. There is a
positive Coombs test with this condition. The predominant bilirubin in
biliary atresia and neonatal sepsis is the direct (conjugated) type. In
addition, it is unlikely that a baby with neonatal sepsis would be
maintaining weight and have no abnormalities other than jaundice on
physical examination.
Which one of the following has been shown to reduce the croup score in
children and lead to shorter hospital stays’

a) Dexamethasone (Decadron), 0.6 mg/kg in a single oral dose


b) Amoxicillin, 45 mg/kg/day divided into two doses, for 10 days
c) Azithromycin (Zithromax), 10 mg/kg the first day, then 5 mg/kg daily
for 4 days
d) Albuterol (Ventolin), 0.63 mg by aerosol every 4 hours
e) Ceftriaxone (Rocephin), 50 mg/kg intramuscularly in a single dose
A 1 month neonate presents with fever and cough. On physical exam she
has coarse breath sounds and labs show an increased WBC count. CXR
clearly is consistent with pneumonia. See picture:
The most likely causative agent in this age group is

a) E. Coli
b) GBS
c) S. Pneumoniae
d) H. Influenza
e) N. Meningitidis
The Correct answer is B

Explanation
Pneumonia is a common illness in all age groups, the most likely
causative bug does differ based on the age of the patient as follows:

Neonatal (0-1 month): Streptococcus agalactiae (group B strep), E. coli


Infants (1-6 months): Chlamydia trachomatis (afebrile pneumonia), RSV
Children (6 months -5 years): RSV, Parainfluenza virus
Children (5-15 years): Mycoplasma pneumoniae, Influenza virus type A
Young Adults (16-30 years): Mycoplasma pneumoniae
Older Adults: Streptococcus pneumoniae, Haemophilus influenzae

Neonatal pneumonia tends to be caused by organisms that are acquired


from the maternal genital tract or the nursery. Group B Strep being the
most common.
Which one of the following is the most common cause of visual loss in
children?

a) Iritis
b) Glaucoma
c) Amblyopia
d) Eye trauma
e) Conjunctivitis
The Correct answer is C

Explanation
Evaluation of visual symptoms in children can be challenging, but is
important for identifying correctable conditions. Amblyopia , or ?lazy
eye?, is the most common cause of visual loss, with a prevalence of 2%
in childhood. It is often related to strabismus, in which the image from
one eye is suppressed in order to eliminate diplopia. Iritis is unusual
and may have minimal symptoms; it is frequently associated with juvenile
rheumatoid arthritis. Glaucoma does occur in children, often after
cataract surgery. Eye trauma is relatively common, especially in boys.
They may sustain abrasions, foreign bodies and penetrating injuries.
Conjunctivitis will usually resolve without visual loss except when
complicated by keratitis, such as in herpetic infections.

A 15-year-old female with Down syndrome will compete in Special Olympics


gymnastics. She should be evaluated prior to completion due to the
potential risk for subluxation of her

a) Patella
b) Calcaneus
c) Hip
d) Radial head
e) Altantoaxial joint
The Correct answer is E

Explanation
People with Down syndrome have a 15% increased incidence of atlantoaxial
instability (AAI). There is a resulting risk of spinal cord injury in
these patients. Certain sports are contraindicated for those with AAI,
including gymnastics, and radiographs should be obtained prior to
participation.
Causes of microcytic anemia in children include all of the following, except

a) Excessive cow's milk intake


b) Iron deficiency
c) Folic acid deficiency
d) Thalassemias
e) Lead poisoning
The Correct answer is C

Explanation
Causes of microcytic anemia (MCV < 80) can be remembered with the
mnemonic ?TICS’, which stands for thalassemia, iron deficiency, chronic
disease and sideroblastic anemia. Lead poisoning can also cause
microcytic anemia.

Causes of macrocytic anemia (MCV > 100) include folate and vitamin B12
deficiencies.
All of the following are appropriate steps in managing the patients in
following figures *except*:
a) Echocardiogram
b) Renal ultrasonography
c) Chromosome analysis
d) Brain MRI
e) Growth hormone therapy
The Correct answer is D

Explanation
This patient has Turner’s syndrome, which is not typically associated
with central nervous system malformations or mental retardation,
although they may have some mild learning disabilities. Lymphedema of
the hands and feet at birth is common in Turner’s syndrome. Cystic
hygroma is very common in Turner’s and may lead to hydrops fetalis and
death in utero. When it resolves, webbing of the neck skin may be seen.

A. Congenital heart disease occurs in 20% of patients with Turner’s


syndrome, most commonly coarctation of the aorta, aortic stenosis, and
bicuspid aortic valve.
B. Renal anomalies are seen in 40% of patients with Turner’s syndrome,
most commonly horseshoe kidney.
C. Turner’s syndrome is diagnosed by chromosome analysis. The most
common karyotype is 45,X (60%), X chromosome abnormalities account for
another 25% of cases, and 15% of patients have a mosaic karyotype, which
may include a Y chromosome cell line.
E. Short stature and gonadal dysgenesis are typical in Turner’s
syndrome. Growth hormone therapy is standard of care to improve height
and oral estrogen/progesterone are used to induce secondary sexual
characteristics, although most patients are sterile.
The viral infection most likely to cause CNS involvement and focal
neurological findings is

a) Coxsackievirus
b) Herpes simplex
c) Enterovirus
d) Rabies
e) Rhinovirus
The Correct answer is D

Explanation
Rabies is a viral encephalitis transmitted by the saliva of infected
bats and certain infected mammals. Initial symptoms are nonspecific:
fever, headache, and malaise. Within days, encephalitis (?furious’
rabies; in 80%) or paralysis (?dumb? rabies; in 20%) develops.
Encephalitis causes restlessness, confusion, agitation, bizarre
behavior, hallucinations, and insomnia.

Diagnosis is by serologic tests or biopsy. Vaccination is indicated for


people at high risk of exposure. Postexposure prophylaxis involves wound
care and passive and active immunoprophylaxis. The disorder is almost
universally fatal. Treatment is supportive.
A 4 year old child presents with an enlarged submandibular node that is
4 cm in diameter, nontender, and not fluctuant. The node has been
enlarged for about 4 weeks and there is no history of fever or contact
with any person who was ill. A complete blood count (CBC) is normal, and
a Mantoux test with 5 tuberculin units of purified protein derivative
shows 6 mm of induration. Which one of the following is the most likely
diagnosis’

a) Cat-scratch fever
b) Acute pyogenic lymphadenitis
c) Acute lymphoblastic leukemia
d) Tuberculous lymphadenitis
e) Atypical mycobacteria lymphadenitis
The Correct answer is E

Explanation
Atypical mycobacterial infection is due to non-tuberculous mycobacteria.

In particular, Mycobacterium Scrofulaceum is a common cause of


lymphadenitis in children aged 1 to 3 years. Lymphadenitis usually
involves a single node or a cluster of nodes in the submandibular area.

Characteristically, the nodes enlarge slowly over a period of weeks.


There are very few local or systemic symptoms. Untreated, the infection
will usually point to the surface, rupture, form a draining sinus and
eventually calcify. Infection in other tissues occurs occasionally. A
very few cases resembling progressive primary tuberculosis have been
encountered in children.
A 5 year old girl was diagnosed with otitis media about 10 days ago and
was prescribed oral amoxicillin. She has since developed bloody diarrhea
with mucus, crampy abdominal pain, and fever. On physical examination,
her temperature is 39.4 C (102.9 F), pulse is 88/min, and respirations
are 16/min. She has normal bowel sounds and is diffusely tender to
palpation. Which of the following is the most appropriate initial step
in diagnosis’

a) Barium enema
b) Evaluation of stool for Clostridium difficile toxins
c) Evaluation of stool for rotavirus
d) Stool examination for ova and parasites
e) Stool Hemoccult test
The Correct answer is B

Explanation
The girl in this clinical vignette has pseudomembranous colitis, which
is caused by the toxins produced by Clostridium difficile. The colon is
colonized by C. difficile after eradication of the normal microflora by
a course of antibiotics. Virtually all antibiotics, including
metronidazole and vancomycin, have been implicated in the pathogenesis
of pseudomembranous colitis. Patients usually present with watery or
bloody diarrhea, tenesmus, fever, and abdominal pain. Symptoms typically
occur 7-10 days after initiation of the antibiotic; in rare cases,
pseudomembranous colitis can occur up to 6 weeks after antibiotic
initiation.

On sigmoidoscopy or colonoscopy, the disease is characterized by an


accumulation of an inflammatory exudate, the "pseudomembrane" over the
mucosa. Assay for C. difficile toxins is useful in diagnosing
pseudomembranous colitis. An alternative is to perform stool cultures
for C. difficile. Oral metronidazole is the treatment of choice.
A mother brings her 10 year old son to your office because he lost
consciousness the day before while running. She says that he had similar
episodes in the past, but has never been seen by a doctor. She also
states that he does not seem to be able to play as long as most of his
friends. On physical examination you detect a systolic ejection murmur
and find that the apical impulse is lateral to the mid clavicular line.
Which one of the following is the most likely diagnosis’

a) Mitral valve stenosis


b) Aortic stenosis
c) Coarctation of the aorta
d) Aortic insufficiency
e) Patent ductus arteriosus
The Correct answer is B

Explanation
Aortic stenosis (AS) is narrowing of the aortic valve obstructing blood
flow from the left ventricle to the ascending aorta during systole.
Causes include a congenital bicuspid valve, idiopathic degenerative
sclerosis with calcification, and rheumatic fever.

Progressive untreated AS ultimately results in one or more of the


classic triad of syncope, angina, and exertional dyspnea, heart failure
and arrhythmias may develop. A carotid pulse with small amplitude and
delayed upstroke and a crescendo-decrescendo ejection murmur are
characteristic.

Diagnosis is by physical examination and echocardiography. Asymptomatic


AS often requires no treatment. For progressive severe or symptomatic AS
in children, balloon valvotomy is used, adults require valve replacement.
A 6 year old boy with hypochromic, microcytic anemia is unresponsive to
iron supplements prescribed by his family doctor. The doctor
investigates further by requesting hemoglobin electrophoresis, which
shows elevated hemoglobin A2 and normal hemoglobin A and F. Which one of
the following is the most likely explanation for the persistent anemia?

a) Lead poisoning
b) Sideroblastic anemia
c) Sickle cell trait
d) Hereditary spherocytosis
e) Beta-thalassemia trait
The Correct answer is E

Explanation
Thalassemias are a group of inherited microcytic, hemolytic anemias
characterized by defective Hb synthesis. They are particularly common in
people of Mediterranean, African, and Southeast Asian ancestry. Symptoms
and signs result from anemia, hemolysis, splenomegaly, bone marrow
hyperplasia, and, if there have been multiple transfusions, iron overload.

Beta-thalassemia results from decreased production of beta-polypeptide


chains. Alpha-thalassemia, which results from decreased production of
alpha-polypeptide chains. Diagnosis is based on quantitative Hb analysis
(hemoglobin electrophoresis). Treatment for severe forms may include
transfusion, splenectomy, chelation, and stem cell transplantation.
A 3 year old female is brought to your office for evaluation of mild
intoeing. The child’s patellae face forward, and her feet point slightly
inward. Which of the following would be most appropriate?

a) Reassurance
b) Foot stretching exercises
c) Use of orthotics
d) Use of night splints
e) Surgery
The Correct answer is A

Explanation
Intoeing, as described, is usually caused by internal tibial torsion.
This problem is believed to be caused by sleeping the prone position,
and sitting on the feet. In 90% of cases, internal tibial torsion
gradually resolves without intervention by the age of 8. Avoiding prone
sleeping enhances resolution of the problem. Night splints, orthotics,
and shoe wedges are ineffective. Surgery (osteotomy) has been associated
with a high complication rate, and is therefore not recommended in mild
cases before the age of 8.
After diagnosis and treatment of a recurrent urinary tract infection in
a 3 year old female child, further investigation should include

a) Renal ultrasound only


b) Renal ultrasound and voiding cystogram
c) Intravenous pyelogram only
d) Voiding cystogram only
e) Intravenous pyelogram and voiding cystogram
The Correct answer is B

Explanation
Recurrent UTIs are sometimes seen in conjunction with conditions, such
as: vesico-ureteral reflux (VUR) and hydronephrosis.
VUR which is found in 30% to 50% of children diagnosed with a UTI and is
a congenital condition in which urine flows backward from the bladder to
the ureters and sometimes reaches the kidneys. If the urine in the
bladder is infected with bacteria, VUR can lead to pyelonephritis.

Hydronephrosis, which is an enlargement of one or both kidneys due to


backup or blockage of urine flow and is usually caused by severe VUR or
a blocked ureter. Children with hydronephrosis are sometimes at risk of
recurrent UTIs and may need to take daily low doses of antibiotics to
prevent UTIs.

Diagnostic workup should include ultrasound and voiding cystourethrogram.


You see an obese female child in your office. In reviewing the
management options for this patient, the most appropriate step is to

a) Give her a written diet to follow


b) Recommend a behavior-oriented treatment program
c) Refer her to a commercial weight-loss center for diet management
d) Refer her to an endocrinologist for hormonal assessment
e) Tell her not to worry because she will "grow into her weight"
The Correct answer is B

Explanation
The most successful interventions in children who are obese are those
that are family-based and behavior-oriented. This includes a diet
program, physical activity, behavior modification techniques, and
parental role modeling. A written diet and a commercial weight loss
center do not the complete issue.

An endocrinologist referral is not indicated at this time because this


patient is most likely obese from overeating. Telling her not to worry
and that she will ?grow into her weight? is inappropriate as this girl
is at increased risk for medical disorders, such as slipped capital
femoral epiphysis, and therefore she should be encouraged to lose weight.

A full term infant with a birth weight of 3.5 kg, length of 50 cm and
head circumference of 35 cm (all at 50th percentile) comes for an office
appointment at 2 weeks of age. The infant is being fed Carnation milk
diluted to 25%. His weight today is identical to birth. Why has the
infant failed to gain weight?

a) This infant was small for gestational age at birth


b) This infant is microcephalic
c) The nutritional support was inadequate for a newborn
d) The infant was not breastfed.
e) Weight drops as much as 10% in the first few days of life. Birth
weight should be regained within 2 weeks after birth.
The Correct answer is E

Explanation
To recognize abnormal growth, one needs to understand normal growth. The
average birth weight for a term infant is 3.3 kg. Weight drops as much
as 10% in the first few days of life, probably as a result of loss of
excess fluid; however, birth weight should be regained within 2 weeks
after birth. Breastfed infants tend to regain birth weight a little
later than bottle-fed infants.

In breastfed infants and formula-fed infants, the frequency of feeds,


number of wet diapers and stools each day, and a history of sequential
weights allow the physician the ability to gauge if the child is
receiving adequate amounts of fluid and calories and is gaining weight
appropriately.
A 16-year-old high-school football player presents for a
preparticipation evaluation. He is healthy and has no significant
medical history. However, his brother died suddenly during football
practice at age 15.

Which one of the following is the most likely cause of the brother’s death?

a) Congenital long QT syndrome


b) Congenital short QT syndrome
c) Hypertrophic cardiomyopathy
d) Wolff-Parkinson-White syndrome
e) Aortic stenosis
The Correct answer is C

Explanation
Hypertrophic cardiomyopathy is the most common cause of sudden cardiac
death in young athletes in Canada. It is autosomal dominant with
variable penetrance. Subaortic stenosis is present in about 25% of cases
(also known as idiopathic hypertrophic subaortic stenosis or asymmetric
septal hypertrophy). Symptoms range from none to weakness, fatigue,
exertional dyspnea, dizziness, chest pain, and syncope. A systolic
ejection murmur increasing with the Valsalva maneuver is present in many
cases. Long QT syndrome and aortic stenosis are also causes of sudden
death in the young athlete, but are less common.
Antibiotic prophylaxis against infective endocarditis is required for
all of the following, except

a) Rheumatic valve lesions


b) Prosthetic heart valves
c) Isolated secundum ASD
d) Pacemaker leads
e) PDA
The Correct answer is C

Explanation
Endocarditis prophylaxis recommended for the following high-risk
categories: Prosthetic cardiac valves, including bioprosthetic and
homograft valves. Previous bacterial endocarditis. Complex cyanotic
congenital heart disease (eg, single ventricle states, transposition of
the great arteries, tetralogy of Fallot). Surgically constructed
systemic-pulmonary shunts or conduits.

Endocarditis prophylaxis is not recommended for isolated secundum atrial


septal defect because it is in the negligible-risk category (no greater
risk than the general population).
A 4 year old child has ingested a large number of iron tablets. What is
likely to be the first symptom?

a) Nausea and abdominal pain


b) Hyperventilation
c) Seizure
d) Metabolic acidosis
The Correct answer is A

Explanation
Acute iron intoxication seen exclusively in young children, where even
small numbers of tablets can be fatal. Symptoms will be initially
vomiting, abdominal pain, bloody diarrhea and then later shock,
lethargy, dyspnea and severe metabolic acidosis.

Treatment involves whole bowel irrigation to remove unabsorbed tablets.


Deferoxamine is given to remove absorbed tablets. Activated charcoal
can’t bind to iron, so will have no benefit.
A 6 year old child presents complaining of patchy hair loss on the back
of the scalp. Examination reveals well-demarcated areas of erythema and
scaling, and although there is still some hair in the area, it is noted
that the hairs are extremely short and broken in appearance. See picture:

Which of the following is the patient most likely suffering from?

a) Cutaneous candidiasis
b) Tinea capitis
c) Alopecia areata
d) Scalp psoriasis
e) Seborrheic dermatitis
The Correct answer is B

Explanation
Tinea capitis is a dermatophyte infection of the scalp (scalp ringworm).
Tinea capitis mainly affects children, is contagious, and can be
epidemic. Tinea capitis causes the gradual appearance of round patches
of dry scale and/or alopecia. T. tonsurans infection causes ?black dot
ringworm,? in which hair shafts break at the scalp surface; M. audouinii
infection causes ?gray patch ringworm,? in which hair shafts break above
the surface, leaving short stubs. Tinea capitis less commonly manifests
as diffuse scaling, like dandruff, or in a diffuse pustular pattern.

Dermatophyte infection occasionally leads to formation of a kerion, a


large, boggy, inflammatory scalp mass caused by a severe inflammatory
reaction to the dermatophyte. A kerion may have pustules and crusting
and can be mistaken for an abscess. A kerion may result in scarring hair
loss.
A chest x-ray in a 4 year old shows a posterior mediastinum mass. Which
one of the following is the most probable diagnosis’

a) Teratoma
b) Lymphoma
c) Thymic hyperplasia
d) Neuroblastoma
e) Bronchogenic cyst
The Correct answer is D

Explanation
Solid mediastinal masses in infancy and childhood occur most frequently
in the posterior mediastinum. For posterior mediastinal mass the median
age at diagnosis was 6 years. Thirty patients were female. Forty-five
percent of the patients presented with respiratory symptoms or chest
pain; 13% had neurologic symptoms, one half of which were related to
spinal cord compression; and 5% had a palpable mass.

In 32% of patients the mass was an incidental finding. The tumors were
of neurogenic origin in 89% of patients, of which neuroblastoma was the
most common. Of all patients with posterior mediastinal masses, 60% had
malignant tumors.
A six year old boy presents with sudden loss of vision in his right eye
of one day's duration. His vision in the right eye is restricted to
light perception only. His vision in the left eye is 20/20. Pupils are 4
mm in size each eye, pupillary reactions are sluggish right eye, but
brisk with a normal consensual reaction when the light is shown to the
left eye. Swinging the flashlight from left to right eye, the right
pupil dilates. Swinging the flashlight from right to left eye, the left
pupil constricts.

The pupillary reactions demonstrated represent

a) Horner’s Syndrome (impaired pupil dilatation)


b) Adie’s pupil (pathological pupil reaction)
c) Afferent pupillary defect (Marcus-Gunn pupil)
d) Normal pupillary reactions
e) Anisocoria (inequality of pupils in diameter)
The Correct answer is C

Explanation
Marcus Gunn pupil is a medical sign observed during the
swinging-flashlight test whereupon the patient's pupils constrict less
(therefore appearing to dilate) when the light swings from the
unaffected "good" eye to the affected "bad" eye. There is no anisocoria,
and the "bad eye" still senses light and produces pupillary constriction
to some degree, albeit reduced. The commonest cause of Marcus Gunn pupil
is a lesion of the optic nerve (before the optic chiasm) or severe
retinal disease.

The Marcus Gunn phenomenon is a relative afferent pupillary defect. That


is to say, the "bad eye" can still perceive light and respond to it, but
not as much as the "good eye"; the bad eye is relatively less responsive
than the good eye, but both eyes are still responsive to light. If you
shine the light in the bad eye, both pupils will constrict (due to the
still-intact consensual light response). However, if you shine the light
in the "good eye", the pupils will constrict even more. It is as if you
are shining a light of lesser intensity at the bad eye.

In context of the swinging flashlight test, you first shine the light in
the good eye, causing full pupillary contraction in both eyes. Then you
move the light to the bad eye. The bad eye perceives this same light as
if were not as bright, and thus causes the pupils to constrict less.
This gives the illusion that both pupils are now dilating as a response
to the light. They are actually still constricting in response to the
light, but constricting less than when the light was shining at the good
eye, because the bad eye perceives a dimmer light.

The infant in the picture below presented to the pediatric intensive


care unit with T-39?C, decreased urine output, P190, BP 60/30,
disseminated intravascular coagulation (DIC), and a palpable rash.
Immediate steps should include all of the following EXCEPT:

a) Antibiotic treatment to cover gram-positive cocci, meningococci, and


gram-negative bacilli
b) Topical antibiotics applied to all blisters noted on physical exam
after they have been appropriately drained and unroofed
c) Isolation of the hospitalized patient
d) Initial intravascular support with normal saline and/or lactated-ringers
e) Blood culture (preferably before antibiotics)
The Correct answer is B

Explanation
Skin care in sepsis-associated purpura fulminans is an important part of
therapy. Topical antibiotics may be used for open areas, but blisters
should not be unroofed because these are at high risk for secondary
infection.

A. Broad-spectrum empiric antibiotic therapy is appropriate until the


etiology is firm (i.e., results from blood culture available). Numerous
bacterial agents have been associated with purpura fulminans.
C. Isolation is required for patients presenting with purpura fulminans.
D. Treatment of sepsis-assocaited purpura fulminans is directed against
the underlying etiology as well as shock. An initial step is LR or NS
boluses.
E. Blood cultures are important in the diagnosis of this disease. While
they should never delay antibiotics, they are often positive in
sepsis-associated purpura fulminans and may be used to narrow antibiotic
coverage.
A spermatocele is found on physical exam in a 3 year old child. What is
the next step?

a) Elective surgery
b) Needle aspiration
c) Observation
d) Orchiectomy
The Correct answer is C

Explanation
Spermatocele (spermatic cyst) usually occurs at the upper pole of the
testis adjacent to the epididymis and appears as a cystic scrotal mass.
Generally painless and noncancerous (benign), a spermatocele usually is
filled with milky or clear fluid that may contain dead sperm.

Most spermatoceles require no treatment. If it causes discomfort,


over-the-counter pain medications, such as acetaminophen or ibuprofen
are appropriate. A common condition, a spermatocele doesn't impair
fertility, nor does it require treatment unless is grows large enough to
cause discomfort.

Repairing a spermatocele requires surgery to remove the cyst. A


procedure called a spermatocelectomy generally is performed on an
outpatient basis, using local or general anesthetic. The surgeon makes
an incision in the scrotum and separates the spermatocele from the
epididymis.
A 12 year old female is brought to your office because of the recent
onset of a white vaginal discharge. She is otherwise asymptomatic and
has never menstruated. She denies sexual activity and a general
examination reveals no abnormalities. You note the presence of breast
buds and scant pubic hair. Microscopic examination of the vaginal
discharge shows sheets of vaginal epithelial cells. Which of the
following is most likely in this setting?

a) Pinworm (Enterobius vermicularis) infestation


b) Sexual abuse
c) Vaginal foreign body
d) Trichomoniasis
e) Physiologic secretions
The Correct answer is E

Explanation
This child is entering puberty. In the 6- to 12-month period before
menarche, girls often develop a physiologic vaginal discharge to the
increase in circulating estrogens. The gray-white discharge is
non-irritating. When physiologic discharge is examined with the
microscope, sheets of vaginal epithelial cells are seen. The only
treatment necessary is reassurance of both patents and child that this
is a normal process that will subside with time. The other conditions
listed are pathologic and have other associated symptoms and findings
not seen in this case. Pinworms normally cause perianal and vulvar
pruritis and irritation. The findings in sexual abuse range from an
inflamed vulvovaginal area, to evidence of sexually transmitted
diseases, to evidence of local trauma. Trichomoniasis would cause
vulvovaginal irritation and microscopic examination of the discharge
would show Tichomonas organisms. A vaginal foreign body would usually
present with a foul and/or bloody vaginal discharge.
A previously healthy 3-year-old male is brought to your office with a
4-hour history of abdominal pain followed by vomiting. Just after
arriving at your office he passes bloody stool. A physical examination
reveals normal vital signs, and guarding and tenderness in the right
lower quadrant. A rectal examination shows blood on the examining
finger. Which one of the following is the most likely diagnosis’

a) Appendicitis
b) Viral gastroenteritis
c) Midgut volvulus
d) Meckel’s diverticulum
e) Necrotizing enterocolitis
The Correct answer is D

Explanation
Meckel’s diverticulum is the most common congenital abnormality of the
small intestine. It is prone to bleeding because it may contain
heterotopic gastric mucosa. Abdominal pain, distention, and vomiting may
develop if obstruction has occurred, and the presentation may mimic
appendicitis.

Children with appendicitis have right lower quadrant pain, abdominal


tenderness, guarding, and vomiting, but not rectal bleeding.

With acute viral gastroenteritis, vomiting usually precedes diarrhea


(usually without blood) by several hours, and abdominal pain is
typically mild and nonfocal with no localized tenderness. The incidence
of midgut volvulus peaks during the first month of life, but it can
present anytime in childhood. Volvulus may present in one of three ways:
as a sudden onset of bilious vomiting and abdominal pain in the neonate;
as a history of ?feeding problems’ with bilious vomiting that now
appears to be due to bowel obstruction; or, less commonly, as a failure
to thrive with severe feeding intolerance. Necrotizing enterocolitis is
typically seen in the neonatal intensive-care unit, occurring in
premature infants in their first few weeks of life. The infants are ill,
and signs and symptoms include lethargy, irritability, decreased oral
intake, abdominal distention, and bloody stools. A plain abdominal film
showing pneumatosis intestinalis, caused by gas in the intestinal wall,
is diagnostic of this disease.

A 4 month old child, has been noticed to have episodes where he tenses
his arms and leans his head forward. He has also had poor feeding and a
history of upper respiratory infections. What is the most likely diagnosis’

a) Autism
b) Infantile spasms
c) Febrile seizures
d) Absence seizures
The Correct answer is B

Explanation
Infantile spasms are characterized by sudden flexion of the arms,
forward flexion of the trunk, and extension of the legs. Seizures last a
few seconds and recur many times a day. They occur only in the 1st 5
years of life, then are replaced by other types of seizures.
Developmental defects are usually present.

Absence seizures do not present until age 1-8 years. Febrile seizures
would occur when the child has a fever.
A 6-year-old male is brought to your office 10 days after the onset of a
cough and low-grade fever. On examination, his temperature is 37.9°C
(100.2°F), pulse 100 beats/min, respirations 22/min, and O2 saturation
94%. He has diffuse wheezes on auscultation of his chest. His WBC count
is 9800/mm3 (N 4500 ? 11,000) with a slight left shift. His C-reactive
protein level is mildly elevated and a chest radiograph reveals an
interstitial infiltrate.

Which one of the following would be the most appropriate initial therapy?

a) A beta-lactam antibiotic
b) A macrolide antibiotic
c) Amoxicillin
d) Ceftriaxone (Rocephin)
The Correct answer is B

Explanation
The most common cause of pneumonia in children ages 5 ? 15 is Mycoplasma
pneumoniae, which is sensitive to macrolides. The low-grade temperature,
borderline WBC count, and lack of a markedly elevated C-reactive protein
do not suggest pneumococcal disease. Wheezing is characteristic of both
viral and mycoplasmal disease. Respiratory syncytial virus is the most
common cause of pneumonia in children age 4 months to 4 years. A
6-year-old is more likely to have mycoplasmal disease.
A 12-year-old boy comes to your office because of unexplained bruising.
There is no history of previous bruising or excessive bleeding. The
child has had no fever or respiratory symptoms. Three weeks ago, the
child had chickenpox (varicella). On examination today, the patient is
cooperative and in no acute distress. A complete CBC has the following
results: hemoglobin is 12 g/dl, WBC is 12,500, and the platelet count is
45,000. Large platelets are seen on the smear. Prothrombin time and
activated partial thromboplastin time (APPT) are normal. Treatment of
this child should include:

a) Platelet transfusion
b) Oral prednisone
c) Admit the child to the intensive care unit to observe for
intracranial bleeding
d) Reassure the parents that no specific treatment is needed at this time
e) Administer intravenous immunoglobulin (IVIG)
The Correct answer is D

Explanation
This patient has idiopathic thrombocytopenic pupura (ITP), a condition
that often follows viral infection or immunization. Most cases resolve
spontaneously without therapy. Parents should be advised that children
should not engage in activities that increase their risk for injury or
bleeding. Aspirin and ibuprofen should be avoided. Parents need to be
reassured that most children with ITP get better within 2-3 months.

A. Platelet transfusions are indicated only in cases of life threatening


bleeding.
B. Experts disagree on whether or not to give steroids for children with
platelet counts less than 20,000. Bleeding is not generally a problem
with a platelet count of 45,000.
C. This child does not require admission to an intensive care unit for
observation.
E. Spontaneous bleeding mostly occurs in the first two weeks of illness.
As with steroids, IVIG is not indicated in a child with a platelet count
of 45,000.
A newborn, shortly after birth develops respiratory distress. Vital
signs show tachypnea and tachycardia. On physical exam you hear bowel
sounds when you place your stethoscope on her chest. Which of the
following does she most likely have?

a) Transient tachypnea of newborn


b) Ventral septal defect
c) Pulmonary hypoplasia
d) Diaphragmatic hernia
The Correct answer is D

Explanation

A diaphragmatic hernia is a birth defect, which is an abnormality that


occurs before birth as a fetus is forming in the mother's uterus. An
opening is present in the diaphragm (the muscle that separates the chest
cavity from the abdominal cavity). With this type of birth defect, some
of the organs that are normally found in the abdomen move up into the
chest cavity through this abnormal opening.

Respiratory distress usually develops shortly after the baby is born,


because of ineffective movement of the diaphragm and crowding of the
lung tissue, which causes collapse. The reason why this occurs is not
known. Symptoms include severe breathing difficulty, bluish coloration
of the skin due to lack of oxygen, fast breathing (tachypnea) asymmetry
of the chest wall and fast heart rate (tachycardia).

Examination of the infant shows: chest movements asymmetric with


breathing, breath sounds absent on the affected side and bowel sounds
heard in the chest. A chest x-ray may show abdominal organs in chest cavity
A 10-year-old female presents to your office with a 4-day history of
non-productive cough, low grade fever of 100.5?F, and now complains of a
rash for one day. She has been taking an over-the-counter cough
suppressant and Tylenol. She is otherwise healthy. On physical exam, she
has a temperature of 99.9?F and a respiratory rate of 20. Her lung exam
reveals no rhonchi or wheezes. Her skin has several ?target? lesions
scattered on her trunk and upper arms. A chest x-ray reveals a fine
interstitial pattern with normal cardiac silhouette. She most likely is
infected with what organism?

a) /Streptococcus pneumoniae /
b) /Chlamydia pneumoniae /
c) /Mycoplasma pneumoniae /
d) /Haemophilus influenzae /
e) Influenza A
The Correct answer is C

Explanation
This school-age child has an atypical pneumonia with erythema
multiforme, which is consistent with mycoplasma pneumonia infections.
Mycoplasma is the most common cause of atypical pneumonias in
school-aged children.

A. Streptococcus pneumoniae is the most common cause of typical


bacterial pneumonia in children. Patients usually are tachypneic and
febrile with a consolidated lobar infiltrate on chest x-ray.
B. Chlamydia pneumoniae may cause interstitial, atypical pneumonias.
Patients are usually afebrile. There is no associated with erythema
multiforme. See Answer A.
D. Haemophilus influenzae is a cause of bacterial pneumonia in children,
again with a consolidated lobar infiltrate.
E. Influenza A may cause a viral pneumonia with interstitial
infiltrates, but patients typically have systemic symptoms such as
fever, malaise, and myalgias.
How would you approach the administration of the MMR vaccine in a child
with an egg allergy?

a) Do not give MMR vaccine


b) Only give MMR vaccine after skin testing of child
c) Give the child the MMR vaccine under medical supervision
d) Do not give if the child is allergic to egg proteins
The Correct answer is C

Explanation
The current measles-mumps-rubella vaccine (MMR) does not contain a
significant amount of egg proteins. In the past skin testing of all
children with severe egg allergies before they received the MMR was
recommended. This is no longer necessary. Even those with dramatic egg
allergies are extremely unlikely to have an anaphylactic reaction to the
MMR. The benefits of the vaccine far outweigh the risks.

Although egg protein in the MMR is no longer a big problem, if your


child has severe allergies with systemic symptoms, whatever the cause,
it pays to become familiar with the hidden ingredients found in products
of all kinds.
A 6 year old boy is brought to the office by his mother because of the
gradual onset of abdominal pain. On physical examination today the child
does not appear to be in acute distress. Abdominal examination discloses
normal bowel sounds and no tenderness, and is otherwise inconclusive.
Which of the following is the most appropriate next step?

a) Ask the mother about problems separately from her son


b) Call the school to check on details of the onset of pain
c) Do rectal examination
d) Obtain serum liver chemistry profile
e) Order supine x-ray film of the abdomen
The Correct answer is A

Explanation
It is important to differentiate whether the patient’s abdominal pain is
due to an underlying organic, psychogenic, or functional cause. A full
history must be taken to determine the nature and characteristics of the
pain and any associated symptoms. The initial interview should be
performed with the entire family together; however, the patient and
parents should then be interviewed separately. At this point, the
physician may be able to discern if the abdominal pain is a
manifestation of a stress in the home or school environment. The patient
may also be more forthcoming when inter
You are caring for a 4-year-old child with Henoch-Schönlein purpura.
Which one of the following is the most common serious complication of
this illness’

a) Pancreatitis
b) Subarachnoid hemorrhage
c) End-stage renal failure
d) Chronic arthritis
e) Cardiomyopathy
The Correct answer is C

Explanation
The most serious complication of Henoch-Schönlein purpura is renal
involvement, which occurs in 50% of older children but is serious in
only 10% of these patients. The spectrum of renal disease varies from
microscopic hematuria to a nephritis or nephritic syndrome with renal
failure. Overall, 2%-5% progress to end-stage renal failure.
Gastrointestinal tract disease occurs in approximately two-thirds of
children, varying from colicky pain to intestinal hemorrhage and
intussusception. Subarachnoid hemorrhage is not a recognized
complication of the disease, although both seizures and coma are rare
CNS complications. Pancreatitis and cardiac involvement are also rare
complications. Joint involvement occurs in 60%-84% of children, but is
transient and leaves no permanent deformity.
A child presents with bilateral shin pain. Which of the following
suggests that this is not growing pains’

a) Pain is poorly localized


b) Pain awakens the child at night
c) No fever or rash
d) Pain abates with reassurance and massage
e) Child may limp in the morning from stiffness
The Correct answer is E

Explanation
Growing pains are a common complaint of adolescents. Usually found in
young men and women around the ages of 9 to 14, growing pains are the
result of the rapid growth of these adolescents.

Several conditions such as Osgood-Schlatter Disease, and Sever's


Disease, are types of growing pains. These conditions are caused by
inflammation around sites where large tendons insert. These tendons pull
on the growing bone (at the growth plate) and cause inflammation.

Growing pains are almost always seen in active youths, often while
participating in sports. Growing pains are best treated with rest,
stretching, and ice packs. If activities are causing significant growing
pains, they should be avoided until the symptoms resolve. Growing pains
are not usually associated with a limp.
Patients with Alport’s syndrome are likely to

a) Be female
b) Be sterile
c) Be deaf
d) Have normal renal function
e) Have accelerated atherosclerosis
The Correct answer is C

Explanation
Alport’s syndrome is usually inherited as an X-linked trait. It is
characterized by sensorineural deafness in the majority of cases.
Hematuria, proteinuria, and progressive renal failure are also
associated with this disorder. There is no effect on fertility rates or
atherosclerosis.
Which one of the following is a contraindication to participation in
contact sports’

a) A single testicle
b) Fever
c) Documented scoliosis of 20°
d) Sickle cell trait
The Correct answer is B

Explanation
Having a single testicle is not a contraindication to contact sports,
but it does necessitate a discussion regarding the potential risk, as
well as the use of a protective cup. A single ovary is not a
contraindication because it is well protected.

Fever is a contraindication to participation since it increases


cardiovascular effort, as well as the potential for heatstroke and
orthostatic hypotension and dehydration. The rare possibility of an
associated myocarditis also should be taken into account. Carditis may
result in sudden death with exertion. Scoliosis should be looked into
prior to allowing a child to participate in contact sports, but once the
diagnosis is made it is rarely a contraindication unless the curvature
is greater than 40°. Sickle cell trait is not a contraindication to
contact sports, although sickle cell disease can be a contraindication
to strenuous activities or sports associated with significant contact.

A 12 year old white male asthmatic has an acute episode of wheezing. You
diagnose an acute asthma attack and prescribe an inhaled
Beta2-adrenergic agonist, but despite 1-2 hours of treatment he
continues to experience wheezing and shortness of breath. Which one of
the following is the most appropriate addition to acute outpatient
management?

a) Oral theophylline
b) Oral corticosteroids
c) An oral Beta2-adrenergic agonist
d) Inhaled cromolyn
e) Inhaled corticosteroids
The Correct answer is B

Explanation
The treatment of choice for occasional acute symptoms of asthma is an
inhaled Beta2-adrenergic agonist such as albuterol, terbutaline, or
pirbuterol. However, acute symptoms that do not respond to Beta-agonists
should be treated with a short course of systemic corticosteroids.

Theophylline has limited usefulness for treatment of acute symptoms in


patients with intermittent asthma; it is a less potent bronchodilator
than subcutaneous or inhaled adrenergic drugs, and therapeutic serum
concentrations can cause transient adverse effects such as nausea and
central nervous system stimulation in patients who have not been taking
the drug continuously.

Cromolyn can decrease airway hyperactivity, but has no bronchodilating


activity and is useful only for prophylaxis. Inhaled corticosteroids
should be used for suppressing the symptoms of chronic persistent
asthma. Oral Beta2-selective agonists are less effective and have a
lower onset of action than the same drugs given by inhalation.
The parents of a 40-day-old infant bring her to your clinic because she
has had a persistent fever for the past 2 days with rectal temperatures
between 38.1°C (100.5°F) and 38.9°C (102.0°F). She has been fussy and
wants to be held, but has been nursing well. She is crying when you
enter the room, and on examination she has good skin turgor and
capillary refill. The examination does not reveal any obvious source of
infection. By the time you complete the examination the infant is
resting quietly in her father’s arms. You obtain a CBC and urinalysis.
The WBC count is 12,500/mm3 (N 5000?19,500) with an absolute neutrophil
count of 9500/mm3 (N 1000?9000). The urinalysis is within normal limits.
Which one of the following would be most appropriate at this time?

a) Home care and parental observation only, as long as the temperature


remains under 39.0°C (102.2°F)
b) Home care and reevaluation in 24 hours
c) Oral antibiotics and reevaluation in 24 hours
d) A complete sepsis workup, including blood cultures, stool studies, a
chest radiograph, and cerebrospinal fluid studies
The Correct answer is B

Explanation
Most children will be evaluated for a febrile illness before 36 months
of age, with the majority having a self-limited viral illness.
Nontoxic-appearing febrile infants 29?90 days of age who have a negative
screening laboratory workup, including a CBC with differential and a
normal urinalysis, can be sent home and followed up in 24 hours (SOR B).
A second option is to obtain blood cultures and stool studies, or a
chest film if indicated by the history or examination, and spinal fluid
studies if empiric antibiotics are to be given. This infant’s clinical
status did not indicate that any of these additional studies should be
performed, and empiric antibiotic treatment is not planned.

Observation with no follow-up is an appropriate strategy in nontoxic


children, but only if the child is 3?36 months of age and the
temperature is under 39°C (SOR B). Nontoxic children 3?36 months of age
should be reevaluated in 24?48 hours if the temperature is over 39°C.
Although a positive response to antipyretics has been considered an
indication of a lower risk of serious bacterial infection, there is no
correlation between fever reduction and the likelihood of such an
infection.

Any infant younger than 29 days, and any infant or child with a toxic
appearance regardless of age, should undergo a complete sepsis workup
and be admitted for observation until culture results are obtained or
the source of the fever is found and treated (SOR A).

You are called to the bedside of a 1-month-old infant who is status post
repair of coarctation of the aorta. He has been doing well and his
feedings have been restarted. Since this morning, he has become more
tacypneic. On exam, the patient has diminished breath sounds on the
right with dullness to percussion. CXR shows a large effusion, so you
urgently perform a diagnostic thoracentesis. The fluid returned is
milky, and the patient continues to deteriorate. What is the most likely
diagnosis’

a) Hemothorax from cardiac surgery


b) Parenteral nutrition leaking into the thoracic cavity
c) Chylothorax from thoracic duct injury during surgery
d) Parapneumonic effusion from a post-op pneumonia
e) Hydrothorax
The Correct answer is C

Explanation
A thoracic duct injury, in which chyle leaks into the chest cavity, is a
relatively common complication after neonatal repair of congenital
cardiac disease.

A. A hemothorax would not have milky fluid on thoracentesis.


B. Parenteral nutrition is delivered via venous access, usually in a
large vein (subclavian, femoral). If there were venous rupture in the
thorax, the fluid obtained would be bloody.
D. A post-op pneumonia causing a parapneumonic effusion would tend to be
clear to slightly blood tinged.
E. A hydrothorax would not have milky fluid and generally is associated
with edema or fluid in other parts of the body. Causes include hepatic,
cardiac, or renal failure.

A 2 year old child, who was previously well, presents with a sudden
onset of cough, respiratory distress and wheeze. Examination reveals
that he is afebrile with diminished air entry and wheezing on the right
side. Which one of the following is the most likely diagnosis’

a) Acute asthma
b) Acute pneumothorax
c) Congenital lung cyst
d) Foreign body inhalation
e) Bronchitis
The Correct answer is D

Explanation
Because many patients who have swallowed foreign bodies are
asymptomatic, physicians must maintain a high index of suspicion. An
estimated 40 percent of foreign body ingestions in children are not
witnessed, and in many cases, the child never develops symptoms.

Objects that have passed the esophagus generally do not cause symptoms
unless complications, such as bowel perforation or obstruction, occur.
Patients with objects lodged in the esophagus may be asymptomatic or may
present with symptoms varying from vomiting, coughing or refractory
wheezing to generalized irritability and behavioral disturbances.

Longstanding esophageal foreign bodies may cause failure to thrive or


recurrent aspiration pneumonia. Esophageal perforation may result in
neck swelling, crepitations, and pneumomediastinum. Common sites for
obstruction by an ingested foreign body include the cricopharyngeal
area, middle one third of the esophagus, lower esophageal sphincter,
pylorus, and ileocecal valve.
A 16-year-old male is brought to your office by his mother for
“stomachaches”. On review of systems, he also complains of headaches,
occasional bedwetting, and trouble sleeping. His examination is within
normal limits. His mother says that he is often in the nurse’s office at
school, and doesn’t seem to have any friends. After some questions from
you, he admits to being called names and teased at school.

Which one of the following would be most appropriate?

a) Explain that he must try to conform to be more popular


b) Explain that these symptoms are a stress reaction and will lessen with time
c) Explore whether his school counselor has a process to address this problem
d) Order a TSH level
The Correct answer is C

Explanation
Childhood bullying has potentially serious implications for bullies and
their targets. The target children are typically quiet and sensitive,
and may be perceived to be weak and different. Children who say they are
being bullied must be believed and reassured that they have done the
right thing in acknowledging the problem. Parents should be advised to
discuss the situation with school personnel.

Bullying is extremely difficult to resolve. Confronting bullies and


expecting victims to conform are not successful approaches. The
presenting symptoms are not temporary, and in fact can progress to
serious issues such as suicide, substance abuse, and victim-to-bully
transformation. These are not signs or symptoms of thyroid disease.

The Olweus Bullying Program developed in Norway is a well documented,


effective program for reducing bullying among elementary and
junior-high-school students by altering social norms and by changing
school responses to bullying incidents, including efforts to protect and
support victims. Students who have been bullied regularly are most
likely to carry weapons to school, be in frequent fights, and eventually
be injured.
A 4 year old female has been discovered to have congenital hearing loss.
Her mother is an 18 year old migrant farm worker who is currently at 8
weeks gestation with her second pregnancy. The mother has been found to
have cervical dysplasia on her current Papanicolaou (Pap) smear and has
also tested positive for Chlamydia. The most likely cause of this
child’s hearing loss is

a) Human parvovirus B19


b) Varicella zoster virus
c) Herpes simplex virus
d) Toxoplasmosis
e) Cytomegalovirus
The Correct answer is E

Explanation
Cytomegalovirus (CMV) is the most common congenital infection and occurs
in up to 2.2% of newborns. It is the leading cause of congenital hearing
loss. The virus is transmitted by contact with infected blood, urine, or
saliva, or by sexual contact. Risk factors for CMV include low
socioeconomic status, birth outside North America, first pregnancy prior
to age 15, a history of cervical dysplasia, and a history of sexually
transmitted diseases. Infection can be primary or a reactivation of a
previous infection. While the greatest risk of infection is during the
third trimester, those occurring in the first trimester are the most
dangerous to the fetus.
A newborn male spits up his first feeding and develops bilious emesis
with subsequent feedings. On physical exam he appears ill, has a
scaphoid abdomen and absent bowel sounds. Abdominal x-ray shows air in
the proximal small bowel, but a paucity of air in the distal digestive
tract. The most likely cause for this infant's vomiting and clinical
finding is

a) Antral web
b) Choldochal cyst
c) Hirschsprung disease
d) Tracheoesophageal fistula
e) Volvulus
The Correct answer is E

Explanation
Bilious vomiting, with or without abdominal distention, is an initial
sign of intestinal obstruction in newborns. A naso- or orogastric tube
should be placed immediately to decompress the stomach. Physical
examination should be followed by plain abdominal films. Dilated bowel
loops and air-fluid levels suggest surgical obstruction. Contrast
radiography may be required. Duodenal atresia, midgut malrotation and
volvulus, jejunoileal atresia, meconium ileus and necrotizing
enterocolitis are the most common causes of neonatal intestinal obstruction.
What is the immediate goal in the treatment of new onset insulin
dependent diabetes mellitus (IDDM) and diabetic ketoacidosis (DKA)?

a) Start administration of dextrose intravenously


b) Treat the acidosis with sodium bicarbonate
c) Restore fluid and electrolyte losses and reverse the catabolic state
d) Start antibiotics to treat any underlying infection that may have
precipitated the DKA
e) Screen the patient’s siblings to see if they have IDDM also
The Correct answer is C

Explanation
The immediate goal in treating DKA is to restore intravascular volume,
paying attention to electrolyte losses associated with DKA, especially
potassium and phosphate. Intravenous administration of insulin follows
to reverse the catabolic state and the ketosis.

A. The serum glucose is elevated in DKA and supplemental administration


of dextrose is not helpful.
B. Sodium bicarbonate is usually not necessary to correct the acidosis
and is certainly not the immediate treatment indicated.
D. Antibiotic administration should be initiated only if an infection
has been identified.
E. Screening siblings is not indicated and is certainly not addressed as
an immediate issue when a patient presents in DKA.
A 4 year old boy has a history of easy bruising, nosebleeds, and a
similar history among male and female family members. Laboratory
investigations show normal INR and prolonged PTT. Which one of the
following is the most likely cause of this boy's symptoms’

a) Hemophilia A
b) Christmas disease
c) Factor XIII deficiency
d) Von Willebrand's disease
e) Familial platelet function disorder
The Correct answer is D

Explanation
Von Willebrand's disease is a hereditary deficiency of von Willebrand's
factor (VWF), which causes platelet dysfunction. Bleeding tendency is
usually mild. Screening tests show a prolonged bleeding time, normal
platelet count, and, possibly, a slightly prolonged PTT. Diagnosis is
based on low levels of VWF antigen and abnormal ristocetin cofactor
activity. Treatment involves control of bleeding with replacement
therapy (cryoprecipitate or pasteurized intermediate-purity factor VIII
concentrate) or desmopressin.

Hemophilia A and hemophilia B (Christmas disease) are X-linked


congenital bleeding disorders affecting male infants, usually diagnosed
through family history and prolonged PTT. Undiagnosed hemophilia may
cause severe bleeding with circumcision. It can also result in
significant ecchymosis with minimal trauma or joint and muscle bleeding,
usually by the end of infancy or in early childhood. These children have
a significantly prolonged PTT and normal PT. Diagnosis is made through
measurement of Factor VIII activity for Hemophilia A and Factor IX
activity for Hemophilia B.
One of your patients recently adopted a 4-year-old girl and brings her
to your office for an initial visit. When reviewing the child’s history,
you discover that the birth mother has retinitis pigmentosa.

When counseling the adoptive mother, you would advise her that this
disease often is initially manifested during adolescence as

a) eye pain
b) night blindness
c) color blindness
d) tunnel vision
e) inability to see a whiteboard at the front of the class
The Correct answer is B

Explanation
Retinitis pigmentosa has multiple inheritance patterns, including
autosomal dominant, autosomal recessive, and X-linked recessive.
Symptoms can begin during either childhood or adulthood, but it
classically presents as night blindness during adolescence, secondary to
the initial degeneration of rods. As the disease progresses peripheral
vision worsens but central vision is frequently spared, so that reading
is still possible. Tunnel vision follows as peripheral vision worsens.
Later, as the cones degenerate, color blindness and central visual loss
progress. Eye pain is not a part of this process.

4 year old girl is brought to you. She has developed knee pain. On
exam the knees are swollen, warm and visible redness is noted. A lab
workup shows the following:

WBC 6 x 10^9/L, Normal (4-10 x10^9/L)


Hemoglobin (Hb) 105 g/L, N (123-157 g/L)
Hematocrit (Hct) 31 %, N (37-46%)
Platelets 250 x10^9/L, N (130?400 x10^9/L)
MCV 77 fl, N (80?97.6 fl)
Rheumatoid factor (+), N (-)
ANA (-), N (-)
ESR 40 mm/hour, N (0-7 mm/hour)

What is the likely diagnosis’

a) Iron deficiency anemia


b) Growing pains
c) Juvenile rheumatoid arthritis
d) Fanconi syndrome
The Correct answer is C

Explanation
Juvenile rheumatoid arthritis pain can develop in kids aged 1-16 years
of age. Common presentations include swelling, red and warm joints. The
knee and wrist joints are the most commonly affected.

Initial lab workup involves: CBC, ESR, RF and ANA. Treatment is with a
combination of medication, physical therapy and exercise. Nonsteroidal
anti-inflammatory drugs (NSAIDs), like ibuprofen are used most commonly.
Fanconi syndrome is a disorder in which the proximal renal tubules of
the kidney do not properly reabsorb electrolytes and nutrients back into
the body, but instead "spill" them in the urine. Symptoms include
excessive drinking (polydipsia), excessive urination (polyuria) and
glucose in the urine (glucosuria.) If Fanconi is left untreated, muscle
wasting, acidosis and poor condition will also occur.

Abnormal labs values would not be present in growing pains and joint
pain is not associated with iron deficiency anemia.
Which one of the following is the most appropriate screening test for
vesicoureteral reflux in the initial evaluation of a child with a
urinary tract infection?

a) Renal ultrasonography
b) Intravenous pyelography (IVP)
c) Voiding cystourethrography (VCUG)
d) A technetium-99m dimercaptosuccinic acid (DMSA) renal flow scan
e) Nuclear cystography
The Correct answer is C

Explanation
The most significant anomaly associated with urinary tract infections
(UTIs) in children is vesicoureteral reflux, which occurs in 30%-50% of
children with UTIs. When screening a child for reflux, the initial test
should be voiding cystourethrography. Although renal ultrasonography is
less invasive, findings are normal in 50%-75% of patients with reflux. A
DMSA renal flow scan is the best study for detecting renal scarring, but
will not detect reflux in children who have not yet developed scarring.
Nuclear cystography is as sensitive for detecting reflux as a standard
VCUG, but grading of reflux is less precise and this test will not
detect associated bladder abnormalities.
A 10 year old girl presents with a 3 cm mass under her nipple. What is
the next step?
a) Mammography
b) U/S guided fine needle aspiration
c) U/S guided needle biopsy
d) Excisional biopsy
e) Observation and follow-up in 3 months
The Correct answer is B

Explanation
Mammography is not useful in women under the age of 35 with current
techniques because the breast tissue is too dense to allow accurate
interpretation of the X-rays. The general flow of diagnoses of a breast
mass is to first do a needle aspiration, and then if necessary proceed
to a biopsy.
An infant female's serum chemistry profile shows hyponatremia and
hyperkalemia. On physical examination, she was found to have ambiguous
external genitalia. What is the most likely diagnosis’

a) Congenital adrenal hyperplasia


b) Trisomy 18
c) Conn’s syndrome
d) Hypothyroidism (cretinism)
The Correct answer is A

Explanation
Congenital adrenal hyperplasia is a group of genetic disorders, each
characterized by inadequate synthesis of cortisol, aldosterone, or both.

The salt-wasting form causes hyponatremia (sometimes severe),


hyperkalemia, and hypotension as well as virilization. If undiagnosed
and untreated, this form can lead to life-threatening adrenal crisis,
with vomiting, diarrhea, hypoglycemia, hypovolemia, and shock.

Very young female infants with the salt-wasting form will have ambiguous
external genitals, with clitoral enlargement, fusion of the labia
majora, and a urogenital sinus rather than distinct urethral and vaginal
openings. Male infants typically have normal sexual development. When
the enzyme deficiency is much milder, neonates have little or no
virilization, but androgen excess manifests later with early appearance
of pubic hair and increase in growth velocity in both sexes, clitoral
enlargement in girls, and penile enlargement and earlier deepening of
voice in boys.
A 5 year old child is bitten by his neighbors dog. The dog has received
all the necessary vaccines. What is the most appropriate management?

a) Observe the dog 10 days and give anti-rabies serum to the child
b) Observe the dog and give anti-rabies serum and vaccine to the child
c) Kill the dog and examine brain for rabies
d) Vaccinate the child for rabies
e) Observe the dog
The Correct answer is E

Explanation
The patient's risk of infection with rabies virus must be addressed
immediately. Because of the serious risk to the public of a rabid animal
on the loose, it is important to document the conditions surrounding the
attack. As a result of widespread vaccination of dogs against rabies,
the most common source of the rabies virus is now wild animals,
specifically raccoons, skunks and bats.

Nonetheless, there are still reported cases of rabies virus associated


with a dog bite. Patients with a bite from a nonprovoked dog should be
considered at higher risk for rabies infection than patients with a bite
from a provoked dog. If the dog owner is reliable and can confirm that
the animal's vaccination against rabies virus is current, the dog may be
observed at the owner's home.

Observation by a veterinarian is appropriate when the vaccination status


of the animal is unknown. If the animal cannot be quarantined for 10
days, the dog bite victim should receive rabies immunization.
A 17-year-old white male is involved in a rollover motor vehicle crash.
He was the driver. The primary trauma survey does not reveal any
life-threatening conditions.

If found on the musculoskeletal examination of the secondary trauma


survey, a dislocation of which one of the following would confer the
greatest risk for an immediately life-threatening condition?

a) Sternoclavicular joint
b) Acromioclavicular joint
c) Shoulder
d) Ankle
e) Elbow
The Correct answer is A

Explanation
Posterior sternoclavicular dislocations are associated with major upper
mediastinal vascular injuries, which can be immediately life
threatening. Neurologic injuries to the brachial plexus may also occur.

All the other dislocations listed have a potential for neurologic


injury. Elbow dislocations may cause neurovascular compromise and
subsequent compartment syndrome. Ankle dislocations may produce skin
necrosis with tension over the malleolus, as well as neurovascular
compromise. Prompt reduction is important to prevent a threat to the
distal limb. The injuries are not immediately life-threatening. Shoulder
dislocations are often complicated by neurologic injuries such as
axillary nerve damage. Vascular injuries may also occur.
Acromicroclavicular injuries may have associated neurovascular
compromise, but less frequently than with shoulder dislocations.

In a 5 year old girl with leg edema and apparent congestive heart
failure, which one of the following would be most effective in inducing
rapid therapeutic diuresis’

a) Digoxin
b) Furosemide
c) Thiazides
d) Spironolactone
e) Mannitol
The Correct answer is B

Explanation
There are several types of medications used to treat congestive heart
failure in children. A diuretic like furosemide (Lasix), which helps the
kidneys to eliminate extra fluid in the lungs, is often the first
medicine given both in babies and older children.

Sometimes medicines to lower the blood pressure like an ACE inhibitor


(Captopril) or more recently beta-blockers (Propranolol) are used.
Theoretically, lowering the blood pressure will decrease the workload of
the heart by decreasing the amount of pressure against which it has to
pump.

Sometimes a medication called Digoxin is used to help make the heart


squeeze better, and help pump blood more efficiently. Since weight gain
is a major challenge for infants with congestive heart failure, giving
babies high calorie formula or fortified breast milk can help give the
extra nutrition they require.
An infant child starts choking while eating his dinner. He becomes
cyanotic, agitated with forceful breathing. What is the most appropriate
first action to do at this time?

a) Hit the child from his back while head downward


b) Introduce your finger in his mouth
c) Allow him to cough up the food
d) Perform immediate CPR
e) Perform abdominal thrusts
The Correct answer is A

Explanation
For an infant, abdominal thrusts are not performed. Instead, the infant
is turned face down, the chest resting on the rescuer's forearm, with
the head lower than the body. The rescuer then strikes the infant
between the shoulder blades 5 times using the heel of the hand (back
blows). The strikes should be firm but not hard enough to cause injury.
The rescuer then checks the mouth, removing any visible objects.

If the airway remains blocked, the rescuer turns the infant face up with
the head down, and using the second and third fingers, thrusts inward
and upward on the infant's breastbone 5 times (chest thrusts). The
rescuer then checks the mouth again.

Blind sweeps of the throat should not be done initially as they may
lodge the obstructing article even further.
A 2 year old boy presents to the office with an intermittent fever of
104F for the past three days. The physical examination reveals no
source of infection. The infant does not appear toxic, and the parents
feel that he appears well between fevers. The differential diagnosis
includes:

a) Rubella
b) Erythema infectiosum (Fifth disease)
c) Erythema toxicum
d) Roseola infantum
e) Meningitis
The Correct answer is D

Explanation
Roseola is characterized by 3 days of high fever, which disappears
suddenly as the typical rash appears.

A. Rubella is typically only a 3-day illness and the rash would already
be present.
B. Children are unlikely to have fever with erythema infectiosum.
C. Erythema toxicum is a common normal newborn rash.
E. This diagnosis is unlikely because the child is acting well between
fevers and does not appear toxic; he is also not seriously ill after a
3-day history of illness.
A child that is pulled up by his mother by the arms, develops pain and
starts crying. He is brought into the ER. Physical exam shows that one
arm is adducted and the forearm is pronated. What is the most likely
diagnosis’

a) Humeral fracture
b) Laxation of the inferior extremity of the ulna
c) Subluxation of radial head
d) Rupture of rotator cuff
The Correct answer is C

Explanation

This is a case of radial head subluxations (nursemaid's elbow). In


toddlers (about 2 to 3 years old), the radial head is no wider than the
radial neck and can easily slip through these ligaments (radial head
subluxation). Subluxation results from traction on the forearm as when a
caregiver pulls a reluctant toddler forward or catches the toddler by
the wrist during a fall?actions many caregivers do not remember.
Symptoms may include pain and tenderness; however, many toddlers cannot
describe their symptoms and simply avoid moving the affected elbow
(pseudoparalysis).
Plain x-rays are normal and considered unnecessary by some experts
unless an alternate diagnosis is clinically suspected. Reduction may be
diagnostic and therapeutic. The elbow is completely extended and
supinated, then flexed, usually without sedation or analgesia. Reduction
is often marked by a subtle palpable pop or click as the radial head
resumes normal position. Children may start to move the elbow after
about 20 min. Immobilization is unnecessary. If pain or dysfunction
lasts longer than 24 hours, incomplete reduction or an occult fracture
should be suspected.
An overweight 13-year-old male presents with a 3-week history of right
lower thigh pain. He first noticed the pain when jumping while playing
basketball, but now it is present even when he is just walking. On
examination he can bear his full weight without an obvious limp. There
is no localized tenderness, and the patella tracks normally without
subluxation. Internal rotation of the hip is limited on the right side
compared to the left. Based on the examination alone, which one of the
following is the most likely diagnosis’

a) Avascular necrosis of the femoral head (Legg-Calvé-Perthes disease)


b) Osteosarcoma
c) Meralgia paresthetica
d) Pauciarticular juvenile rheumatoid arthritis
e) Slipped capital femoral epiphysis
The Correct answer is E

Explanation
This is a classic presentation for slipped capital femoral epiphysis
(SCFE) in an adolescent male who has probably had a recent growth spurt.
Pain with activity is the most common presenting symptom, as opposed to
the nighttime pain that is typical of malignancy. Obese males are
affected more often. The pain is typically in the anterior thigh, but in
a high percentage of patients the pain may be referred to the knee,
lower leg, or foot. Limited internal rotation of the hip, especially
with the hip in 90° flexion, is a reliable and specific finding for SCFE
and should be looked for in all adolescents with hip, thigh, or knee pain.
Meralgia paresthetica is pain in the thigh related to entrapment of the
lateral femoral cutaneous nerve, often attributed to excessively tight
clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of
the femoral head) is more likely to occur between the ages of 4 and 8
years. Juvenile rheumatoid arthritis typically is associated with other
constitutional symptoms including stiffness, fever, and pain in at least
one other joint, with the pain not necessarily associated with activity.

A 9-month-old male is brought to your office by his mother because of


concerns about his eating. She states that he throws tantrums while
sitting in his high chair, dumps food on the floor, and refuses to eat.
She has resorted to feeding him cookies, crackers, and juice, which are
?all he will eat.? A complete physical examination, including a growth
chart of weight, length, and head circumference, is normal. Which one of
the following would be the most appropriate recommendation?

a) Use disciplinary measures to force the child to eat a healthy


breakfast, lunch, and dinner
b) Leave the child in the high chair until he has eaten all of the
healthy meal presented
c) Play feeding games to encourage consumption of healthy meals or snacks
d) Skip the next meal if the child refuses to eat
e) Provide healthy foods for all meals and snacks, and end the meal if
the child refuses to eat
The Correct answer is E

Explanation
It is estimated that 3%?10% of infants and toddlers refuse to eat
according to their caregivers. Unlike other feeding problems such as
colic, this problem tends to persist without intervention. It is
recommended that caregivers establish food rules, such as healthy
scheduled meals and snacks, and apply them consistently. Parents should
control what, when, and where children are being fed, whereas children
should control how much they eat at any given time in accordance with
physiologic signals of hunger and fullness. No food or drinks other than
water should be offered between meals or snacks. Food should not be
offered as a reward or present. Parents can be reassured that a normal
child will learn to eat enough to prevent starvation. If malnutrition
does occur, a search for a physical or mental abnormality should be sought.

The most common cause of apnea in infants less than 6 months is

a) Encephalitis
b) Seizure disorder
c) Cardiac arrhythmia
d) Milk allergy
e) Gastroesophageal reflux
The Correct answer is E

Explanation
The most common cause of apnea in infants is gastroesophageal reflux
(GER) which is caused by immaturity of the muscle at the base of the
esophagus which controls food passage into the stomach. If this muscle
functions improperly, food or formula may reflux back into and up the
esophagus into the back of the pharynx. This may trigger a reflex in
infants which results in apnea.
Non bilious projectile vomiting occurs in which of the following condition?

a) Pyloric stenosis
b) Hiatal hernia
c) Intussusception
d) Constipation
The Correct answer is A

Explanation Hypertrophic pyloric stenosis can cause almost complete


gastric outlet obstruction.

Symptoms develop between 2 and 6 weeks of life. Projectile vomiting


(without bile) occurs shortly after eating. Until dehydration sets in,
the child feeds avidly and otherwise appears well, unlike many of those
with vomiting due to systemic illness.

Diagnosis is by abdominal ultrasonography showing increased thickness of


the pylorus (typically to ? 4 mm; normal, < 2 mm). The classic
electrolyte pattern of an infant with pyloric stenosis is that of
hypochloremic, hypokalemic, metabolic alkalosis.

Initial treatment is directed at hydration and correcting electrolyte


abnormalities. Definitive treatment is a longitudinal pyloromyotomy,
which leaves the mucosa intact and separates the incised muscle fibers.
Which of the following is not correct about the pertussis vaccine

a) Delaying the primary series until the age of 1 year will not reduce
the risk of a seizure
b) The commonly quoted risk of 1:330,000 of brain damage has no basis in fact
c) It can cause febrile seizures
d) It may cause infantile spasms or sudden infant death syndrome
e) The risk of other forms of neurologic illness eg. Transverse myelitis is
extremely small
The Correct answer is D

Explanation
Although serious systemic adverse events such as
hypotonic-hyporesponsive episodes can still occur, they are much less
common than with DTPw. Pertussis vaccine does not cause infantile
spasms, epilepsy or sudden infant death syndrome (SIDS). Vaccine-induced
fever may occasionally lead to a febrile convulsion, though much less
commonly with DTPa than with DTPw.
What is the most appropriate management for a 3 year old boy with
stuttering?

a) Reassurance
b) Speech therapy
c) Referral to ENT specialist
d) Referral to neurologist
The Correct answer is A
Explanation
The first signs of stuttering tend to appear when a child is about 18 to
24 months old and starting to put words together to form sentences. To
parents, the stuttering may be upsetting and frustrating, but it is
natural for kids to do some stuttering at this stage of development.

A child may stutter for a few weeks or several months, and the
stuttering may be sporadic. For most kids who begin stuttering before
the age of 5, the stuttering eventually goes away without any need for
intervention such as speech or language therapy. However, if the child's
stuttering is frequent, continues to get worse, and is accompanied by
body or facial movements, it's a good idea for a speech-language
therapist to evaluate your child before he or she is 3 years old.
Which of the following predisposes infants to chronic otitis media?

a) Bottle-feeding in upright position


b) Abnormal tympanic membrane formation
c) Environmental factors such as daycare and passive smoking
d) Acute allergies
The Correct answer is C

Explanation
Chronic otitis media is a long-standing infection of the middle ear.
Some factors that increase a child's risk for middle ear infections
include crowded living or daycare conditions, exposure to second-hand
smoke, respiratory illnesses, close contact with siblings who have colds
or ear infections, having a cleft palate, allergies that cause
congestion on a chronic basis.
A 3-year-old male is brought to your office because of ear pain. On
examination you find a round, plastic bead in the lower third of the ear
canal close to the tympanic membrane. You restrain the child and
unsuccessfully attempt to remove the object despite several attempts,
first using water irrigation and then fast-acting glue on an applicator.
Which one of the following is the best option for removal?

a) A plastic loop curette through an otoscope


b) Referral for removal under anesthesia
c) Grasping with forceps
d) Applying acetone to dissolve the object
The Correct answer is B

Explanation
After several unsuccessful attempts to remove an object deep in the ear
canal of an uncooperative child, it is best to refer the patient to an
otolaryngologist for removal under anesthesia. Additional attempts are
very unlikely to succeed, especially with the techniques listed. A loop
curette cannot be safely placed behind a foreign body that is close to
the tympanic membrane. A round, hard object cannot be grasped with
forceps. Acetone can be used to dissolve Styrofoam foreign bodies, but
it would not dissolve a plastic bead.
All of the following are present in pyloric stenosis, except

a) Hypochloremic metabolic alkalosis


b) Non-bilious vomiting
c) Olive shaped mass
d) Sausage shaped mass
The Correct answer is D

Explanation
Hypertrophic pyloric stenosis is obstruction of the pyloric lumen due to
pyloric muscular hypertrophy. It is more common in males by a 4:1 ratio.

Projectile vomiting (without bile) occurs shortly after eating. Until


dehydration sets in, the child feeds avidly and otherwise appears well,
unlike many of those with vomiting due to systemic illness. Gastric
peristaltic waves may be visible, crossing the epigastrium from left to
right. A discrete, 2- to 3-cm, firm, movable olive-like pyloric mass is
sometimes palpable deep in the right side of the epigastrium.

The classic electrolyte pattern of an infant with pyloric stenosis is


that of hypochloremic, hypokalemic, metabolic alkalosis.

A palpable abdominal mass, described as sausage-shaped, is sometimes


present in Intussusception.
A 1 year old child presents with abdominal pain. He is drawing his legs
up, bloody mucus in seen in his stool. A sausage shaped mass is palpated
in his abdomen. What is the most likely diagnosis’

a) Meckels diverticulum
b) Appendicitis
c) Pyloric stenosis
d) Intussusception
The Correct answer is D

Explanation
Intussusception is telescoping of one portion of the intestine
(intussusceptum) into an adjacent segment (intussuscipiens), causing
intestinal obstruction and sometimes intestinal ischemia.

Intussusception generally occurs between ages 3 months and 3 years, with


65% of cases occurring before age 1. It is the most common cause of
intestinal obstruction in this age group, in whom it is usually
idiopathic. In older children, there may be a ?lead point,? ie, a mass
or other intestinal abnormality that triggers the telescoping; examples
include polyps, lymphoma, Meckel's diverticulum, and Henoch-Schönlein
purpura. Cystic fibrosis is also a risk factor.

The telescoping segments obstruct the intestine and ultimately impair


blood flow, causing ischemia, gangrene, and perforation.

The initial symptoms are recurrent colicky abdominal pain that occurs
every 15 to 20 min, often with vomiting. The child appears relatively
well between episodes. Later, as intestinal ischemia develops, pain
becomes steady, the child becomes lethargic, and mucosal hemorrhage
causes heme-positive stool on rectal examination and sometimes
spontaneous passage of a ?currant jelly? (blood mixed with mucus) stool.
A palpable abdominal mass, described as sausage-shaped, is sometimes
present.

An 8 year old boy is brought to your office by his mother for


evaluation. She is concerned about his poor school performance. He is
much ‘slower? to learn than the other children in his school. She has
noted several raised lesions on his face, and his ?acne? seems to be
getting worse. You note that he has several flat, hypopigmented macules
on his back .You are concerned that he may have the clinical
manifestations of:

a) Sturge-Weber
syndrome
b) Von Hippel-Lindau disease
c) Neurofibromatosis
d) Tuberous sclerosis
The Correct answer is D

Explanation
The clinical description of the child above most closely fits the
neurocutaneous disorder known as tuberous sclerosis. This is a
progressive, autosomal dominant disorder characterized by ash-leaf spots
(flat, hypopigmented macules), shagreen patches (areas of abnormal skin
thickening), sebaceous adenomas (sometimes confused with acne), and
facial angiofibromas. Mental retardation and seizures usually accompany
the cutaneous manifestations, and neuroimaging demonstrates distinctive
periventricular “tubers”.

A. Sturge-Weber syndrome is characterized by port-wine lesions on the


face in the distribution of the trigeminal nerve and is associated with
vascular proliferation within the brain leading to hemiatrophy and
seizures, as well as vascular proliferation in the eye which may lead to
glaucoma.
B. Von Hippel-Lindau disease is characterized by vascular hamartomas in
the eye and brain and is associated with renal cell tumors and
pehochromocytoma.
C. Neurofibromatosis is characterized by multiple café-au-lait macules
on the skin as well as the development of fibromas. It is also
associated with hypertension secondary to renal artery stenosis.

A married couple bring their newly adopted 5 month old for his first
well child visit. They ask when the child can sit in a safety seat in
the car facing forward. You would advise that the child should face
rearward until he is

a) 12 months of age and weighs 20 lb


b) 15 months of age and weighs 25 lb
c) 15 months of age or weighs 25 lb
d) 18 months of age and weighs 30 lb
e) 18 months of age or weighs 30 lb
The Correct answer is A

Explanation
If a child faces forward in a crash, the force is distributed via the
harness system across the shoulders, torso, and hips, but the head and
neck have no support. Without support, the infant’s head moves rapidly
forward in flexion while the body stays restrained, causing potential
injury to the neck, spinal cord, and brain. In a rear-facing position,
the force of the crash is distributed evenly across the baby’s torso,
and the back of the child seat supports and protects the head and neck.
For these reasons, the rear-facing position should be used until the
child is 12 months old and weighs 20 lb (9 kg). For example, a
13-month-old child who weighs 19 lb should face rearward, and a
6-month-old child who weighs 21 lb should also face rearward.
A red eye in an infant less than 2 weeks of age may be explained by all
of the following EXCEPT:

a) Chlamydia trachomatis or Neisseria gonorrhoeae


b) Herpes simplex virus
c) Chemical irritation after silver nitrate prophylaxis
d) Excessive tearing from a blocked nasolacrimal duct
e) Staphlyococcus aureus
The Correct answer is D

Explanation
Tears are generally not produced before 3 weeks of age, and therefore a
blocked nasolacrimal duct usually becomes apparent after one month of age.

A. Chlamydia and gonorrhea are the most common ocular infections in


neonates.
B. Herpes simplex virus is less common than bacterial eye infections,
but may present after 5 days of age.
C. Chemical irritation is the cause of 80% of red eyes in neonates.
E. Staphylococcus aureus is also a cause of neonatal eye infections.

A newborn baby is noted to have abnormal facies with low-set ears, a


small receding jaw, and widely separated eyes. At 30 hours of age, the
baby develops multiple muscle spasms. Serum studies are notable for
calcium of 4.5 mg/dL. Which of the following is the most likely diagnosis’

a) Bruton's agammaglobulinemia
b) Common variable immunodeficiency
c) DiGeorge syndrome
d) Selective IgA deficiency
e) Transient hypogammaglobulinemia of infancy
The Correct answer is C

Explanation
This is DiGeorge syndrome, which is a congenital syndrome in which
abnormal development of the third and fourth pharyngeal pouches leads to
absence or hypoplasia of the thymus and parathyroid glands. The
diagnosis is suspected in an infant, often with a malformed face, who
develops a difficult-to-manage hypocalcemia, typically at 24 to 48 hours
of life.

The diagnosis can be confirmed with chest x-ray, which will fail to show
the normal thymic shadow. The infants should also be evaluated for
congenital cardiovascular disease, as this may be part of the
developmental abnormality. Infants that survive the initial hypocalcemia
(requiring extremely careful medical management) become vulnerable to
recurrent infections shortly after birth. The defect usually involves T
cells (with normal or near normal B cell function), and, in some cases,
may resolve spontaneously as the child ages and a small remnant of
thymus hypertrophies.
A 4-year-old white female is brought to your office by her mother, who
reports that the child recently developed a foul-smelling vaginal
discharge. After an appropriate history and general examination, you
determine that a genital examination is necessary.

Which one of the following positions is most likely to allow for


visualization of the child’s vagina and cervix without instrumentation?

a) Supine in the mother’s lap


b) The left lateral decubitis position on an examination table
c) Trendelenburg’s position on an examination table
d) The knee-chest position on an examination table
e) Supine with the knees spread apart on an examination table
The Correct answer is D

Explanation
The knee-chest position has been found to allow for visualization of the
vagina and cervix of a prepubertal child after 2 years of age without
instrumentation. The vagina is filled with air when the child is in the
knee-chest position, facilitating inspection. An assistant holds the
child’s buttocks apart and the child asked to relax her abdominal
muscles and take a few deep breaths. With these preliminary steps, the
vaginal orifice opens and the short vaginal canal fills with air. A
bright light will help to illuminate the prepubertal child’s vagina and
cervix.

Inspection of genitalia (where examination of the vaginal canal and


cervix are not indicated) during a general physical examination need not
be in the knee-chest position. In the young child (usually less than 2
years of age), examination is best done with the child lying supine in
the mother’s lap. For the older prepubertal child, examination is best
done with the child lying supine with the knees spread apart on the
examination table. The other positions listed are not helpful or
recommended when examining the genital area of a prepubertal child.
A 36-hour-old male is noted to have jaundice extending to the abdomen.
He is breastfeeding well, 10 times a day, and is voiding and passing
meconium-stained stool. He was born by normal spontaneous vaginal
delivery at 38 weeks gestation after an uncomplicated pregnancy. The
mother’s blood type is A positive with a negative antibody screen. The
infant’s total serum bilirubin is 13.0 mg/dL. Which one of the following
would be the most appropriate management of this infant’s jaundice?

a) Continue breastfeeding and supplement with water or dextrose in


water to prevent dehydration
b) Continue breastfeeding, evaluate for risk factors, and initiate
phototherapy if at risk
c) Discontinue breastfeeding and supplement with formula until the
jaundice resolves
d) Discontinue breastfeeding until total serum bilirubin levels begin
to decrease
e) Discontinue breastfeeding and supplement with formula until total
serum bilirubin levels begin to decrease
The Correct answer is B

Explanation
The current clinical practice guidelines on the management of
hyperbilirubinemia in the newborn infant at 35 or more weeks gestation
focus on frequent clinical assessment of jaundice, and treatment based
on the total serum bilirubin level, the infant’s age in hours, and risk
factors. Phototherapy should not be started based solely on the total
serum bilirubin level. The guidelines encourage breastfeeding 8?12 times
daily in the first few days of life to prevent dehydration. There is no
evidence to support supplementation with water or dextrose in water in a
nondehydrated breastfeeding infant. This infant is not dehydrated and is
getting an adequate number of feedings, and there is no reason to
discontinue breastfeeding at this time.
All the following statements regarding transient tachypnea of the
newborn (TTN) is true, except

a) Infants born by C-section are at increased risk for developing TTN


b) Residual pulmonary function disability is common among infants who
have TTN
c) The incidence of TTN is higher than Respiratory Distress Syndrome
(RDS) among term infants
d) TTN shows marked improvement with 12-24 hrs
e) Chest x-ray findings consistent with TTN include increased pulmonary
vasculature and fluid in the fissures
The Correct answer is B

Explanation
Transient tachypnea of the newborn (TTN) is respiratory distress caused
by delayed resorption of fetal lung fluid. TTN affects premature
infants, term infants delivered by cesarean section, and infants born
with respiratory depression, all of whom have delayed clearance of fetal
lung fluid. Maternal diabetes and asthma are also risk factors, for
unknown reasons, and the disorder can occur in preterm infants with
respiratory distress syndrome (RDS) and in term infants born through
meconium-stained amniotic fluid.

Rapid respirations, grunting, and retractions begin soon after delivery,


and cyanosis may develop. Chest x-ray shows hyperinflated lungs with
streaky perihilar markings, giving the appearance of a shaggy heart
border while the periphery of the lungs is clear. Fluid is often seen in
the lung fissures.

Recovery usually occurs within 2 to 3 days. Treatment is supportive and


involves giving O2 by hood and monitoring ABGs or pulse oximetry.
Rarely, extremely premature infants and/or those with neurologic
depression at birth require continuous positive airway pressure and
occasionally even mechanical ventilation.
A 6 year old girl experiences a severe burn over 20% of her body. What
is the best type of analgesia to give for her pain?

a) Codeine
b) NSAID
c) Aspirin
d) Morphine
The Correct answer is D

Explanation
The immediate pain that follows a burn injury is due to the stimulation
of skin nociceptors (pain sensing nerves). Nerve endings that are
completely destroyed will not transmit pain, but those that remain
intact will trigger pain throughout the time and course of treatment, as
will regenerating nerves - those still connected with intact afferent
fibres.

Intravenous medications, especially IV opioids such as morphine, are


well suited to fulfill analgesic requirements.
A 6 week old infant was seen in the emergency department for a 3 day
history of vomiting and diarrhea without fever. On exam the patient was
tacycardic, normotensive, lethargic, with a depressed fontanelle, dry
mucous membranes, and decreased skin turgor. Mom states that the baby’s
last weight was 4 kg at his 1-month well-child checkup, and his urine
output is noticeably decreased today. What is the initial fluid
resuscitation of choice and what is the fluid deficit?

a) 1/4 NS, 200 cc


b) 1/2 NS, 200 cc
c) NS, 200 cc
d) NS, 400 cc
e) 3% NS, 400 cc
The Correct answer is D

Explanation
Initial fluid resuscitation requires isotonic solution (NS/LR). Other
solutions may result in further complications with electrolyte
disturbances and inadequate treatment of shock. The estimation of
deficit is important in small infants and children because of the
relatively small intravascular volume, and over- or under-treatment can
have serious consequences. Deficit is best calculated by loss of weight,
but often pre-dehydration weights are unknown. Severe signs of
dehydration, such as sunken fontanelle, lethargy, and dry mucous
membranes place the deficit at 10% or greater. A 4-kg infant with 10%
dehydration has a 400-cc deficit. An infant with slightly dry mucous
membranes, tachycardia, and concentrated urine would suggest a
dehydration of about 5%.

Severity Infants (weight <10 kg) Children (weight >10 kg)


Mild dehydration 5% or 50 mL/kg 3% or 30 mL/kg
Moderate dehydration 10% or 100 mL/kg 6% or 60 mL/kg
Severe dehydration 15% or 150 mL/kg 9% or 90 mL/kg
A 4 year old girl presents with impressive areas of bluish discoloration
of the lower extremities, buttocks and upper trunk. She has a low grade
fever but otherwise well looking. The complete blood count reveals the
following results:

Hemoglobin, 120 g/L (Normal 123-157 g/L)


White blood cell, 8.2x10^9/L (Normal 4-10x10^9/L)
Platelets 170x10^9/L (Normal 130-400x10^9/L)

Which one of the following is the most likely diagnosis’

a) Henoch-Schönlein purpura
b) Hemophilia A
c) Meningococcemia
d) Idiopathic thrombocytopenic purpura
e) Acute leukemia
The Correct answer is A

Explanation
Henoch-Schönlein purpura is a vasculitis affecting primarily small
vessels that occurs most often in children. Common manifestations
include palpable purpura, arthralgias, GI symptoms and signs, and
glomerulonephritis. Diagnosis is clinical. Disease is usually
self-limited. Corticosteroids can relieve arthralgias and GI symptoms
but do not alter the course of the disease.
The disease begins with a sudden palpable purpuric rash that typically
involves the extensor surfaces of the feet, legs, and arms and a strip
across the buttocks. The purpura may start as small areas of urticaria
that become indurated and palpable. Crops of new lesions may appear over
days to several weeks. Many patients also have fever and polyarthralgia
with associated periarticular tenderness and swelling of the ankles,
knees, hips, wrists, and elbows.
A mother brings her 12-month-old son to your clinic, concerned that he
is repeatedly banging his head against the floor, wall, or crib. She
reports that this behavior began 2 months ago. It now occurs several
times per week, and at times is incited when the child is frustrated
with a toy or when he does not get what he wants from his parents. The
mother notes that she is sometimes awakened at night by the sound of her
son rhythmically banging his head against the rail of his crib.

Physical examination reveals a normal child with some soft-tissue


swelling of the forehead, but no broken skin, ecchymosis, or signs of
bony damage. Developmental milestones and growth have been normal, and
the child is not on any medications.

Children with this presentation are most likely to have which one of the
following?

a) A history of child abuse


b) A skin laceration or skull fracture
c) An eventual diagnosis of Lesch-Nyhan syndrome
d) Extinction of this habit by age 3
e) Future cognitive delay when compared with children without this habit
The Correct answer is D

Explanation
Head banging has been estimated to be present in 3%-15% of normal
children and usually begins between the ages of 5 and 11 months. The
vast majority of these children will engage in this activity for only a
few months, and most will stop by age 3. Rarely does this behavior cause
lacerations or skull fractures, and the presence of either should prompt
the physician to consider the possibility of another cause such as
abuse. The incidence of head banging is higher in children with
developmental disorders such as Lesch-Nyhan syndromem Down syndrome, or
autism. However, this child has no sign of any such disorder and has
normal developmental milestones.
A 6-week-old male infant with a normal birth history has had poor weight
gain. The mother reports that the infant cries inconsolably for hours at
a time, frequently spits up his formula, and has had watery stools for
the past 2 weeks. She had changed the formula at 1 month of age from
cow-based formula to a soy-based formula because the baby was ?colicky?.
The physical exam is significant for facial eczema, mild abdominal
distention, and occult blood in the stool. Of the following, the most
likely diagnosis is:

a) Lactose intolerance
b) Colic
c) Milk protein allergy
d) Gastroesophageal reflux
e) Necrotizing enterocolitis
The Correct answer is C

Explanation
The above infant presents with evidence of malabsorption with the
chronic diarrhea and poor weight gain. He also has eczema and blood in
the stools, which are often associated with a milk allergy. Twenty-five
percent of patients with a milk protein allergy are also intolerant of a
soy formula. The allergy is to the milk protein, not the sugar, lactose.
The treatment of choice would be breastfeeding for the first year of
life. The mother should be careful to remove whole milk from her diet.
If unable to breastfeed and the patient is intolerant to soy, a
hydrolysated casein formula, such as Nutramigen or Pregestimil, should
be started.

A. Genetically inherited lactose intolerance may produce abdominal


distension, fussiness, and watery stools. However, this patient’s
symptoms progressed on a soy formula, which does not contain lactose.
B. Milk protein intolerance is often mistaken for colic. However, an
infant with colic would continue to feed and grow normally.
D. Gastroesophageal reflux may cause fussiness and frequent spit ups,
and if severe enough, esophagitis, and poor weight gain. However, reflux
usually does not cause abdominal distention and watery stools.
E. Necrotizing enterocolitis does present with acute abdominal
distention and bloody stools, but it is an acute process that rarely
presents in a one-and-a-half-month-old patient with a normal birth history.
You are conducting a well-child visit. The mother is concerned because a
neighbor commented to her that she could only understand about half of
what the 2-year-old boy was saying. The mother is wondering whether this
is appropriate or whether she should be offended. You advise her:

a) This is appropriate for his age


b) This is not appropriate for his age
c) You reassure her but recommend speech therapy if she wants
d) Arrange speech therapy immediately
e) Refer the son to ear, nose, and throat (ENT) clinic
The Correct answer is A

Explanation
Two-year-old children usually produce 2-3 word phrases, may follow
2-step commands, and be understood by a stranger about 50% of the time.

B. See explanation for A.


C. Speech therapy is not necessary and should not be offered as an option.
D. Speech therapy is not necessary.
E. ENT clinic is unnecessary.
At the 6-month well-child visit, you notice that the baby’s right eye is
tearing excessively. On further questioning, the mom states that this
has been happening since birth. On exam, the baby is thriving and the
eye exam is otherwise normal. The most common cause of this condition is:

a) Dacryocystitis
b) Open globe
c) Obstruction of the nasolacrimal duct
d) Congenital glaucoma
e) Chronic irritation from allergies
The Correct answer is C

Explanation
Obstruction of the nasolacrimal duct is a common cause of overflow
tearing (epiphora) in neonates. The most common cause of obstruction is
a persistent membrane that blocks the distal end of the nasolacrimal
duct where it empties into the nose.

A. Dacryocystitis is a superimposed infection of the tear duct.


B. Open globe implies rupture of the sclera and is uncommon.
D. An uncommon cause of painless tearing in a baby.
E. An uncommon cause of painless tearing in a baby.
A 4 year old boy is admitted for the investigation of headaches and is
found to have intermittent hypertension. You suspect a neuroblastoma.
Which one of the following investigations provides a great advantage in
confirming the diagnosis, as well as in following disease activity in
the care of patients with secreting tumors’

a) MRI or CT scan of the involved area of the body


b) MIBG (Meta iodobenzylguanidine) scan
c) Levels of homovanillic acid and vanillylmandelic acid in the urine
d) Serum catecholamines
e) Serum alpha fetoproteins
The Correct answer is C

Explanation
Neuroblastoma is a cancer arising in the adrenal gland or less often
from the extra-adrenal sympathetic chain, including the retroperitoneum,
chest, and neck. Diagnosis is based on biopsy.

When sensitive assays are used, 90 to 95% of tumors produce sufficient


catecholamines to increase urinary metabolites. This provides a great
advantage in confirming the diagnosis of neuroblastoma, as well as in
following disease activity in the care of patients with secreting
tumors. The two enzymes primarily responsible for the catabolism of
catecholamines are catechol-O-methyl transferase and monoamine oxidase.
Dopa and dopamine are converted primarily to homovanillic acid, whereas
norepinephrine and epinephrine are converted primarily to
vanillylmandelic acid. Most laboratories involved in neuroblastoma
diagnosis measure levels of both homovanillic acid and vanillylmandelic
acid in the urine.

Because of the varied clinical presentation, neuroblastoma can be


confused with other neoplasms as well as nonneoplastic conditions.
Diagnosis of the 5 to 10% of tumors that do not produce catecholamines
is particularly difficult, as is that of the 1 % or so in which the
primary tumor is not obvious.

The conventional diagnostic imaging modalities include plain


radiography, bone scintigraphy, CT, and MRI. The potential specificity
and sensitivity of meta-iodobenzylguanidine (MIBG) scintigraphy for
evaluation of bone and soft-tissue involvement of neuroblastoma are
attractive.
The Canadian Preventive Services Task Force makes which one of the
following recommendations regarding screening for speech and language
delay in preschool children using brief, formal screening instruments
that are suitable for use in primary care?

a) Screening is strongly recommended for all preschool children because


good evidence
exists for substantial benefit over harm
b) Screening is not recommended because it is ineffective
c) Screening is not recommended because the potential harm outweighs
the potential
benefits
d) The evidence is insufficient to recommend for or against routine
screening
The Correct answer is D

Explanation
Speech and language delay affects 5%?8% of preschool children. It often
continues into the school years and may be connected to poor school
performance and psychosocial problems. In reviewing the data,
the Canadian Preventive Services Task Force found insufficient evidence
that brief, formal screening instruments that are suitable for use in
primary care for assessing speech and language development can
accurately identify children who would benefit from further evaluation
and intervention. Therefore, the Task Force makes an ?I?
recommendation’the evidence is insufficient to recommend for or against
routinely providing the service.

Fair evidence suggests that interventions can improve the results of


short-term assessments of speech and language skills; however, no
studies have assessed long-term outcomes. Furthermore, no studies have
addressed benefits from the use of brief, formal screening compared to
addressing only those problems identified from clinical or parental
concerns. No studies have addressed the potential harms of screening or
interventions for speech and language delays, such as labeling, parental
anxiety, or unnecessary evaluation and intervention.

The guidelines presented are based on the best available evidence at the
time they are written. In cases where the evidence is insufficient to
recommend for or against an intervention, physicians should base
clinical decisions on the individual patient’s situation.

A 14-year-old Hispanic female presents with a dark spot on her right


lateral chest (see Image). Her mother says the lesion as been there for
“years.”

Which one of the following would be most appropriate initially?

a) A biopsy of the lesion


b) A cosyntropin test
c) An FSH level
d) A yearly skin survey and photographs
e) Observation only
The Correct answer is E

Explanation
This is a classic presentation of an accessory nipple that requires only
observation. These congenital remnants of the ?mammary lines’ may be
found on both the anterior and posterior chest walls. This lesion has no
propensity to malignancy or endocrine relationships.
A 2 year old toddler is brought to the emergency room 8 hours after
accidental ingestion of gasoline. On examination she is afebrile and has
no respiratory distress. Chest x-ray is normal. Which one of the
following is the most appropriate intervention?

a) Oral corticosteroid treatment


b) Antibiotic to prevent pneumonitis
c) Induce vomiting to empty the stomach
d) Admit to ward for observation only
e) Discharge home, but to return if tachypneic
The Correct answer is D

Explanation
There is no antidote for gasoline poisoning. Treatment consists of
support of cardiovascular and respiratory functions. In cases of
ingestion, do not induce emesis or use gastric lavage and do not
administer activated charcoal. Gasoline is poorly absorbed from the
stomach. Catharsis with magnesium or sodium sulfate is acceptable. If
spontaneous vomiting occurs, watch for signs of pulmonary aspiration.

All symptomatic patients should have a chest X-ray taken no sooner than
two hours post- ingestion, and should be observed in the emergency
department for a period of six hours. The patient may be discharged with
observation at home if asymptomatic throughout and X-ray is negative. In
the presence of a positive two-hour X-ray, the patient should be
admitted for monitoring of blood gases, repeat chest X-rays, and
respiratory support if required.
During a routine well-child visit, a patient’s mother tells you she is
concerned about her daughter’s development. On further questioning you
discover that the child knows six words, including ?mama?, walks alone,
and recently started walking backwards. After you demonstrate, she is
able to build a tower of two blocks and scribble with a pen, but cannot
form a circle or a cross. You reassure the mother that her child is
showing normal development for a child of:

a) 9 months
b) 12 months
c) 15 months
d) 24 months
e) 36 months
The Correct answer is C

Explanation
The milestones above are appropriate for a child of 15 months. At this
age a child should be able to walk backwards, creep up stairs, scribble,
build a tower of two blocks, and use 4-6 words.

A. At 9 months, the average child can neither walk nor talk.


B. An average 1-year-old knows 1-3 words and cannot walk backwards.
C. At 2 years, a child should know about 100 words and be able to walk
up and down stairs.
E. At 3 years, a child should be able to use 3-word sentences, dress
himself, and draw a circle.
An 18-month-old boy presents for a well-child visit. Upon entering the
room, you notice him playing with toys, touching everything in the room,
and speaking to his mother in 2-word phrases. According to Piaget’s
stages of cognitive development, he would best be classified in:

a) Sensorimotor stage
b) Preoperational stage
c) Concrete operational stage
d) Abstract operational stage
e) Formal operational stage
The Correct answer is A

Explanation
Sensorimotor stage is the correct answer. This stage encompasses birth
to 2 years of age and consists of children learning by activity,
explanation, and manipulation of the environment.

B. Preoperational stage, ages 2-7: the child engages in symbolic


representation of the world.
C. Concrete operations, ages 7-11: the child is capable of limited,
logical thought process.
D. Abstract operations is not a stage of Piaget’s cognitive development.
E. Formal operations, ages 12 to adult: the child can reason logically
and abstractly.
A 12 year old boy is brought by his mother for difficulty in learning,
lagging behind in school, fatigue and slow growth. What is the most
probable diagnosis’

a) Hypothyroidism
b) Congenital mental disorder
c) Panhypopituitarism
d) Learning disability
The Correct answer is A

Explanation
Hypothyroidism can affect all ages. In children the symptoms are
fatigue, increased sensitivity to cold, fatigue, constipation,
forgetfulness, decreased appetite, growth changes, depression and poor
mental development.

A detailed physical exam should be done on such patients looking


possible physical findings which include a puffy face, weight changes,
pain, stiffness or swelling in joints, abnormal sexual development,
large protruding tongue, yellowing of the skin & whites of eyes and
delayed development of permanent teeth.

Lab tests are TSH and Free T4 levels. Treatment for hypothyroidism is
with thyroid replaced (Synthroid).
A 2 month old girl, with a large ventricular septal defect, has moderate
bronchiolitis due to respiratory syncytial virus. Which one of the
following treatments is the most appropriate?

a) Start continuous intravenous perfusion of theophylline


b) Order continuous intravenous perfusion of salbutamol
c) Send the infant home
d) Administer ventolin/ribavirin
e) Hydrate the infant intravenously
The Correct answer is D

Explanation
Most children with bronchiolitis recover at home in 3 to 5 days. During
the illness, frequent small feedings of clear fluids may be given.
Increasing difficulty in breathing, bluish skin discoloration, fatigue,
and dehydration indicate that the child should be hospitalized. Children
with congenital heart or lung disease or an impaired immune system may
be hospitalized sooner and are far more likely to become quite ill from
bronchiolitis. With proper care, the chance of dying of bronchiolitis is
low, even for children who need to be hospitalized.

In the hospital, oxygen levels are monitored with a sensor on a finger,


toe, or an earlobe, and oxygen is given by an oxygen tent or face mask.
A ventilator may be needed to assist breathing. Intravenous fluids are
given if the child cannot drink adequately. Inhaled drugs that open the
airways (bronchodilators) may be tried, although their effectiveness in
bronchiolitis is questionable. The antiviral drug ribavirin may be given
by nebulizer to infants who are premature or who have other conditions
that put them at high risk for severe breathing problems, such as
congenital heart or lung disease, cystic fibrosis, or AIDS. Antibiotics
are not helpful.
A 9 month old infant on routine physical examination is found to have
the following blood pressure readings: in the left arm 80/40 mmHg and in
the right arm 100/80 mmHg. Which one of the following clinical signs
would you find on physical examination?

a) A systolic murmur in the aortic area


b) Unobtainable blood pressure in both legs
c) Hepatomegaly
d) Central cyanosis
e) S3 gallop on auscultation
The Correct answer is A

Explanation
Coarctation of the aorta is localized narrowing of the aortic lumen that
results in upper-extremity hypertension, left ventricular hypertrophy,
and malperfusion of the abdominal organs and lower extremities.

Symptoms vary with the anomaly's severity and range from headache, chest
pain, cold extremities, fatigue, and leg claudication to fulminant heart
failure and shock. Unequal pressures in the upper extremities is recorded.

A grade 2 to 3/6 ejection systolic murmur is best heard in the left


interscapular area. A soft bruit may be heard over the coarctation site.
Diagnosis is by echocardiography or by CT or MR angiography. Treatment
is balloon angioplasty with stent placement, or surgical correction.
Endocarditis prophylaxis is recommended.
Which one of the following treatments for childhood nocturnal enuresis
has both the highest cure rates and the lowest relapse rates’
a) Bed wetting alarms
b) Positive reinforcement
c) Responsibility training
d) Desmopression (DDAVP)
e) Imipramine (Tofranil)
The Correct answer is A

Explanation
Treatments available for childhood nocturnal enuresis include
nonpharmacologic and pharmacologic treatments. Compared to other
techniques and pharmacologic treatments, the bed-wetting alarm has a
higher success rate (75%) and a lower relapse rate (41%).
An 8 year old boy is brought to the office because his mother is
concerned he is entering puberty already. You examine him and note the
beginnings of facial hair, axillary hair and Tanner stage 2 external
genitalia. If you suspect premature adrenarche, which of the following
would you want to order

a) Testosterone
b) DHEA and DHEA-S
c) Bone age X ray
d) Urinary 17-ketosteroids
e) All of the above
The Correct answer is E

Explanation
Premature adrenarche refers to the precocious secretion of adrenal
androgens, which results in the isolated development of pubic hair
(pubarche) before the age of eight years in girls and nine years in
boys. The female to male ratio is approximately 10:1. The condition is
characterized by activation of adrenal androgen production and by
impressive increases in dehydroepiandrosterone (DHEA),
dehydroepiandrosterone sulfate (DHEAS), androstenedione, and testosterone.

Serum concentrations of DHEA, DHEAS, androstenedione, and testosterone


and urinary 17-ketosteroids should be measured. In premature adrenarche,
these levels are usually increased for chronologic age and are in the
range of those found in early puberty. A bone age x-ray should be
preformed. In premature adrenarche, the bone age is usually within 2
standard deviations of chronologic age.

Moderately elevated levels of serum androgen other than DHEAS, bone age
advancement, or signs of atypical premature pubarche such as cystic acne
or signs of systemic virilization indicate the need for an ACTH test to
rule out congenital adrenal hyperplasia. An excessive increase in serum
17-hydroxyprogesterone level to >45 nmol/L after an ACTH stimulation
test suggests late-onset congenital adrenal hyperplasia.

Marked elevation of serum androgen levels and advanced bone age suggest
the possibility of an adrenocortical or gonadal tumor. A patient with an
androgen-producing adrenocortical tumor does not respond to ACTH
stimulation or dexamethasone suppression, whereas a patient with
congenital adrenal hyperplasia does respond.
A 15 1/2-year-old female is brought to your office by her mother. They
are concerned because she has not started her periods. She has been
healthy, and has grown several inches in the last year. Her height is
now 152 cm (60 in) and she weighs 44 kg (98 lb). She started to develop
breast buds about a year ago and has scant pubic hair. She denies sexual
activity. The mother’s menarche occurred at age 15.

a) The patient has delayed puberty and should have her hormone levels
evaluated
b) The patient will likely start her periods within a year
c) Oral contraceptives will be needed to trigger menarche
d) A pregnancy test should be performed
e) The daughter’s age of menarche is unrelated to her mother’s age of menarche
The Correct answer is B

Explanation
The changes associated with puberty occur in an orderly sequence over a
definite time frame. Any deviation from this sequence or time frame
should be regarded as abnormal.

In girls, pubertal development typically requires 4.5 years. Although


generally the first sign of puberty is accelerated growth, breast
budding is usually the first recognized pubertal change, followed by the
presence of pubic hair, peak growth velocity, and menarche. Girls must
have adequate nutrition and reach a critical body weight and body fat
percentage before menarche occurs. There is a concordance in the age of
menarche in mother-daughter pairs and between sisters.

Delayed or interrupted puberty is defined as failure to develop any


secondary sex characteristics by age 13, to have menarche by age 16, or
to have menarche 5 or more years after the onset of pubertal development.

Which of the following statements about hemorrhagic disease of the


newborn is true?

a) More common in bottle-fed infants


b) Requires therapy with fresh frozen plasma
c) Becomes evident in the first 24 hours of life
d) Results from a deficiency of vitamin K
The Correct answer is D

Explanation
Hemorrhagic disease of the newborn is a bleeding problem that occurs in
a newborn during the first few days of life. Babies are normally born
with low levels of vitamin K, an essential factor in blood clotting. A
deficiency in vitamin K is the main cause of hemorrhagic disease of the
newborn.

Babies at risk for developing hemorrhagic disease of the newborn include


the following: babies who do not receive preventative vitamin K in an
injection at birth, exclusively breastfed babies (breast milk contains
less vitamin K than cow's milk formula).

In addition to a complete medical history and physical examination, a


diagnosis is based on the signs of bleeding and by laboratory tests for
blood clotting times.

If bleeding occurs, vitamin K is given. Blood transfusions may also be


needed if bleeding is severe.
A fourteen year old boy is seen because he is constantly blinking. The
boy is otherwise well. He was suspected to have ADHD. You note that he
frequently clears his throat, yet he denies sore throat or other upper
respiratory tract symptoms. He blinks frequently, yet is able to hold
his eyes open during examination with an ophthalmoscope. His fundi,
visual acuity, extraocular movements, visual fields, eyelids and
eyelashes are normal. He also exhibits intermittent facial grimacing
without apparent pain. Which of the following conditions are frequently
associated with this boy’s diagnosis’

a) Oppositional Defiant Disorder (ODD)


b) Conduct Disorder (CD)
c) Obsessive Compulsive Disorder (OCD)
d) Developmental Coordination Disorder (DCD)
The Correct answer is C

Explanation
People with Tourette's syndrome often have difficulty functioning and
experience considerable anxiety in social situations. In the past, they
were shunned, isolated, or even thought to be possessed by the devil.
Impulsive, aggressive, and self-destructive behaviors develop in many
people, and obsessive-compulsive behavior develops in about half.
Children with Tourette's syndrome often have difficulty learning. Many
also have attention-deficit/hyperactivity disorder. Whether Tourette's
syndrome itself or the extraordinary stresses of living with the
disorder cause these problems is unclear.
A 3-year-old female is seen for a well child examination. You note that
her labia minora seem to adhere together except for about 4 mm at the
upper aspect under the clitoris.

The most appropriate action would be to

a) make no attempt to separate the labia, but monitor for signs of


urinary tract infection
b) refer to a pediatric surgeon for separation
c) have the child’s mother apply gentle traction twice daily
d) prescribe a lubricating jelly to be applied daily until the labia
separate
e) prescribe a topical estrogen cream to be applied daily until the
labia separate
The Correct answer is E

Explanation
Labial adhesion is a common clinical problem that is not simply
cosmetic, as 20%?40% of females with this condition (generally <6 years
of age) have urinary symptoms. The treatment of choice is topical
estrogen cream applied each evening. It is effective within 1 week in
most patients, but may take longer.
A 3-year-old male is brought to your office because of a slowly
spreading rash on his face of several days’ duration. The mother states
that he is otherwise healthy. Examination shows a 2-cm area of yellow
crust on his right cheek. There is no surrounding erythema. Examination
of the nose and throat reveals normal findings.

Which one of the following would be the most appropriate treatment?

a) Amoxicillin
b) Cephalexin (Keflex)
c) Mupirocin cream (Bactroban)
d) Watchful waiting
e) Warm, wet packs
The Correct answer is C

Explanation
Impetigo is caused by group A beta-hemolytic Streptococcus and/or
Staphylococcus aureus, and is one of the most common skin infections in
children. Even though it is thought to be self limiting, treatment is
recommended because of its contagiousness.

Amoxicillin would not cover Staphylococcus, and sometimes it is


difficult to get young children to take oral antibiotics. In addition,
they increase the risk of antibiotic-associated diarrhea or allergic
reactions. Mupirocin cream has been found to be just as effective as
oral antibiotics in cases of limited infections.
A 2 year old white male is brought to your office by his mother, who
says he has ?infected ant bites’. He was playing in his cousin’s yard
yesterday in and cried when small brown ants crawled on his feet and
legs. A physical examination is normal except for about 20
pustular-appearing lesions on erythematous bases on his lower
extremities. The lesions are 1-2 mm in size. The most appropriate
management of this problem is to

a) Prescribe an oral antibiotic that is active against Staphylococcus


aureus
b) Administer procaine penicillin intramuscularly
c) Administer high doses of corticosteroids
d) Recommend that the lesions be kept clean
e) Report this case of child abuse to the authorities
The Correct answer is D

Explanation
The lesions described are typical of fire ant bites and are not
infected. Fire ants are aggressive and these lesions do not imply abuse
or neglect of the child. The lesions should be thoroughly cleaned with
soap and water. Corticosteroids should be employed in severe cases,
although their maximum effect is not achieved until several hours after
administration.
A 3 year old with a history of asthma is brought to the Emergency
Department in acute respiratory distress. His mother relates that she
stopped his twice daily sodium cromoglycate 1 week ago. Physical
examination reveals a distressed child with a harsh cough. On
auscultation of the chest, there are areas of reduced air entry and
diffuse expiratory wheezes. Which one of the following is the most
appropriate initial management?

a) Aerosolized ipratropium bromide by nebulization


b) Aerosolized sodium cromoglycate by nebulization
c) Aerosolized budesonide
d) Subcutaneous epinephrine, 1:1000 dilution
e) Aerosolized salbutamol by nebulization
The Correct answer is E

Explanation
The most severe form of asthma is called status asthmaticus. In this
condition, the lungs are no longer able to provide the body with
adequate oxygen or adequately remove carbon dioxide. Without oxygen,
many organs begin to malfunction. The buildup of carbon dioxide leads to
acidosis, an acidic state of the blood that affects the function of
almost every organ. Blood pressure may fall to low levels. The airways
are so narrowed that it is difficult to move air in and out of the lungs.

Status asthmaticus requires intubation and ventilator support as well as


maximum doses of several medications such as salbutamol or albuterol.
Which are a short-acting Beta2-adrenergic receptor agonists used for the
relief of bronchospasm.
Between 7 and 8 years of age, your patient has grown 4.5 cm. His height,
however, remains below and parallel to the 5th percentile. Clinical
examination is entirely normal. His mother is anxious for further
investigations to be undertaken. Which one of the following would you
undertake?

a) Growth hormone secretion using insulin-induced hypoglycemia


b) Computed tomography scan of the head
c) Thyroid-stimulating hormone (TSH)
d) 24-hour urine collection for cortisol
e) None of the above
The Correct answer is E

Explanation
The growth percentiles by themselves don't say much. What really matters
is the velocity of growth. A normal velocity of growth means the child's
growth points will closely parallel the percentile line above it on the
chart. Physicians don't worry about insufficient (or excessive) growth
until a child's growth velocity has crossed at least two percentile
lines (e.g., from above the 90th to below the 50th percentile).

Additionally, if a child's weight, height, or head size is below the 5th


percentile, they might also call them small for age. In that case,
what's most important is to see if the growth points parallel the 5th
percentile line (meaning growth velocity is normal) or if the child is
falling further behind (which is more concerning).
A 3 week old baby is brought to the Emergency Department with a 36 hour
history of progressive vomiting. The birth weight was 3.1 kg. On
physical examination, his weight is 2.8 kg; he is 5% dehydrated and is
very irritable but not toxic. His blood work reveals:

pH 7.50
paCO2 30mm Hg
HCO3 31 mmol/L
Base excess 7 mmol/L
Potassium 3.0 mmol/L
Sodium 135 mmol/L
Chloride 70 mmol/L
Urea nitrogen 7.2 mmol/L

Which one of the following diagnoses is the most likely?

a) Congenital adrenal hyperplasia


b) Cystic fibrosis
c) Gastroenteritis
d) Pyloric stenosis
e) Obstructive uropathy
The Correct answer is D

Explanation
Hypertrophic pyloric stenosis may cause almost complete gastric outlet
obstruction. It is more common in males by a 4:1 ratio. The exact
etiology is uncertain, but a genetic component is likely because
siblings and offspring of affected people are at increased risk.

Symptoms develop between 2 and 6 weeks of life. Projectile vomiting


(without bile) occurs shortly after eating. Until dehydration sets in,
the child feeds avidly and otherwise appears well, unlike many of those
with vomiting due to systemic illness. Gastric peristaltic waves may be
visible, crossing the epigastrium from left to right. A discrete, 2- to
3-cm, firm, movable olive-like pyloric mass is sometimes palpable deep
in the right side of the epigastrium. With progression of illness, the
child fails to gain weight, and signs of dehydration appear.

Diagnosis is by abdominal ultrasonography showing increased thickness of


the pylorus (typically to ? 4 mm; normal, < 2 mm). The classic
electrolyte pattern of an infant with pyloric stenosis is that of
hypochloremic, hypokalemic metabolic alkalosis.

The most common cause of pneumonia in preschool-age children is

a) /Chlamydia pneumoniae/
b) /Haemophilus influenzae /
c) /Listeria monocytogenes /
d) /Streptococcus pneumoniae /
e) Viruses
The Correct answer is E

Explanation
Viruses are the most common cause of pneumonia in preschool-aged
children. /Streptococcus pneumoniae/ is the most common bacterial pathogens.

An abdominal mass in the newborn is most frequently due to

a) Neuroblastoma
b) Anomalies of the kidney and urinary tract
c) Anomalies of the bowel
d) Teratoma
e) Mesenteric cyst
The Correct answer is B

Explanation
The discovery of an abdominal mass on physical examination in the
newborn period causes concern and the need for a rapid diagnosis. The
incidence of an abdominal mass is 1/1000 live births.

The majority of masses are of benign origin and greater than 50% are of
renal origin. Examples include multicystic dysplastic kidney, posterior
urethral valves and mesoblastic nephromas.
A 2-month-old baby girl is brought to your office for a routine visit.
The baby is growing and developing well, and there are no medical
problems. There were no problems with the pregnancy. Her mother tells
you that her friend had a baby who recently died of sudden infant death
syndrome (SIDS). Although there is no history of SIDS in her family, the
mother is worried about her own child. You advise her to:

a) Use an apnea monitor (with a computer memory that is able to be


downloaded for analysis)
b) Make sure the baby sleeps on her belly, to prevent aspiration if she
vomits
c) Put the baby to sleep on her back
d) Make an appointment for a sleep study to rule out central and
obstructive apnea
e) Inform the mother that she should stop worrying since nothing she
does can prevent SIDS
The Correct answer is C

Explanation
Since 1992, when the American Academy of Pediatrics recommended babies
be put to sleep on their backs, there has been a dramatic decrease in
the incidence of SIDS.

A. Apnea monitors are usually used after a severe life-threatening event


or when a baby is having apneic episodes or periodic breathing. Some
experts believe in using an apnea monitor for siblings of a SIDS victim.
In this child’s case, there is no reason to use a home apnea monitor.
B. Only babies with certain problems, such as severe gastroesophageal
reflux or craniofacial abnormalities, should be placed to sleep in a
prone position.
D. A sleep study is not indicated for this asymptomatic baby with no
family history of apnea.
E. It is important to pay attention to the mother’s concerns. In this
case, placing the baby to sleep on her back will reduce the risk of SIDS
significantly.
Neurological, intellectual, and physical development in infants and
children occur in an orderly and sequential manner. All of the following
are integers of developmental milestones EXCEPT:

a) Gross motor
b) Fine motor
c) Bone age
d) Language
e) Social
The Correct answer is C

Explanation
Bone age is not a developmental milestone, but rather a physiologic
standard of growth based on radiographs.

All of the remaining choices are recognized developmental milestones.

All of the following statements comparing the effects of aspirin and


acetaminophen in children are true, except

a) In therapeutic does, acetaminophen does not have the hemorrhagic


side effects of aspirin
b) Aspirin and acetaminophen are equally effective in relieving fever
when administered in the same dose
c) The anti-platelet effect of aspirin is greater than that of
acetaminophen
d) Because of the toxic effects of acetaminophen, aspirin is preferred
in children over acetaminophen
e) Acetaminophen, when given in therapeutic doses does not produce the
adverse gastrointestinal effects of aspirin
The Correct answer is D

Explanation
Aspirin has anti-platelet, anti-pyretic, anti-inflammatory and analgesic
properties. Acetaminophen only has anti-pyretic, anti-inflammatory and
analgesic properties.

Aspirin use in children can cause Reye's syndrome, which is a rare form
of acute encephalopathy and fatty infiltration of the liver that tends
to follow some acute viral infections.

Therefore, in children, acetaminophen is preferred over aspirin.


A 5 year old boy presents to your office complaining of right ear pain.
Upon examination of the ear, pain is elicited with traction of the
tragus, the tympanic membrane is not visualized well, and some
periauricular lymph nodes are palpable. What is the most likely diagnosis’
a) Acute otitis media
b) Acute otitis externa
c) Mastoiditis
d) A blocked eustachian tube
e) Acute viral conjunctivitis
The Correct answer is B

Explanation
External otitis is infection of the ear canal, typically by bacteria.
Symptoms include itching, pain, and discharge. Pain can be elicited by
traction of the tragus or pinna, although pain becomes persistent as the
disease progresses.

External otitis often can be prevented by irrigating the ears with a 1:1
mixture of rubbing alcohol and vinegar immediately after swimming. The
alcohol helps remove water, and the vinegar alters the pH of the canal.

Diagnosis is based on inspection. When discharge is copious, external


otitis can be difficult to differentiate from perforated otitis media;
pain with pulling on the pinna indicates external otitis.

Treatment is with topical drugs, including antibiotics, corticosteroids,


and/or acetic acid.
Which of the following is a characteristic chest x-ray appearance of
respiratory distress syndrome (RDS)?

a) Air bronchograms
b) Fluid in fissure
c) Patchy infiltrate
d) Concentrated Atelectasis
e) Enlarged heart
The Correct answer is A

Explanation
Respiratory distress syndrome is caused by pulmonary surfactant
deficiency in the lungs of neonates born at < 37 weeks gestation. Risk
increases with degree of prematurity. Symptoms and signs include
grunting respirations, use of accessory muscles, and nasal flaring
appearing soon after birth.

Diagnosis is by clinical presentation, including recognition of risk


factors; ABGs demonstrating hypoxemia and hypercapnia; and chest x-ray.
Chest x-ray shows diffuse (spread out over a large area; not
concentrated) atelectasis classically described as having a ground-glass
appearance with visible air bronchograms; appearance correlates loosely
with clinical severity.
Which of the following is NOT a cause of apnea in infants’

a) Sepsis
b) Prematurity
c) Hyperglycemia
d) Severe hypoxemia
e) Intraventricular hemorrhage
The Correct answer is C

Explanation
Metabolic disturbances are frequent causes of apnea in preterm and term
infants. However, hypoglycemia, NOT hyperglycemia, may preset as apnea
in the newborn.

A. Sepsis in a newborn may frequently present as new onset apnea or as


an increase in apneic events in preterm infants. It may be the only symptom.
B. Apnea of prematurity is a diagnosis of exclusion in preterm infants
<37 weeks gestation who present with apnea after birth. It is centrally
mediated and metabolic, infectious, and structural anomalies need to be
excluded.
D. Severe hypoxemia in utero or during delivery may result in central
apnea, secondary to neurologic damage.
E. Intraventricular hemorrhage may cause apnea in preterm and term
infants. It may be associated with a decreasing hematocrit. Head
ultrasound will reveal the hemorrhage.
A 12-month-old comes into the office with a 5-day history of diarrhea.
Stools are soupy without water loss and no blood has been seen. Vomiting
is intermittent. No fever has been noted. There is no history of foreign
travel, but the child attends daycare. The most appropriate approach is:

a) Stool culture and sensitivity


b) Stool ova and parasites
c) Imodium orally or Lomotil orally
d) Trial of oral rehydration solution, increasing the diet gradually
e) Start antibiotics orally
The Correct answer is D

Explanation
This child most likely has a viral gastroenteritis as there is no blood,
no fever, the diarrhea is not severe, and the illness is acute. It is
best to manage this patient with dietary changes to rest the
gastrointestinal tract and provide hydration. If there is no improvement
in 2-3 days, consider further workup.

A. Stool culture and sensitivity are not cost effective until the
illness is prolonged >7-14 days or unless there is a history of bloody
stools.
B. Parasitic causes are less likely in patients this young without a
history of foreign travel.
C. Oral antidiarrheal medications are not necessary, and the risk of
obstruction is greater than the benefits.
E. Antibiotics are not necessary because this illness is viral, and
antibiotics may worsen the symptoms.

A toddler presents to your office with his arm in flexion and his hand
in pronation. He will not let anyone touch that arm. There is no history
of trauma. The attending physician performs a rapid maneuver, and within
20 minutes the child is using the arm normally. Which of the following
is true?
a) X-rays are always in order
b) This is almost pathognomonic of child abuse
c) This problem requires casting
d) This almost certainly is subluxation of the radial head
The Correct answer is D

Explanation
This is ordinary ?nursemaids elbow? which is a subluxation of the radial
head. It is usually an innocent injury, commonly inflicted by lifting
the child by one arm.

A. X-rays are usually not needed.


B. This diagnosis is rarely associated with child abuse.
C. Subluxation of the radial head is easily reduced by flexing the arm
and the elbow and supinating the arm.
A 13 year old boy comes into your office for a pre-participation sports
physical. He has a harsh systolic ejection murmur at the right upper
sternal border, which diminishes with the Valsalva maneuver. The murmur
is preceded by an ejection click. The patient reports no symptoms at
rest or with activity. Which advice is most appropriate for this patient?

a) He should avoid all sports until he is evaluated further


b) He has an innocent flow murmur and is able to participate in all
sports without restrictions
c) He has a pathologic murmur, but because he is asymptomatic, there is
no reason to limit his participation in sports
d) There is no need for antibiotic prophylaxis prior to dental procedures
The Correct answer is A

Explanation
The patient described above has an exam consistent with aortic stenosis.
Symptoms are often absent even if obstruction is severe. The patient
should not be allowed to participate in sports, as sudden death has been
reported. An echocardiogram should be performed to assess the valvular
lesion, the degree of the stenosis, and the left ventricular function.
All of these factors will determine the appropriate intervention to
repair or replace the valve. Patients with this valvular lesion should
receive antibiotic prophylaxis to prevent bacterial endocarditis when
undergoing dental manipulation of instrumentation of the
gastrointestinal or genitourinary tract.
Each of the following statements about rotavirus gastroenteritis in
children is correct, except

a) It usually occurs in the winter months


b) It is self-limited
c) It is often associated with respiratory symptoms
d) It is often accompanied by fever and vomiting
e) It is often associated with grossly bloody diarrhea
The Correct answer is E

Explanation
Rotavirus is a common and contagious virus that causes vomiting and
diarrhea. Rotavirus is one of the most common causes of diarrhea in
children. Although hardly any children die from rotavirus, worldwide the
virus causes over 600,000 deaths a year, mostly in developing countries.
Infection is spread mainly by swallowing material contaminated by the
virus. Adults can become infected, but serious illness is rare.

Symptoms begin with fever and vomiting, followed by watery diarrhea,


which typically lasts 5 to 7 days. If fluid losses are not replaced,
dehydration develops. Dehydration makes the child weak and listless,
with a dry mouth and rapid pulse.
A 16 year old white female experiences the sudden onset of tender,
bleeding gums, malodorous breath, and a bad taste in her mouth. On
examination she is febrile and has cervical lymphadenopathy and
tachycardia. Her mouth has marginal punched-out, crater-like depression
of the interdental gingival papillae and gingival margins that are
covered with a gray pseudomembranous slough. The drug of choice for
treating this condition is

a) Acyclovir (Zovirax)
b) Penicillin
c) Clotrimazole troche (Mycelex)
d) Ketoconazole (Nizoral)
e) Prenisone
The Correct answer is B

Explanation
This patient has acute necrotizing ulcerative gingivitis. The onset is
sudden and findings include tender, bleeding gums, malodorous breath,
and a bad taste in the mouth. The disease is frequently associated with
systemic findings such as fever, anorexia, malaise, tachycardia,
cervical lymphadenopathy, and leukocytosis. Characteristic gingival
lesions are seen, appearing as marginal punched-out, crater-like
depressions of the interdental gingival papillae and gingival margin.
They are covered with a gray pseudomembranous slough that is demarcated
from the remainder of the gingival and bleeds when removed.

These lesions may be related to a single tooth, a group of teeth, or the


gingival throughout the mouth. Management includes removing predisposing
factors such as stress, fatigue, heavy smoking, and poor nutrition that
can cause tissue breakdown. Mouth rinses with warm half-strength
hydrogen peroxide are useful. When fever and lymphadenopathy occur,
antibiotic treatment is warranted and penicillin is the drug of choice.
Tetracycline and erythromycin are good alternatives.
A 4 month old baby has developed a fever of 40.2°C and become very
irritable within 8 hours of receiving his second dose of routine
immunization. He had a seizure lasting for 10 to 15 seconds. Which one
of the following options would you consider for completing the
immunization of this baby?

a) Next time omit pertussis vaccine from the schedule


b) Give DTP instead of acellular pertussis
c) Omit Hib and administer DTaP and IPV
d) Reassure the mother and proceed with DTaP, IPV, Hib
e) Omit diphtheria toxoid from the combination
The Correct answer is D

Explanation
Short-term, mild reactions to immunizations are common. Immunizations
that may cause a fever include: Diphtheria, tetanus, acellular pertussis
(DTaP) or diphtheria, pertussis, tetanus (DPT). Babies can have a fever
of up to 40°C (104°F) within 2 to 3 hours of getting the DTaP or DPT
shot. Children may be fussy and have other mild symptoms such as poor
appetite, sleepiness, or redness and swelling at the shot site for a few
days.

With Measles, mumps, and rubella (MMR), the shot site may become red,
swollen, hard, and slightly warm within the first 24 to 48 hours. Fever
also may occur 1 to 2 weeks after the shot. A mild rash may develop up
to 3 weeks after the shot.

Fever is a common clinical complaint in adults and children and a


frequently reported adverse event following immunization. It is a
generally benign and common clinical sign.
You diagnose attention-deficit/hyperactivity disorder in a 10 year old
male, and the parents ask about drug treatment. Which one of the
following would you tell the parents with regard to potential side
effects of drug treatments’

a) Methylphenidate (Ritalin) may precipitate seizures


b) Although anorexia may occur, it will not lead to substantial weight loss
c) Methylphenidate has significantly fewer side effects than
dextroamphetamine (Desedrine)
d) The effect on eventual adult height is minimal in patients treated
with methylphenidate or dextroamphetamine
The Correct answer is D

Explanation
Stimulant medications do not precipitate seizures and can be given
safely to patients with a history of seizures. Substantial weight loss
may occur in up to 15% of patients, but eventual adult height and weight
are not affected. The number of side effects is similar for
methylphenidate and dextroamphetamine. No significant changes in pulse
or blood pressure occur either at rest or with exercise.

A one year old girl presents to the ER. Her mother has been treating her
with Tylenol, and although the child appears flushed and ill when the
fever is high, she is her usual self when the fever is down. Her mother
is concerned because the child has had a fever once before and it was an
ear infection that required antibiotics. The child has otherwise been a
healthy child and has received all her immunizations including MMR
vaccine one week ago.

On examination, her temperature is 40 degrees Celsius rectally. Her


tympanic membranes are normal. Her throat is mildly erythematous, with
no exudate. Her lungs are clear, respiratory rate is 30/min, and there
are no extra heart sounds. Abdomen is soft. She has a diaper rash.
What investigation would you probably not obtain in this case?

a) Lumbar puncture
b) Urinalysis and urine culture
c) CBC and differential
d) Blood cultures
The Correct answer is A

Explanation A lumbar puncture is not necessary in this child as she


does not have a presentation that is suspicious for meningitis.

Which one of the following measures is the most appropriate in the


initial management of neonatal seizures’

a) Phenobarbital
b) Pyridoxine hydrochloride
c) Diazepam
d) Magnesium sulfate
e) 20% glucose solution
The Correct answer is E

Explanation
Neonatal seizures are abnormal electrical discharges in the CNS of
neonates usually manifesting as stereotyped muscular activity or
autonomic changes. Diagnosis is confirmed by EEG; testing for causative
conditions is indicated.

The abnormal CNS electrical discharge may be caused by a primary


intracranial process (eg, meningitis, ischemic stroke, encephalitis,
intracranial hemorrhage, tumor) or may be secondary to a systemic
problem (eg, hypoxia-ischemia, hypoglycemia, hypocalcemia, hyponatremia).

Hypoglycemia is common among neonates whose mothers have diabetes, who


are small for gestational age, or who have hypoxia-ischemia or other
stresses. Seizures due to hypoglycemia tend to be focal and variable.
Prolonged or recurrent hypoglycemia may permanently affect the CNS.

For low plasma glucose, 10% dextrose 2 mL/kg IV is given, and plasma
glucose level is monitored; additional infusions are given as needed.

The mother of a 4 week old baby is concerned about a protrusion that


exists on the baby’s abdomen. You diagnose this as an umbilical hernia.
What is true about most umbilical hernias in children?

a) Need strapping
b) Resolve spontaneously
c) Require elective surgery
d) Require immediate surgery
e) Are associated with a higher incidence of inguinal hernias
The Correct answer is B
Explanation
Umbilical hernias rarely incarcerate. They can safely be managed with
observation and most will usually resolve spontaneously by the time the
child reaches 1-3 years of age. If an umbilical hernia persists beyond
then, surgical repair should be considered.

An 8 year old boy has had paroxysmal abdominal pain since his parents
separated 6 months ago. Which of the following symptoms would support an
organic basis for his disease?

a) Headaches accompanies the pain


b) Pain located in the periumbilical region
c) Pain awakens child at night
d) Symptoms last < 1 hour
The Correct answer is C

Explanation
Recurrent abdominal pain (RAP) is common in children especially in
pre-school children and adolescents. Recurrent abdominal pain is an
expression of physiological maladjustments in response to family or
school problems in predisposed children. Contrary to this belief, many
studies have found organic causes of RAP to be more common. The
occurrence of nocturnal pain is considered an important indicator of an
organic (disease-based). Night pain or pain on awakening suggests a
peptic origin, while pain that occurs in the evening or during dinner is
a feature of constipation.

Organic causes include (but are not limited to) gastrointestinal


disease, urinary tract infections, parasite infestation and
esophagitis/gastritis.

A 4-year-old male has a fever of 1 week’s duration. It has been at or


slightly above 38?C (101?F) and has responded poorly to antipyretics.
The patient complains of photophobia, burning in his eyes, and a sore
throat. His mother also notes that his eyes look red, his lips are red
and cracked, and he has a ‘strawberry tongue?. The child’s palms and
soles are erythematous and the periungal regions show desquamation of
the skin. He has minimally painful nodes located in the anterior
cervical region, about 2x2 cm in size. A Streptococcus screen is negative.

The most appropriate management at this time would be

a) Intramuscular benzathine penicillin G (Bicillin L-A), 600,000 U


b) Intravenous nafcillin (Nallpen)
c) Intravenous immune globulin and aspirin
d) Prednisone, 2-3 mg/kg daily
e) A fine-needle biopsy of the lymph nodes
The Correct answer is C
Explanation
Kawaski disease, or mucocutaneous lymph node syndrome, is a common form
of vasculitis in childhood. It is typically self-limited, with fever and
acute inflammation lasting 12 days on average without therapy. However,
if untreated, this illness can result in heart failure, coronary artery
aneurysm, myocardial infarction, arrhythmias, or occlusion of peripheral
arteries. It is most common in those under the age of 5 years. To
diagnose this disease, fever must be present for 5 days or more with no
other explanation. In addition, at least four of the following symptoms
must be present: 1) nonexudative conjunctivitis that spares the limbus;
2) changes in the oral membranes such as diffuse erythema, injected or
fissured lips, or ‘strawberry tongue?; 3) erythema of palms and soles,
and/or edema of the hands or feet followed by periungual desquamation;
4) cervical adenopathy in the anterior cervical triangle with at least
one node larger than 1.5 cm in diameter; and, 5) an erythematous
polymorphous rash, which may be targetoid or purpuric in 20% of cases.
The disease must be diagnosed from toxic shock syndrome, streptococcal
scarlet fever, Stevens-Johnson syndrome, juvenile rheumatoid arthritis,
measles, adenovirus infection, echovirus infection, and drug reactions.

Treatment significantly diminishes the risk of complications. Current


recommendations are to hospitalize the patient for treatment with
intravenous immune globulin. In addition, aspirin is used for both its
anti-inflammatory and antithrombolitic effects. While prednisone is used
to treat other forms of vasculitis, it is considered unsafe in Kawaski
disease, as a previous study showed an extraordinarily high rate of
coronary artery aneurysm with its use.

A 12 months old child who has had gastroenteritis is asymptomatic after


2 days of dietary management. A stool culture then is reported positive
for Salmonella group B. Which one of the following treatments is the
most appropriate?

a) Oral chloramphenicol
b) Dietary management only
c) Oral sulfamethoxazole/trimethoprim
d) Oral ampicillin
e) Oral cefaclor
The Correct answer is B

Explanation
Salmonella gastroenteritis is diagnosed by isolating the organism from
stool or another infected site. In bacteremic and focal forms, blood
cultures are positive, but stool cultures are generally negative. In
stool specimens stained with methylene blue, WBCs are often seen,
indicating inflammatory colitis.

Salmonella gastroenteritis is treated symptomatically with oral or IV


fluids.
For uncomplicated gastroenteritis caused by nontyphoidal Salmonella
species, antimicrobial therapy is not indicated because it does not
shorten the duration of illness and may prolong the duration of fecal
excretion.
Antimicrobial agents and hospital admission may be recommended in
Salmonella gastroenteritis in infants younger than 3 months, infants
younger than 12 months with temperatures of more than 39°C and unknown
blood culture results, and patients with hemoglobinopathies, human
immunodeficiency virus (HIV) infection or other causes of
immunosuppression, neoplasms, or chronic GI
illnesses. Trimethoprim-sulfamethoxazole (TMP-SMX) for children and
ciprofloxacin for adults.

A 5-year-old black male presents with behavior problems noted in the


first 3 months of kindergarten. The mother explains that the child does
not pay attention and often naps in class. He averages 10 hours of sleep
nightly and is heard snoring frequently. The boy’s examination is within
normal limits except for his being in the 25th percentile for weight and
have 3+ tonsillar enlargement.

The most reasonable plan at this point would include which one of the
following?

a) An electroencephalogram
b) Polysomnography
c) Atomoxetine
d) Methylphenidate (Ritalin)
The Correct answer is B

Explanation
Obstructive sleep apnea is increasingly recognized in children. The peak
incidence is in the preschool-age range of 2-5 years when adenotonsillar
tissue is greatest in relation to airway size. It is associated with
obesity in older children. Common clinical manifestations include
snoring with sleep interruptions and respiratory pauses. Polysomnography
is not the gold standard for the diagnosis.

Although the child has inattention, excessive drowsiness is not seen in


attention-deficit/hyperactivity disorder (ADHD) and medications for that
condition are not indicated. None of his symptoms suggests a seizure
disorder, so an EEG would not be helpful.

A 3-day-old infant born at 27 weeks gestation in the NICU suddenly


develops severe metabolic acidosis with abdominal distension. You
suspect necrotizing enterocolitis (NEC). Which of the following signs or
symptoms would you least likely see with necrotizing enterocolitis’

a) Ileus on abdominal x-ray


b) Temperature instability
c) Increased gastric aspirates (feeding residuals)
d) Oliguria
e) Non-bloody diarrhea
The Correct answer is E
Explanation
Absence of blood in the diarrheal stools should point you away from the
diagnosis of NEC. Trace guaiac positivity to grossly bloody stools may
be present with NEC.

A. A fixed position loop of bowel, ileus, on abdominal films is


consistent with NEC. Pneumatosis cystoids intestinalis is the radiologic
hallmark. Thickened bowel wall, gross perforation with free air, and
hepatic venous air may also be seen.
B. Temperature instability is a non-specific sign in neonates but is
frequently seen with NEC. It may also be seen with prematurity alone or
with sepsis.
C. Increased gastric aspirates are seen secondary to the development of
an ileus. When NEC is suspected, feeds should be discontinued immediately.
D. Oliguria may be seen in the presence of hypotension and decreased
renal perfusion.
A young couple bring their 30 month old infant son to their pediatrician
because he has not learned to speak, does not interact or play with
other children, does not display eye contact and repeatedly flaps his
hands. Physical examination is normal. Which one of the following is the
most likely diagnosis’

a) Oppositional defiant disorder


b) Attention deficit disorder - inattentive type
c) Down syndrome
d) Pervasive developmental delay (autism)
e) Deafness
The Correct answer is D

Explanation
Autism is a neurodevelopmental disorder characterized by impaired social
interaction and communication, repetitive and stereotyped patterns of
behavior, and uneven intellectual development often with mental
retardation.

Symptoms begin in early childhood. The cause in most children is


unknown, although evidence supports a genetic component; in some, autism
may be caused by a medical condition. Diagnosis is based on
developmental history and observation. Treatment consists of behavioral
management and sometimes drug therapy.

Erythema infectiosum (fifth disease) is caused by which one of the


following?

a) Mycoplasma
b) Parvovirus B19
c) Herpes simplex virus
d) Streptococcus
e) An unknown virus
The Correct answer is B
Explanation
Erythema infectiosum is characterized by a prodomal illness usually
consisting of malaise, pharyngitis, and low-grade fever, followed by the
appearance of a ‘slapped-cheek? rash. The cause of erythema infectiosum
has been identified as parvovirus B19.

A woman gives birth to a baby with cleft palate. You are going to send
her home after counseling. For what reason she is going to come to your
office more often?

a) Feeding problems
b) Recurrent otitis media
c) Teeth problems
d) Breathing problems
The Correct answer is A

Explanation
Cleft palate if untreated will lead to the baby having feeding problems,
speech pathologies and recurrent infections, but in the first months
feeding problem have greater importance. Surgical repair can be done at
6-9 months of age.

A 15-month-old male is brought to the pediatrician’s office because he


seems much smaller than his two older brothers were at that age. His
mother states that he has been generally healthy except for two episodes
of otitis media and an occasional ?cold?. He began walking at 11 1/2
months and can now say ?mama?, ?dada?, ?byebye?, and the names of his
brothers and dog. What is the most appropriate first step in evaluating
his size?

a) Perform a Denver Developmental Screening Test


b) Ask Mom to complete a 3-day food diary
c) Send blood for quantitative immunoglobulins
d) Plot his height and weight on the growth chart and compare to
previous chart
e) Obtain a sweat chloride test
The Correct answer is D

Explanation
To make the diagnosis of failure to thrive (FTT), it is important to
plot height and weight on standard growth curve and especially important
to compare these to previous values if they are known. FTT refers to
growth <3rd or 5th %ile on >1 occasion in a child <2 years old; a child
<2 years whose weight is <80% of the ideal weight for age; or a child <2
years whose weight crosses two major percentiles.

A. According to the history, this child is meeting his developmental


milestones appropriately.
B. This is an important component of an FTT workup, but FTT must be
established first.
C. The child’s previous illness are minor and would not result in growth
problems or warrant an immune workup.
E. Cystic fibrosis is one cause of FTT, but this is not the initial step.

A 6 year old girl is going to summer camp. Her parents come to your
office seeking advice as she had a severe reaction to a honey bee sting
2 years ago. Which one of the following recommendations should be given?

a) If stung, the child should be given an antihistamine then be observed


b) Self-administered epinephrine should be carried by the child at all
times
c) The child should eat indoors at all times
d) The child should wear insect repellent
The Correct answer is B

Explanation
Anaphylaxis is an acute, life-threatening, IgE-mediated allergic
reaction that occurs in previously sensitized people when they are
re-exposed to the sensitizing antigen. Symptoms include stridor,
dyspnea, wheezing, and hypotension. Diagnosis is clinical. Bronchospasm
and upper airway edema are treated with inhaled or injected ?-agonists
and sometimes endotracheal intubation. Hypotension requires IV fluids
and vasopressors.

Epinephrine is the cornerstone of treatment and should be given


immediately. It can be given SC or IM. An self injectable “epinephrine
pen” can be carried by patients with them at all times.