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Question Count: 263
Question #1
QID: 15399
Topic: Cystic Fibrosis
Subject: Pediatrics
The parents brought in their 10-month-old boy, who present with a history of excessive
straining when trying to have a bowel movement. On physical exam you clearly see he has
developed a rectal prolapse (see image below.)
What is your next step in management?
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.
Rectal prolapse should be viewed as a symptom of an underlying condition rather than a
discrete disease entity. Potential causes are increased intraabdominal pressure, diarrheal and
neoplastic diseases, malnutrition, and conditions predisposing to pelvic floor weakness. Its
strong association with cystic fibrosis makes the sweat test mandatory for infants and
children with recurrent rectal prolapse.
The treatment of rectal prolapse is mainly conservative and is directed at the underlying
conditions. Surgical intervention may be required for recurrent rectal prolapse refractory to
conservative measures.
Cystic Fibrosis
Question #2
QID: 16255
Topic: Cystic Fibrosis
Subject: Pediatrics
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. 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).
Cystic Fibrosis
Question #3
QID: 16654
Topic: Cystic Fibrosis
Subject: Pediatrics
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)
b)
c)
d)
e)
A serum angiotensin-converting enzyme level
A serum alpha-1-antitrypsin level
A serum ceruloplasmin level
An erythrocyte sedimentation rate
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.
Question #4
QID: 17415
Topic: Cystic Fibrosis
Subject: Pediatrics
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
placed 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.
Question #5
QID: 17804
Topic: Cystic Fibrosis
Subject: Pediatrics
A child’s sweat chloride test value is 65 mmol/L (normal < 60 mmol/L) on two occasions.
He will very likely suffer from:
a) Mild gastrointestinal inflammation
b) Profuse perspiration
c) Chest pain, dyspnea and Horner's
d) Severe lung disease, pancreatic insufficiency and infertility
e) Peripheral edema, eosinophilia, cardiomyopathy
The correct answer is d)
Explanation:
Cystic fibrosis (CF)
CF can affect a multitude of organ systems (GI, MSK, Endocrine, Cardiovascular,
Respiratory and GU). Its hallmark manifestations are poor growth, difficulty breathing &
lung infections (due to decreased mucociliary clearance and inflammation); infertility
(especially in males due to a congenital absence of the vas deferens) and gastrointestinal
malabsorption (due to insufficient pancreatic enzymes).
CF is caused by a mutation in the cystic fibrosis transmembrane conductance regulator gene
which codes for a membrane transport protein involved in controlling the movement of
halogens (such as chloride) in and out of cells.
Along with the sweat chloride test, investigations include: CXR, PFT’s and ABG’s.
Management of CF involves respiratory rehabilitation, bronchodilation, antibiotics,
mucolytics, and lung transplant.
Mild gastrointestinal inflammation (a) and profuse perspiration or hyperhidrosis (b) can
manifest from a number of etiologies. Chest pain, dyspnea and Horner’s syndrome (c) are
suggestive of a mediastinal mass. Peripheral edema, eosinophilia and cardiomyopathy (e)
are characteristic of Loeffler’s endocarditis.
PEARL: The hallmark systems affected by CF are the Respiratory, GI and
Reproductive systems.
Question #6
QID: 18074
Topic: Cystic Fibrosis
Subject: Pediatrics
An 8-month-old child was brought to the emergency department with cough, fever, and
breathlessness. Physical examination confirmed the diagnosis of pneumonia. The medical
record of the child showed that this child had four attacks of pneumonia in the last four
months. Given these and the family history, cystic fibrosis was suspected and sweat test was
requested and showed a slightly raised chloride. Conditions other than cystic fibrosis might
increase sweat chloride concentration and result in false positive results. One of these is:
a) Dehydration
b) Hypovolemia
c) Steroid therapy
d) High sweat rates
e) Congestive heart failure
The correct answer is d)
Explanation:
After the primary sweat secretion is produced in the body of the sweat gland, the ducts
reabsorb sodium and chloride. With high sweat flow rates, the ducts would have little time
to reabsorb large amounts of sodium and chloride resulting high levels of these ions in
collected sweat (Choice D).
→ Dehydration, by decreasing the effective renal blood flow, stimulates aldosterone
secretion. As in the renal tubules, aldosterone would stimulate reabsorption of sodium and
chloride by the ducts of sweat glands. A false negative, rather than false positive result is
expected with dehydration.
→ Hypovolemia has an effect similar to dehydration.
→ Steroids, even if they are of the glucocorticoid type like cortisol would some
mineralocorticoid activity. A false negative rather than false positive is expected.
→ The generalized edema of congestive heart is partly due to secondary aldosteronism. A
false negative is more likely than false positive.
Key point:
Although measurement of sweat chloride level is probably the most usefull test in diagnosis
of cystic fibrosis, false postive test result is possible. The collection process of sweat should
thus, be standardized and the hemodynamic stability of the patient optimized before sweat
collection.
Question #7
QID: 15400
Topic: Bell's Palsy
Subject: Pediatrics
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 says that it is 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's palsy, a postinfectious allergic or immune demyelinating facial
neuritis. Epstein Barr Virus (EBV) (choice A) 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 (choice B), HIV (choice C), and influenza (choice D) are not
associated with Bell's palsy. However, herpes simplex virus, Lyme disease caused by
Borrelia burgdorferi and mumps have been associated with Bell's palsy.
→ Measles (choice E) is associated with subacute sclerosing panencephalitis, a chronic
encephalitis of the central nervous system manifested by progressively bizarre behavior and
decline in cognitive function.
Question #8
QID: 15506
Topic: Hypothyroidism
Subject: Pediatrics
A child suffering from constipation, decreased activity and poor feeding is shown here. The
mother says that overall he is a "good baby" since he rarely cries and sleeps most of the
time. You notice a large protruding tongue.
What is the most likely diagnosis?
a) Hypothyroidism
b) Down syndrome
c) Trisomy 13
d) Trisomy 18
e) Hypopituitarism
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). Often, they are described as "good babies" because they rarely cry and sleep
most of the time.
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.
Question #9
QID: 16262
Topic: Hypothyroidism
Subject: Pediatrics
A 14-week-old infant is brought to the office for a visit. His mother states that 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
e) Kawasaki disease
The correct answer is b)
Explanation:
The signs and symptoms of congenital hypothyroidism may not be obvious for several
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.
Question #10
QID: 15431
Topic: Acute Iron Intoxication
Subject: Pediatrics
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
e) Tachycardia
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.
Question #11
QID: 15488
Topic: Epiglottitis
Subject: Pediatrics
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
e) Laryngoscopy
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.
Question #12
QID: 15565
Topic: Epiglottitis
Subject: Pediatrics
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.
Question #13
QID: 17365
Topic: Epiglottitis
Subject: Pediatrics
A child is brought to the emergency department. He has a temperature of 39.4°C and
respiratory distress. He is leaning forward and has a very anxious look. His voice is muffled,
and he is unable to swallow. X-ray 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:
Children with epiglottitis should be allowed to sit and lean forward to help their aiways
open (choice B is the correct answer). 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.
→ The first emergency department priority for a patient with epiglottitis is securing and
providing respiratory support before a definitive airway is obtained. Initially, humidified
oxygen (choice A) can be given by a nasal cannula or a nonrebreather mask, as required.
→ Reassurance and allowing the mother to hold the child (choice C) will decrease distress
while you arrange proper treatment.
→ This child should be evaluated in a controlled setting (i.e., in an operating room in the
presence of an anesthesiologist and/or otolaryngologist) (choice D) so that rapid airway
control may be achieved, if necessary.
→ Sudden pulmonary arrest (choice E) is a likely occurrence in children with epiglottitis
and should be anticipated.
Question #14
QID: 15516
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
Nonbilious projectile vomiting occurs in which of the following condition?
a) Pyloric stenosis
b) Hiatal hernia
c) Intussusception
d) Constipation
e) Annular pancreas
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.
Pyloric Stenosis
Question #15
QID: 15675
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
All of the following are present in pyloric stenosis, except:
a) Hypochloremic metabolic alkalosis
b) Non-bilious vomiting
c) Olive shaped mass in right upper quadrant
d) Sausage shaped mass in right lower quadrant
e) Visible gastric peristaltic waves
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. An enlarged pylorus (firm, movable mass), classically described as an "olive," can
be palpated in the right upper quadrant or epigastrium of the abdomen in 60-80% of infants.
The classic electrolyte pattern of an infant with pyloric stenosis is that of hypochloremic,
hypokalemic, metabolic alkalosis.
→ The hallmark physical findings in intussusception are a right hypochondrium sausageshaped mass and emptiness in the right lower quadrant (Dance sign).
Pyloric Stenosis
Question #16
QID: 15943
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
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. There's a small and firm
movable mass palpated deep in epigastrium. 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 (choice D) 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). Hypochloremic, hypokalemic metabolic alkalosis is
the classic electrolyte and acid-base imbalance of pyloric stenosis. Persistent emesis causes
progressive loss of fluids rich in hydrochloric acid, which causes the kidneys to retain
hydrogen ions in favor of potassium.
> Congenital adrenal hyperplasia-CAH (choice A) encompasses a group of autosomal
recessive disorders, each of which involves a deficiency of an enzyme involved in the
synthesis of cortisol, aldosterone, or both.Deficiency of 21-hydroxylase accounts for 90% of
all CAH. In 21-hydroxylase deficiency most severe form, it is a salt-wasting disease
characterized by ambiguous genitalia and aldosterone and cortisol levels are both reduced,
which leads to hyperkalemia.
> Cystic fibrosis (choice B) is a genetic disease with manifestations that could be noted in
the first 48 hours with delayed passage of meconium. The clinical picture of this child
suggests pyloric stenosis.
> Gastroenteritis (choice C) is commonly caused viruses in western countries and is
associated with osmotic and secretory diarrhea. This child has a firm movable mass palpated
deep in epigastrium, which is a characteristic physical finding in pyloric stenosis.
> Obstructive uropathy (choice E) impedes urine flow and causes distention of the urinary
tract proximal to the point of obstruction.Symptoms and signs of obstruction are often mild,
occurring over long periods of time and requiring a high index of suspicion for diagnosis.
Presentation varies with the location, duration, and degree of obstruction. This child's
clinical picture suggests an upper gastrointestinal pathology and the findings on physical
examination and initial laboratory studies are suggestive of pyloric stenosis.
Pyloric Stenosis
Question #17
QID: 16241
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
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.
Question #18
QID: 16750
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
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
hypochloremic metabolic alkalosis (choice A). The latter is a characteristic sign of pyloric
obstruction. As the child vomits chloride and hydrogen-rich gastric contents, hypochloremic
alkalosis sets in.
→ Pneumonia (choice B) 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 (choice C),
especially in the malnourished infant.
→ Currant jelly stool (choice D) is a common clinical manifestation of intussusception.
→ Mild jaundice with elevated indirect bilirubin (not direct, as stated in choice E) is seen in
about 5% of infants with pyloric stenosis, but is not a characteristic sign.
Question #19
QID: 16847
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
A 4-week-old full-term male is brought to your office by his parents. They report that their
child started vomiting just after his 1-week visit. The parents are concerned because they
think the vomiting is worsening, occurring after every feeding, and “shooting across the
room”. You note that the baby is afebrile, but has not gained any weight since birth.
Based on this information, the most likely diagnosis is:
a) Formula intolerance
b) Meningitis
c) Viral gastroenteritis
d) Pyloric stenosis
e) Inappropriate feeding
The correct answer is d)
Explanation:
Pyloric stenosis fits the described scenario; it is characterized by the early onset of
worsening projectile vomiting and poor weight gain, and occurs most often in full-term
male infants who are otherwise healthy. Formula intolerance causes regurgitation, as would
inappropriate feeding. Meningitis, whether viral or bacterial, would be associated with
fever. Viral gastroenteritis is a common cause of vomiting in older children, and is usually
associated with fever and diarrhea.
Question #20
QID: 17361
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
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.
Question #21
QID: 17787
Topic: Hypertrophic Pyloric Stenosis
Subject: Pediatrics
A 3-week-old baby boy has been having nonbilious vomiting after feeds. There is a palpable
mass at the margin of his right rectus abdominus muscle. Which of the following
presentation patterns and treatments best applies?
a) Respiratory distress; tracheoesophogeal repair
b) Air fluid levels and double-bubble on x-ray; small bowel surgery
c) Distended abdomen and shock; emergent small bowel surgery
d) Foreign body on x-ray; removal of object
e) Hypochloremic metabolic alkalosis; pylorotomy
The correct answer is e)
Explanation:
Pyloric stenosis
Diagnosing and managing the cause of vomiting in the newborn period requires a good
understanding of the signs and symptoms of the most common causes (tracheo-esophageal
fistulae, duodenal atresia, pyloric stenosis and intestinal malrotation).
a) Tracheoesophageal fistula: A history of vomiting, coughing, gagging and /or cyanosis on
feeding +/- recurrent pneumonia. X-ray will show abnormalities and an NG tube curled into
a pouch. Treatment is surgical (tracheoesophogeal repair).
b) Duodenal atresia: There is a higher incidence in premature births, or children with Down
syndrome. History of bilious vomiting (which may eventually lead to hypochloremic
metabolic alkalosis); air fluid levels and/or double-bubble on x-ray. Surgery is required.
c) Intestinal malrotation: recurrent vomiting (bilious intermittently), distended abdomen,
complications such as perforation and peritonitis can lead to shock. Surgical emergency.
d) Objects swallowed or choked on would not likely be palpable.
e) Pyloric stenosis: History of forceful non-bilous vomiting in a newborn; can be detected as
a palpable “olive” shaped abdominal mass, leads to a pattern of hypochloremic metabolic
alkalosis and requires pylorotomy.
PEARL: Pyloric stenosis is suggested by a history of non-bilious vomiting in a newborn and
an abdominal mass on exam.
Question #22
QID: 15966
Topic: Breast Mass
Subject: Pediatrics
A 11-year-old girl complains that one of her breasts is much larger and firmer than the other.
These differences were confirmed by examination with no papable mass. 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.
Question #23
QID: 15527
Topic: Cryptorchidism
Subject: Pediatrics
The most likely complication of an undescended testis is:
a) Inguinal hernia
b) Hydrocele
c) Malignancy
d) Torsion
e) Ischemic atrophy
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.
Question #24
QID: 17040
Topic: Cryptorchidism
Subject: Pediatrics
You are conducting a routine physical examination on a 4-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) Regular re-examination until 6-12 months
b) Order pelvic ultrasonography
c) Order serum testosterone, LH, FSH, and müllerian inhibiting substance levels
d) Hormonal therapy (hCG or LH)
e) Monitor the patient and refer only if the testicle does not descend by 2 years of age
The correct answer is a)
Explanation:
This patient most likely has an undescended right testicle (cryptorchidism), which needs to
be addressed as soon as possible, certainly before the child reaches 1 year of age. Testes that
have not descended by 12 months of age are unlikely to descend. Descent can preserve
spermatogenesis if performed by 1yr of age; untreated bilateral cryptorchidism: - 100%
infertility. The choice of initial treatment is a reflection of the preference of both physician
and the patient or the patient’s caretaker.
→ Pelvic ultrasonography (choice B), with or without the noted hormonal studies, is
appropriate only when testicles are bilaterally absent.
→ For unilateral undescended testis without hypospadias, no laboratory studies (choice C)
are needed.
→ Hormonal therapy (choice D) not proven to be of benefit over standard surgical treatment
Question #25
QID: 15552
Topic: Child Abuse
Subject: Pediatrics
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) Idiopathic thrombocytopenic purpura
d) Accidental burning
e) Scarlet fever
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.
Question #26
QID: 15553
Topic: Child Abuse
Subject: Pediatrics
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
e) Take no action
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.
Question #27
QID: 15667
Topic: Child Abuse
Subject: Pediatrics
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
e) Perpetrators of sexual abuse are usually female
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.
Perpetrators of sexual abuse are usually male, and often trusted adult acquaintances.
Question #28
QID: 17370
Topic: Child Abuse
Subject: Pediatrics
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.
Question #29
QID: 17432
Topic: Child Abuse
Subject: Pediatrics
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.
Question #30
QID: 17402
Topic: Aortic Stenosis
Subject: Pediatrics
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) Antibiotic prophylaxis prior to dental procedures is indicated in this patient
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.
Antibiotic prophylaxis is no longer indicated for the prevention of infective endocarditis in
patients with aortic stenosis.
Question #31
QID: 15580
Topic: Gastroenteritis
Subject: Pediatrics
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. Which of the following culprits
is the most likely causative agent of the patient's symptoms?
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.
Question #32
QID: 15933
Topic: Gastroenteritis
Subject: Pediatrics
A 12-month-old child who has had gastroenteritis is asymptomatic after two days of dietary
management. A stool culture then is reported positive for gram-negative Salmonella
typhimurium bacteria. 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.
Question #33
QID: 16238
Topic: Gastroenteritis
Subject: Pediatrics
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 commonly associated with respiratory symptoms
d) It is accompanied by low-grade fever
e) It is often associated with watery, heme-negative diarrhea
The correct answer is c)
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 bloodless 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. Rough
skin or diarrhea-induced diaper dermatitis may occur.
→ In normal hosts, infections rarely occur in another organ system, although extraintestinal
infections have been seen in immunocompromised hosts.
Question #34
QID: 17376
Topic: Gastroenteritis
Subject: Pediatrics
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.
Question #35
QID: 18010
Topic: Congenital Adrenal Hyperplasia
Subject: Pediatrics
A 21-year-old primigravida has just given birth. Examining her infant, you note that it has
what appears to be an enlarged protuberant clitoris along with partially fused, rugated, and
pigmented labia majora. No palpable gonads are noted.
Which of the following enzyme defects is the infant most likely to have?
a) 11 beta hydroxylase
b) 3 beta hydroxysteroid dehydrogenase
c) 17 beta hydroxysteroid dehydrogenase
d) 21 alpha hydroxylase
e) 17,20 desmolase
The correct answer is d)
Explanation:
21-hydroxylase (choice D) deficiency accounts for 95% of the cases of congenital adrenal
hyperplasia. It is also the most frequent endocrine cause of neonatal death. With severe
forms, salt wasting, shock, and significant virilization occur. The genes for this enzyme are
within the HLA complex on the short arm of chromosome 6w.
→ 11 beta hydroxylase (choice A) deficiency is one of the causes of congenital adrenal
hyperplasia, but it is much less common than 21 alpha hydroxylase deficiency.
→ 3 beta hydroxysteroid dehydrogenase (choice B) converts pregnenolone to progesterone
as well as 17 OH prenenolone to 17 OH progesterone, as well as DHEA to androstenedione.
→ 17 beta hydroxysteroid dehydrogenase (choice C) converts androstenedione to
testosterone and estrone to estradiol.
→ 17,20 desmolase (choice E) converts 17 OH pregnenolone to DHEA and 17 OH
progesterone to androstenedione.
Question #36
QID: 18159
Topic: Congenital Adrenal Hyperplasia
Subject: Pediatrics
A mother brings her 2-month-old infant to the emergency department because of profuse
vomiting and severe diarrhea. The infant is dehydrated, has a cardiac arrhythmia, appears to
have ambiguous genitalia, and is in distress.
This presentation suggests a diagnosis of:
a) Acute gastroenteritis
b) Hypertrophic pyloric stenosis
c) Congenital adrenal hyperplasia
d) Congenital intestinal malrotation
e) Turner's syndrome
The correct answer is c)
Explanation:
Congenital adrenal hyperplasia is a family of diseases caused by an inherited deficiency of
any of the enzymes necessary for the biosynthesis of cortisol. In patients with the salt-losing
variant, symptoms begin shortly after birth with failure to regain birth weight, progressive
weight loss, and dehydration.
Vomiting is prominent, and anorexia is also present. Disturbances in cardiac rate and rhythm
may occur, along with cyanosis and dyspnea. In the male, various degrees of hypospadias
may be seen, with or without a bifid scrotum or cryptorchidism.
Question #37
QID: 15616
Topic: Asthma
Subject: Pediatrics
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 one 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 (choice E). Which are a short-acting
Beta2-adrenergic receptor agonists used for the relief of bronchospasm.
→ Aerosolized ipratropium bromide by nebulization (choice A) Ipratropium is not first-line
therapy and is added to short acting beta-agonists in severe exacerbation. It is not given as
initial medication.
→ Aerosolized sodium cromoglycate by nebulization (choice B) would not very effective
in acute asthma exacerbation. Short acting beta agonists are always initial therapy in acute
asthma attacks.
→ Aerosolized budesonide (choice C) is used for maintenance and prophylactic treatment
of asthma, it is not appropriate for acute asthma attack cases. When 3 doses of short acting
beta agonists do not relieve the symptoms, oral prednisone or intraveneous
methylprednisolone can be given.
→ Subcutaneous epinephrine (choice D) has no proven advantage over aerosol therapy with
selective beta2-agents. It may, however, be considered in severe bronchoconstriction
precipitated by an allergen or in situations where aerosolized selective beta-2-agonists are
not available within reasonable time.
Question #38
QID: 15781
Topic: Asthma
Subject: Pediatrics
An 11-year-old boy presents with acute asthma exacerbation. His arterial blood gas in the
ED shows a normal pCO2 value. What does this finding suggest?
a) Mild asthma
b) Normal value
c) The patient may go into respiratory failure
d) Moderate asthma
e) The patient is stable
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.
Question #39
QID: 16564
Topic: Asthma
Subject: Pediatrics
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 cromolyn. 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.
Question #40
QID: 16766
Topic: Asthma
Subject: Pediatrics
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)
e) Treatment is not necessary at this time. Schedule followup for reevaluation
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.
Question #41
QID: 16906
Topic: Asthma
Subject: Pediatrics
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.
Question #42
QID: 17029
Topic: Asthma
Subject: Pediatrics
Metered-dose inhaler (MDI) and/or nebulizers can be used to administer short-acting
beta-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 β2 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.
Question #43
QID: 17153
Topic: Asthma
Subject: Pediatrics
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 beta-2-agonists
c) Intravenous theophylline is recommended as a second-line therapy in acute
asthma exacerbations
d) Ipratropium added to an inhaled beta-agonist lessens the need for hospitalization
The correct answer is d)
Explanation:
The addition of ipratropium to inhaled beta-2-agonists has been found to be more effective
in acute asthmatic attacks than beta-2-agonists alone. Sudden exacerbations of asthma are
common in children. Numerous treatments have been used in the past.
Beta-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.
Question #44
QID: 17160
Topic: Asthma
Subject: Pediatrics
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 beta-2-agonists when added to
inhaled corticosteroids for asthma
d) They are appropriate monotherapy for moderate persistent asthma
The correct answer is a)
Explanation:
In general, asthma is most effectively treated with inhaled corticosteroids (choice B).
Adding a leukotriene inhibitor may be effective, but is less effective than adding a longacting beta-2-agonist (choice C). Leukotriene inhibitors are also less effective than
intranasal corticosteroids for allergic rhinitis (choice A). Leukotriene inhibitors are
considered inappropriate monotherapy for moderate persistent asthma (choice D), 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.
Question #45
QID: 17383
Topic: Asthma
Subject: Pediatrics
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.
Question #46
QID: 17400
Topic: Asthma
Subject: Pediatrics
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. He complains of waking up almost every night 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) Intermittent
b) Mild persistent
c) Moderate persistent
d) Severe persistent
e) Severe intermittent
The correct answer is d)
Explanation:
This patient has continual daytime and frequent nighttime symptoms (almost every night)
despite good medical therapy. His PEF is < 60%, which classifies him as severe persistent
(choice E). He may benefit from addition of low dose daily or every other day oral steroids
to try and control his symptoms.
→ Intermittent (choice A) has daily symptoms < 2x/week and nighttime symptoms < 2x/
month. Their PEF is > 80%.
→ Mild persistent (choice B) has daytime symptoms > 2 days a /week and nighttime
symptoms 3-4x/month. Their PEF is > 80%.
→ Moderate persistent (choice C) has daily daytime symptoms with nighttime symptoms
occurring > 1 time/week. Their PEF is > 60% and < 80%.
→ Severe intermittent (choice E) is not part of the known asthma classification.
Question #47
QID: 17434
Topic: Asthma
Subject: Pediatrics
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)
b)
c)
d)
e)
2 fold risk compared to general population
≥ 4 fold risk compared to general population
Less than the general population
Equal to that of the general population
There is no clear association
The correct answer is b)
Explanation:
Asthma is the most common chronic illness of childhood. This child has a history of rash on
his cheek and lesions on the extensor surfaces of the upper and lower extremities, which are
suggestive of eczema/atopic/dermatitis. It is important to note that in infants extensor
surfaces are often affected while in older children and adults flexor surfaces are often
affected. Children with allergies and/or eczema are at an increased risk for developing
asthma compared to the general population. Studies have shown that children with atopic
eczema had a 4-fold risk of asthma and 5 fold risk of allergic asthma (choice B)
→ 2 fold risk compared to general population (choice A) is incorrect. While the risk of
developing asthma is certainly greater in children with eczema, the increased risk is higher
than 2 fold.
→ Less than the general population (choice C), equal to that of the general population
(choice D), there is no clear association (choice E) are all incorrect. Children with atopic
eczema have risk of developing asthma greater than the general population.
Question #48
QID: 17820
Topic: Asthma
Subject: Pediatrics
A 12-year-old white male asthmatic has an acute episode of wheezing. You diagnose an
acute asthma attack and prescribe an inhaled beta-adrenergic agonist. After 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 (Theo-Dur)
b) Oral corticosteroids
c) An oral beta-adrenergic agonist
d) Inhaled cromolyn (Intal)
e) Inhaled corticosteroids
The correct answer is b)
Explanation:
The treatment of choice for occasional acute symptoms of asthma is an inhaled beta-2adrenergic agonist such as albuterol, terbutaline, or pirbuterol. If symptoms do not respond
to beta-agonists, they 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 hyperreactivity, but has no bronchodilating activity and is
useful only for prophylaxis.
→ Inhaled corticosteroids should be used to suppress the symptoms of chronic persistent
asthma.
→ Oral beta-2-selective agonists are less effective and have a slower onset of action than
the same drugs given by inhalation.
Question #49
QID: 18129
Topic: Asthma
Subject: Pediatrics
A 14-year-old female with a history of asthma is having daytime symptoms about once a
week and symptoms that awaken her at night about once a month. Her asthma does not
interfere with normal activity, and her FEV1 is > 80% of predicted.
Which one of the following is the most appropriate treatment plan for this patient?
a)
b)
c)
d)
e)
A short-acting inhaled beta-agonist as needed
Low-dose inhaled corticosteroids daily
A leukotriene receptor antagonist daily
Medium-dose inhaled corticosteroids daily
Low-dose inhaled corticosteroids plus a long-acting inhaled beta-agonist daily
The correct answer is a)
Explanation:
Based on this patient’s reported frequency of asthma symptoms, she should be classified as
having intermittent asthma. The preferred first step in managing intermittent asthma is an
inhaled short-acting Beta-agonist as needed. Daily medication is reserved for patients with
persistent asthma (symptoms >2 days per week for mild, daily for moderate, and throughout
the day for severe) and is initiated in a stepwise approach, starting with a daily low-dose
inhaled corticosteroid or leukotriene receptor antagonist and then progressing to a mediumdose inhaled corticosteroid or low-dose inhaled corticosteroid plus a long-acting inhaled
beta-agonist.
Question #50
QID: 15623
Topic: Developmental Milestones
Subject: Pediatrics
Which of the following is not part of the normal developmental milestones for a 24-monthold child?
a) Builds tower of four blocks or more
b) Begins to run
c) Scribbles spontaneously
d) Begins to copy some capital letters
e) Walks backwards
The correct answer is d)
Explanation:
Choices A, B, C and E 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.
Question #51
QID: 16475
Topic: Developmental Milestones
Subject: Pediatrics
Children typically manifest anxiety toward strangers at what age?
a) 3 months
b) 6 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 (at ~ 6 months). Coincident
with the increased mobility gained by walking (usually at 12-15 months of age), these
anxieties normally abate.
Question #52
QID: 16770
Topic: Developmental Milestones
Subject: Pediatrics
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.
Question #53
QID: 17359
Topic: Developmental Milestones
Subject: Pediatrics
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 skills
b) Fine motor skills
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.
Question #54
QID: 17385
Topic: Developmental Milestones
Subject: Pediatrics
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.
Question #55
QID: 17405
Topic: Developmental Milestones
Subject: Pediatrics
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.
D. 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.
Question #56
QID: 17419
Topic: Developmental Milestones
Subject: Pediatrics
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 2word 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.
Question #57
QID: 17438
Topic: Developmental Milestones
Subject: Pediatrics
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 3word 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.
Question #58
QID: 17785
Topic: Developmental Milestones
Subject: Pediatrics
A mother is concerned that her 12 month old son is not developing normally. “My son
doesn’t walk on his own yet and he only speaks a few words”. At this stage of development,
the child should be able to:
a) Walk with support, throw objects, speak in single words
b)
c)
d)
e)
Walk without support, create a tower of 3 cubes, speak in 3 word phrases
Climb stairs with support, copy a square, speak in single words
Crawl, pincer grasp, babble
Walk with support, put on shoes, speak in 3 word phrases
The correct answer is a)
Explanation:
Developmental milestones
At 12 months, a child should be able to walk with support, pincer grasp, throw objects and
speak in single words.
6 months: tripod sit, object transfer from hand to hand, babble, stranger anxiety
2 years: 2 word sentences, understands 2 step commands, up/down steps
3 years: 3 word combos, 3 digit repeat, rides tricycle
4 years: Counts 4 objects, knows 4 colours, draws 4 sided object (square)
Developmental red flags:
• Not smiling at 3 months
• No peek-a-boo at 9 months
• Exhibits handedness < 10 months
• Not walking and < 3 words at 18 months
PEARL: Remember the 1 year “W.O.W.” (Walk, One Word)
Question #59
QID: 15648
Topic: Atypical Mycobacterial Lymphadenitis
Subject: Pediatrics
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.
Question #60
QID: 15663
Topic: Gastroesophageal Reflux
Subject: Pediatrics
A 5-week-old male infant presents with a history of vomiting and spitting up 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.
Question #61
QID: 16374
Topic: Gastroesophageal Reflux
Subject: Pediatrics
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) 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.
Question #62
QID: 16712
Topic: Gastroesophageal Reflux
Subject: Pediatrics
Which one of the following is true regarding gastroesophageal reflux (GER) in infants and
children?
a) It is important to perform a diagnostic evaluation prior to starting drug therapy even
when structural defect is not highly suspected
b) Failure to thrive is a common presentation of GER
c) All infants with GER have visible regurgitation
d) GER in infants usually resolves by one year of age without treatment
e) Esophageal reflux in infats should be quantified by monitoring esophageal pH
The correct answer is d)
Explanation:
Gastroesophageal reflux (GER) is a functional process occurring in a healthy infant. It is
common and self-limited, and represents a physiologic process of “spitting up”. GER occurs
in the absence of poor weight gain, irritability, cough, pain, or anemia. The majority of
infants with GER are thriving.
It is important to consider other systemic disorders, and rule them out when appropriate.
Possible causes of spitting up include pyloric stenosis, infections (e.g., gastrointestinal,
genitourinary), and metabolic disorders. It is not necessary to perform a diagnostic
evaluation prior to starting drug therapy unless a structural defect is highly suspected. GER
in infants is usually self-limited and resolves by 1 year of age. Esophageal reflux can be
quantified by monitoring esophageal pH (pH probe) or impedance (multichannel
intraluminal impedance). However, these studies rarely are useful in evaluating GER or
establishing the diagnosis of gastroesophageal reflux disease in infants.
Question #63
QID: 15670
Topic: Anaphylaxis
Subject: Pediatrics
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 two 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 β-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.
Question #64
QID: 15978
Topic: Anaphylaxis
Subject: Pediatrics
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) intramuscularly
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.
Question #65
QID: 17358
Topic: Anaphylaxis
Subject: Pediatrics
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.
Question #66
QID: 17779
Topic: Apgar Score
Subject: Pediatrics
You are asked to evaluate a newborn at 1 minute of life. The infant is pale, with slow,
irregular respirations and a heart rate of 80 bpm. 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.
→ An Apgar score of 2 (choice A) 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).
→ Infants with Apgar score of 6 (choice C) may need some stimulation and resuscitation
efforts.
→ Infants with Apgar score of 8 (choice D) are usually vigorous and require no significant
resuscitation efforts.
→ Infants with Apgar score of 10 (choice 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.
Question #67
QID: 15683
Topic: Coarctation of the Aorta
Subject: Pediatrics
A 3-year-old child has a blood pressure of 138/95 mmHg. 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) Patent ductus arteriosus
c) Atrial septal defect
d) Ventricular septal defect
e) Mitral stenosis
The correct answer is a)
Explanation:
Coarctation of the aorta is localized narrowing of the aortic lumen that results in upperextremity 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.
Question #68
QID: 15828
Topic: Coarctation of the Aorta
Subject: Pediatrics
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 leftaxis 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 upperextremity 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.
Question #69
QID: 15888
Topic: Coarctation of the Aorta
Subject: Pediatrics
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, best heard in the left interscapular area
b) Wide pulse pressure, and diastolic murmurs
c) Hepatomegaly
d) Dehydration, hypotension, tachycardia, hypoglycemia
e) S3 and rales on auscultation
The correct answer is a)
Explanation:
Coarctation of the aorta is localized narrowing of the aortic lumen that results in upperextremity 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. 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 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. Additional murmurs that result from the
presence of associated abnormalities, such as VSD or aortic valve stenosis, may also be
detected. An ejection click may be audible when an associated bicuspid aortic valve and a
murmur of aortic stenosis or insufficiency are present, whereas a gallop rhythm may
indicate ventricular dysfunction.
→ Wide pulse pressure, and diastolic murmurs are seen in aortic dissection
→ Patients with acute adrenal insufficiency (Addison disease) generally present with acute
dehydration, hypotension (especially orthostatic hypotension and tachycardia), symptomatic
hypoglycemia, or altered mental status.
→ Clinical presentation of viral myocarditis may include: presence of S3, and a heart
murmur caused by atrioventricular valve regurgitation; hepatomegaly; rales; jugular venous
distention and edema of the lower extremities.
Question #70
QID: 15684
Topic: G6PD Deficiency
Subject: Pediatrics
A 4-year-old black boy on trimethoprim/sulfamethoxazole for tonsillitis presents with
jaundice. Labs show anemia, and a reticulocyte count of 8%. What is the most likely
diagnosis?
a) Sickle cell anemia
b) Thalassemia
c) Spherocytosis
d) G6PD deficiency
e) Iron deficiency anemia
The correct answer is d)
Explanation:
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked enzymatic defect
common in blacks that can result in hemolysis after acute illnesses or intake of oxidant
drugs (including salicylates and sulfonamides). Diagnosis is based on assay for G6PD,
although tests are often falsely negative during acute hemolysis. Treatment is supportive.
Hemolysis occurs commonly after fever, acute viral and bacterial infections, and diabetic
acidosis. Hemolysis also occurs after exposure to drugs or to other substances that produce
peroxide and cause oxidation of Hb and RBC membranes. These drugs and substances
include primaquine, salicylates, sulfonamides, nitrofurans, phenacetin, naphthalene, some
vitamin K derivatives, dapsone, phenazopyridine and fava beans.
Question #71
QID: 17363
Topic: G6PD Deficiency
Subject: Pediatrics
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 62 g/L 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) Folate 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 90 and 100 g/L.
E. The mean corpuscular volume is abnormally large in folate deficiency.
Question #72
QID: 15686
Topic: Frostbite
Subject: Pediatrics
A 10-year-old boy who was out playing in the cold weather develops frost bite 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) Debridement
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.
Question #73
QID: 15702
Topic: Hereditary Angioedema
Subject: Pediatrics
A 7-year-old patient with family history of urticaria, presents for consultation. Further
investigation reveals C1 esterase inhibitor deficiency. What is the diagnosis?
a) Hives
b) Hereditary angioedema
c) Normal allergic response
d) Immunodeficiency
e) Drug eruption
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.
Question #74
QID: 15719
Topic: Choledochal Cyst
Subject: Pediatrics
A 3-year-old female patient presents with a painless mobile mass in her right upper quadrant
with mild jaundice and no fever. 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
e) Constipation
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.
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 physical examining the abdomen. Blood studies such as a serum amylase and
liver function tests may be drawn during acute episodes of pain.
Abdominal ultrasonography is the test of choice for the diagnosis of a choledochal
cyst. Abdominal CT scan and MRI help to delineate the anatomy of the lesion and the
surrounding structures. These tests also can assist in defining the presence and extent of
intrahepatic ductal involvement.
The treatment of choice for choledochal cysts is complete excision of the cyst with
construction of a biliary-enteric anastomosis to restore continuity with the gastrointestinal
tract.
Question #75
QID: 15738
Topic: Deafness
Subject: Pediatrics
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 speech development
e) Low Apgar scores
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.
Question #76
QID: 17357
Topic: Congenital Heart Disease
Subject: Pediatrics
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 50 g/L
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 ventricular septal defect
e) A 10-year-old boy with a congenital atrial septal defect
The correct answer is c)
Explanation:
Truncus arteriosus (choice C) 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.
→ Although tetralogy of Fallot (choice A) is usually also associated with cyanosis, there
must be at least 50 g/L of deoxygenated hemoglobin present in order for cyanosis to be
present. Therefore, in severely anemic states, cyanosis may not be present. Of note, cyanosis
cannot be detected by observation in patients with severe anemia (Hb < 50 g/L).
→ Coarctation of the aorta (choice B) is not typically a cyanotic lesion. Femoral pulses will
be weak or absent with upper extremity hypertension.
→ VSD (choice D) is the most common congenital heart disease. A severe lesion may result
in congestive heart failure but without cyanosis.
→ ASD (choice E) is not a cyanotic lesion, although high flow or secundum lesions may
require SBE prophylaxis.
Question #77
QID: 15765
Topic: Foreign Body Aspiration
Subject: Pediatrics
A 3-year-old boy comes to the ED 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) Arterial blood gas
e) Assessment of electrolyte levels
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.
Question #78
QID: 15873
Topic: Foreign Body Aspiration
Subject: Pediatrics
A 2-year-old child, who was previously well, presents with a sudden onset of brassy 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:
Children, especially those aged 1-3 years, are at risk for foreign body aspiration because of
their tendency to put everything in their mouths and because of the way they chew.
A foreign body in the trachea may result in a brassy cough, with or without loss of voice,
and bi-directional stridor (during inspiration and expiration). Complete airway obstruction
and asphyxia can result from a large object lodged in the trachea or larynx. Early signs of
respiratory failure include respiratory rate outside the normal range for the patient's age
(either too fast or too slow), tachycardia progressing to bradycardia, and initial increased
work of breathing, which can progress to decreased and inadequate work of breathing.
Cyanosis, stridor, and altered level of consciousness are ominous signs, and may predict
impending respiratory arrest.
Predictive signs of bronchial foreign body aspiration (FBA) include stridor, asphyxia, radioopaque object seen on chest x-ray, a history of foreign body aspiration associated with
unilaterally decreased breath sounds, localised wheezing, obstructive hyper-inflation, or
atelectasis.
FBA is a very serious, often life-threatening, condition. 3% of all unintentional deaths
among children (<15 years old) are secondary to the inhalation/ingestion of food or objects.
In fact, 5% of all FBA deaths occur in this age group. Of children younger than 15 years,
toddlers seem to be the most vulnerable for foreign body aspiration (77% of deaths).
Question #79
QID: 17410
Topic: Foreign Body Aspiration
Subject: Pediatrics
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.
Question #80
QID: 15772
Topic: Group B Streptococcal Septicemia
Subject: Pediatrics
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
e) Congestive heart failure
The correct answer is b)
Explanation:
Group B streptococcal (GBS) 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.
Premature rupture of membranes without other complications for more than 24 hours before
delivery is associated with a 1% increase in the incidence of neonatal sepsis. However,
when chorioamnionitis accompanies the rupture of membranes, the incidence of neonatal
infection is quadrupled.
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.
Question #81
QID: 15790
Topic: Herpangina
Subject: Pediatrics
A five-year-old child presents with fever, irritability, and sore throat. Physical exam shows
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
e) Hand-Foot-and-Mouth Disease
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.
Question #82
QID: 18089
Topic: Herpangina
Subject: Pediatrics
A 4-year-old white male is brought to your office because he has had a low-grade fever and
decreased oral intake over the past few days. On examination you note shallow oral
ulcerations confined to the posterior pharynx.
Which one of the following is the most likely diagnosis?
a) Herpangina
b) Herpes
c) Mononucleosis
d) Roseola infantum
e) Rubella
The correct answer is a)
Explanation:
Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and
subsequent ulcers develop in the posterior pharyngeal area. Herpes infection causes a
gingivostomatitis that involves the anterior mouth. Mononucleosis may be associated with
petechiae of the soft palate, but does not usually cause pharyngeal lesions. The exanthem in
roseola usually coincides with defervescence. Mucosal involvement is not noted. Rubella
may cause an enanthem of pinpoint petechiae involving the soft palate (Forschheimer
spots), but not the pharynx.
Question #83
QID: 15809
Topic: Hirschsprung's Disease
Subject: Pediatrics
An infant child develops abdominal obstruction. His history includes no passing of
meconium on the first day of life. You suspect Hirschsprung's disease. Which of the
following is considered the gold standard for diagnosis?
a) Barium enema
b) Colonic transit time with radio opaque markers
c) Abdominal radiograph
d) Rectal biopsy
e) Anorectal manometry
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.
Question #84
QID: 15993
Topic: Hirschsprung's Disease
Subject: Pediatrics
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.
Question #85
QID: 15815
Topic: Hemorrhagic Disease of the Newborn
Subject: Pediatrics
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
e) A prothrombin time is usually within normal limits
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. A prolonged PT is
usually the first laboratory test result to be abnormal in vitamin K deficiency bleeding.
If bleeding occurs, vitamin K is given. Blood transfusions may also be needed if bleeding is
severe.
Question #86
QID: 15817
Topic: Aspirin
Subject: Pediatrics
Which of following statements comparing the effects of aspirin and acetaminophen in
children is false?
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 its toxic effects, 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 and analgesic properties. Though acetaminophen is
used to treat inflammatory pain, it is not generally classified as an NSAID because it
exhibits only weak anti-inflammatory activity.
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.
Question #87
QID: 15830
Topic: Hyperkalemia
Subject: Pediatrics
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.
Hyperkalemia
Question #88
QID: 15839
Topic: Acute Otitis Externa
Subject: Pediatrics
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.
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.
Question #89
QID: 15840
Topic: Diet
Subject: Pediatrics
A mother brings her 2-year-old toddler saying "he refuses to 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 toddler's diet.
Question #90
QID: 16218
Topic: Diet
Subject: Pediatrics
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.
Question #91
QID: 15841
Topic: Abdominal Mass
Subject: Pediatrics
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.
Question #92
QID: 16247
Topic: Abdominal Mass
Subject: Pediatrics
The most likely diagnosis in a 3-year-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
*Common. †Rare.
Question #93
QID: 15886
Topic: Henoch-Schönlein Purpura
Subject: Pediatrics
A 10-year-old white male presents to the emergency department 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 selflimited. 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.
Question #94
QID: 16785
Topic: Henoch-Schönlein Purpura
Subject: Pediatrics
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 reveal the following:
Hemoglobin: 110 g/L
Hematocrit: 33%
WBCs: 14.5 x 10^9/L; 85% segs, 15% lymphs
Platelets: 345 x 10^9/L
Prothrombin time: 12 sec
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 (choice C) 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 twothirds 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 erythrocyte
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 (choice A) usually presents with an
evanescent salmon-pink rash.
→ Rocky Mountain spotted fever (choice B) does not present with arthritis and the rash
begins distally on the legs.
→ Iron ingestion (choice D) does not typically cause a rash, fever, or arthritis.
→ Disseminated anthrax (choice E) does not present with a rash or joint symptoms.
Question #95
QID: 17032
Topic: Henoch-Schönlein Purpura
Subject: Pediatrics
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.
Question #96
QID: 17194
Topic: Henoch-Schönlein Purpura
Subject: Pediatrics
The presence of nonthrombocytopenic palpable purpura, colicky abdominal pain, and
arthritis in a pediatric patient 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.
Question #97
QID: 18338
Topic: Henoch-Schönlein Purpura
Subject: Pediatrics
A 7-year-old boy is brought to your department by his parents because he had a reddish rash
of both legs and buttocks for the last 5 days. The boy also has been complaining of
abdominal pain and pain in both knees. He was recently evaluated for sore throat.
Physical examination reveals erythematous papules on both legs and buttocks, knee joints
are swollen and tender on palpation, and the abdomen is diffusely tender.
Which of the following is a key feature of this condition?
a) Rickettsia infection
b) Consumptive coagulopathy
c) Nonthrombocytopenic purpura
d) Thrombocytopenic purpura
e) Nonimmune hemolytic anemia
The correct answer is c)
Explanation:
This patient presents with Henoch-Schonlein purpura (HSP) triad of erythematous rash,
abdominal pain/renal failure, and arthralgias. While some patients with HSP may not have
all the 3 symptoms at presentation and others could have other symptoms, majority of
patients with this condition have been observed to have these 3 major symptoms. 75% of
affected patients are between 2 and 11 years of age. HSP is a clinical diagnosis and
generally laboratory evaluation is not necessary to establish this diagnosis. The key feature
of this disease is nonthrombocytopenic purpura (choice C).
→ Rickettsia infection (choice A) is a key feature of Rocky Mountain spotted fever, a
disease that should be in the differential of HSP. Patients affected with Rocky Mountain
spotted fever usually have an erythematous rash that can sometimes be confused with HSP,
but they do also have some clear exposure to ticks, vectors of Rickettsia rickettsii.
→ Consumptive coagulopathy (choice B) characterizes disseminated intravascular
coagulation, which results in abnormalities of most clotting indicators such as bleeding
time, prothrombin time, and partial thromboplastin time.
→ Thrombocytopenic purpura (choice D) can be idiopathic or thrombotic. HSP is a
nonthrombocytopenic vasculitis.
→ Nonimmune hemolytic anemia (choice E) characterizes hemolytic uremic syndrome,
another condition in the differential of HSP. It is often associated with E. coli O157:H7
infection and results in acute renal failure. Erythematous rash is not commonly seen.
Key point:
Erythematous macules, abdominal pain, and arthralgias in a child < 12 years old, is
suggestive of Henoch-Schonlein purpura. The key feature of this disease is
nonthrombocytopenic purpura.
Question #98
QID: 15851
Topic: Hypernatremia
Subject: Pediatrics
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.
Question #99
QID: 15866
Topic: Hypertension
Subject: Pediatrics
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 physician in a
‘white coat’.
As the notion of "normal" is subjective and changes from individual to individual, a
reference measurement is necessary. As night-time and self measured values are often not
subject to daily stress while clinical values are subject to unusual anxiety, daytime
ambulatory blood pressure is used as a reference because 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.
Question #100
QID: 17752
Topic: Hypertension
Subject: Pediatrics
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.
Question #101
QID: 15872
Topic: Delayed Hypersensitivity
Subject: Pediatrics
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.
Question #102
QID: 15887
Topic: Autism
Subject: Pediatrics
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.
Question #103
QID: 17047
Topic: Autism
Subject: Pediatrics
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.
Autism
Question #104
QID: 15913
Topic: Constitutional Growth Delay
Subject: Pediatrics
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.
Question #105
QID: 16235
Topic: Constitutional Growth Delay
Subject: Pediatrics
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.
Question #106
QID: 15915
Topic: Diarrhea, toddler's
Subject: Pediatrics
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.
Question #107
QID: 15979
Topic: Gasoline Poisoning
Subject: Pediatrics
A 2-year-old toddler is brought to the emergency department eight 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 e)
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 postingestion, 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 Xray is negative, as in this patient.
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. This child has no
respiratory distress and Chest X-ray did not show any abnormalities, therefore, he should be
discharged home (choice E).
→ Steroids (choice A) and Antibiotic prophylaxis (choice B) are of no proven benefit in
gasoline and other hydrocarbon poisoning.
→ Induce vomiting to empty the stomach (choice C) is incorrect. Gasoline is poorly
absorbed from the stomach and emesis should not be induced. Decontamination should
focus on removing any remaining hydrocarbon that might be on the clothes or skin, in the
correct clinical setting.
→ Admit to ward for observation (choice D) is unnecessary for a patient whose condition is
consiered stable in the emergency room.
Question #108
QID: 15999
Topic: Bronchiolitis
Subject: Pediatrics
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 considered principal
therapy?
a) Nebulized racemic epinephrine
b) Continuous intravenous perfusion of salbutamol
c) Oxygen therapy
d) Administer ventolin/ribavirin
e) Hydrate the infant intravenously
The correct answer is c)
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. Among numerous medications and
interventions used to treat bronchiolitis, thus far, only oxygen appreciably improves the
condition of young children. Therefore, therapy is directed toward symptomatic relief and
maintenance of hydration and oxygenation.
→ Nebulized racemic epinephrine (choice A) shows significant improvement in wheezing
and respiratory distress but does not reduce the need of oxygen therapy and is considered to
be as effective as nasal decongestants. It s not principal therapy for bronchiolitis
management in infants.
→ Bronchodilator therapy with salbutamol (choice B) to relax bronchial smooth muscle,
though common, is not supported as routine practice by convincing evidence.
→ The antiviral drug ribavirin (choice D) is incorrect. Although ribavirin has the potential
to reduce days of mechanical ventilation and hospitalization, the data are insufficient to
support its routine use to treat RSV infections, it is not recommended.
→ Intravenous hydration (choice E) is incorrect. Oral therapy is preferred. Parenteral
therapy may be necessary in patients who are unable to take fluids by mouth or who have a
respiratory rate higher than 70 breaths/min.
Key Point:
Oxygen therapy is the cornerstone of bronchiolitis management in infants.
Question #109
QID: 17241
Topic: Bronchiolitis
Subject: Pediatrics
An otherwise healthy 1-year-old boy 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%.
Which of the following should be included in this patient's management?
a) A trial of nebulized albuterol
b) Ribavirin
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. Although inhaled bronchodilators are not used routinely for
children with bronchiolitis, a one-time trial of albuterol (choice A) or epinephrine may be
warranted for infants and children with bronchiolitis and severe disease (eg, nasal flaring;
retractions; grunting; respiratory rate > 70 breaths per minute; dyspnea; or cyanosis) or
respiratory failure. For patients in whom such a trial is warranted, albuterol 0.15 mg/kg
(minimum 2.5 mg; maximum 5 mg) diluted in 2.5 to 3 mL normal (0.9%) saline and
administered over 5 to 15 minutes or four to six puffs via a metered dose inhaler with spacer
and face mask is suggested. If the child responds to a trial of albuterol, then treatment can
be continued; otherwise, evidence shows no benefit.
→ Ribavirin (choice B) should not routinely be used.
→ Oxygen (choice C) is indicated if the saturation is less than 90%.
→ Antibiotics (choice D) are indicated for signs of bacterial infection.
→ Corticosteroids (choice E) have not been shown to be of benefit.
Question #110
QID: 17834
Topic: Bronchiolitis
Subject: Pediatrics
A previously healthy 18-month-old male is brought to your office with a 2-day history of
cough and fever. On examination the child has a temperature of 38.3°C (100.9°F), a
respiratory rate of 30/min, and mild retractions and mild wheezes bilaterally. Oxygen
saturation is 90%.
The most appropriate initial management would be:
a) Azithromycin
b) A short course of corticosteroids
c) Aerosolized racemic epinephrine every 4 hours
d) Postural drainage
e) A single treatment with aerosolized albuterol, continued only if there is a positive
response
The correct answer is e)
Explanation:
For patients with bronchiolitis, evidence supports a trial of an inhaled bronchodilator,
albuterol, or epinephrine, with treatment continued only if the initial dose proves beneficial.
There is no evidence to support the use of antibiotics unless another associated infection is
present (e.g., otitis media). Neither corticosteroids nor postural drainage has been found to
be helpful.
Question #111
QID: 16003
Topic: Anorexia Nervosa
Subject: Pediatrics
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.
Question #112
QID: 17026
Topic: Anorexia Nervosa
Subject: Pediatrics
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.
Question #113
QID: 17869
Topic: Anorexia Nervosa
Subject: Pediatrics
A 14-year-old female is brought to your office by her parents because of concerns regarding
her low food intake, excessive exercise, and weight loss. Her weight is less than 75% of
ideal for her height.
Which one of the following sets of additional findings would indicate that the patient suffers
from severe anorexia nervosa?
a) Hypertension, tachycardia, and hyperthermia
b) Hypertension, tachycardia, and hypothermia
c) Hypotension, tachycardia, and hypothermia
d) Hypotension, bradycardia, and hyperthermia
e) Hypotension, bradycardia, and hypothermia
The correct answer is e)
Explanation:
Characteristic vital signs in patients with severe anorexia nervosa include hypotension,
bradycardia, and hypothermia. Criteria for hospital admission include a heart rate < 40
beats/min, blood pressure < 80/50 mm Hg, and temperature < 36°C (97°F). Increased
cardiac vagal hyperactivity is thought to cause the bradycardia.
Question #114
QID: 16009
Topic: Atlantoaxial Instability
Subject: Pediatrics
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.
Question #115
QID: 17046
Topic: Atlantoaxial Instability
Subject: Pediatrics
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.
Question #116
QID: 16017
Topic: Congestive Heart Failure
Subject: Pediatrics
A 5-year-old girl is a well known patient to you who suffers from congestive heart failure.
Today she comes in with leg edema. Your goal is to induce rapid therapeutic diuresis. Which
one of the following would be most effective medication?
a) Chlorothiazide
b) Furosemide
c) Digoxin
d) Aldosterone antagonist
e) Carvedilol
The correct answer is b)
Explanation:
There are several types of medications used to treat congestive heart failure in children.
Improvement in symptoms can be achieved by diuretics, digoxin, angiotensin-converting
enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). Diuretics decrease
preload by promoting natriuresis, and provide relief of volume overload symptoms such as
pulmonary and peripheral edema. Loop diuretics inhibit sodium and chloride reabsorption in
the thick ascending limb of the loop of Henle. Furosemide (choice B) is the most commonly
used loop diuretic.
→ Thiazide diuretics inhibit reabsorption of sodium and chloride ions from the distal
convoluted tubules of kidneys. They generally are used as second-line agents and often in
combination with a loop diuretic. Commonly used thiazide diuretics are chlorothiazide
(choice A), hydrochlorothiazide, and metolazone.
→ Although digoxin (choice C) is no longer used in children with asymptomatic ventricular
dysfunction, it continues to be used in the treatment of infants and children with stage C
heart failure because of its physiologic benefit and symptom relief. However, for this
patient, a loop diuretic would be the first choice in treatment.
→ Aldosterone antagonists (choice D) decrease sodium reabsorption and potassium
excretion in the collecting ducts of kidneys. Their potassium-sparing diuretic effect makes
them particularly suitable for use in conjunction with loop diuretics and thiazides. Both
spironolactone and eplerenone have been shown to reduce mortality in adults with heart
failure when added to standard therapy
→ Based on the current evidence in adult and pediatric patients, most pediatric heart failure
experts use carvedilol (choic E) in children with a systemic LV and systolic dysfunction in
stage C heart failure who are stable on other heart failure medications. Beta-blockers are
usually added to an established regimen of diuretics, digoxin, and an ACE inhibitor.
Question #117
QID: 16737
Topic: Congestive Heart Failure
Subject: Pediatrics
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.
Question #118
QID: 16020
Topic: Epistaxis
Subject: Pediatrics
Which one of the following is the most common etiology of recurrent epistaxis in children?
a)
b)
c)
d)
e)
Von Willebrand's disease
Inflammatory disorders (Wegener's granulomatosis)
Juvenile nasopharyngeal angiofibroma
Mucosal irritation (allergic rhinitis, infection)
Trauma (nose-picking, foreign body)
The correct answer is e)
Explanation:
Childhood epistaxis is common and rarely severe enough to require
hospitalization. Epistaxis that occurs in children younger than 10 years usually is mild and
originates in the anterior nose, whereas epistaxis that occurs in individuals older than 50
years is more likely to be severe and to originate posteriorly. Nosebleeds in children have a
variety of etiologies, ranging from self-limited mucosal irritation to life-threatening
neoplasms.
Local causes:
- Trauma: nose-picking (most common); foreign body; blunt or penetrating facial trauma;
child abuse, postoperative; nasotracheal intubation; nasogastric tube placement
- Mucosal irritation: dry air (most common); allergic rhinitis; inhaled irritants/drugs (inhaled
corticosteroids, tobacco, cocaine heroin, volatile inhalants of abuse); upper respiratory
infection or systemic infection with nasal congestion; localized skin or soft tissue infection
- Anatomic: septal deviation or unilateral choanal atresia causing asymmetric airflow
- Tumors: hemangioma, juvenile nasopharyngeal angiofibroma (particularly in adolescent
males), pyogenic granuloma, rhabdomyosarcoma, nasopharyngeal carcinoma, inverting
papilloma
Other: Increased nasal venous pressure secondary to paroxysmal coughing
Systemic causes:
- Bleeding disorders: inherited or acquired coagulation disorders, platelet disorders, blood
vessel disorders (eg, hereditary hemorrhagic telangiectasia)
- Medications: aspirin, ibuprofen, anticoagulants (including rodenticides), valproic acid
- Granulomatous disorders: granulomatosis with polyangiitis (Wegener's), sarcoidosis,
tuberculosis
- Hypertension: primary hypertension, secondary hypertension (renal disease,
corticosteroids), increased venous pressure (exertion, superior vena cava syndrome)
Recurrent epistaxis is usually related to the recurrent/chronic nasal trauma (choice E) or
irritation, but may be the presenting symptom of bleeding disorder, hereditary hemorrhagic
telangiectasia, nasopharyngeal carcinoma, posttraumatic pseudoaneurysm of internal carotid
artery.
Question #119
QID: 16022
Topic: Erythema Infectiosum
Subject: Pediatrics
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.
Erythema Infectiosum
Erythema Infectiosum
Question #120
QID: 17686
Topic: Hearing Loss
Subject: Pediatrics
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.
Question #121
QID: 16260
Topic: Diaphragmatic Hernia
Subject: Pediatrics
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.
Diaphragmatic Hernia
Diaphragmatic Hernia
Question #122
QID: 16713
Topic: Bacterial Infection
Subject: Pediatrics
What is the most frequent etiologic agent of occult bacteremia in children?
a) Haemophilus influenzae
b) Streptococcus pyogenes
c) Streptococcus pneumoniae
d) Neisseria meningitides
e) Staphylococcus aureus
The correct answer is c)
Explanation:
With widespread immunization against Haemophilus influenzae infection, Streptococcus
pneumoniae has become the predominant cause of serious bacterial infection in infants and
young children. In a study of about 9000 well-appearing older infants and young children,
149 (1.7%) had positive blood cultures, 92% of which were S. pneumoniae.
Question #123
QID: 16074
Topic: Diagnostic Investigations
Subject: Pediatrics
A 6-year-old boy is brought to the office by his mother because of the gradual onset of
abdominal pain. Today, on physical examination, the child does not appear to be in acute
distress. Abdominal examination shows normal bowel sounds, no tenderness, and is
otherwise inconclusive. Which of the following is the most appropriate next step?
a) Talk to the patient and mother separately
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 interviewed alone, and may verbalize any fears or
complaints more easily.
Question #124
QID: 16135
Topic: Diagnostic Investigations
Subject: Pediatrics
A 12-year-old girl, who has been undergoing treatment for chronic juvenile rheumatoid
arthritis for the past three 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 (choice B) 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 (choice A) 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 (choice C) would not be helpful, as we already
know that this patient has juvenile rheumatoid arthritis (JRA), and an ANA (choice D)
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.
Question #125
QID: 16213
Topic: Diagnostic Investigations
Subject: Pediatrics
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 (choice D). 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.
→ ABG (choice B) measurements should be obtained in patients with marked respiratory
distress or signs and symptoms of impending respiratory failure.
→ Chest x-ray (choice C) is not necessary for most exacerbations but should be obtained in
patients with symptoms suggestive of pneumonia or pneumothorax.
Question #126
QID: 16504
Topic: Diagnostic Investigations
Subject: Pediatrics
You perform a health maintenance examination on a 2-year-old white male. He is
asymptomatic and is meeting all developmental milestones. The only significant finding is a
grade 3/6 diastolic murmur heard at the right upper sternal border. Which one of the
following would be the most appropriate at this time?
a) No further evaluation
b) Referral to a pediatric cardiologist
c) Reevaluation in 6 months
d) Maintenance doses of digoxin
e) Pulse oximetry
The correct answer is b)
Explanation:
Children who have a murmur that is diastolic or is greater than 3/6 should be referred for
cardiovascular evaluation, perhaps after an echocardiogram is obtained. Other reasons for
referral include cardiac symptoms, abnormal splitting of S2, a murmur that increases on
standing, a holosytolic murmur, or ejection clicks. Digoxin is not indicated at this point in
this asymptomatic patient.
Question #127
QID: 17426
Topic: Diagnostic Investigations
Subject: Pediatrics
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 skull 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.
Question #128
QID: 17642
Topic: Diagnostic Investigations
Subject: Pediatrics
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.
Question #129
QID: 17865
Topic: Diagnostic Investigations
Subject: Pediatrics
A 3-year-old male is carried into the office by his mother. Yesterday evening he began
complaining of pain around his right hip. Today he has a temperature of 37.6°C (99.7°F),
cries when bearing weight on his right leg, and will not allow the leg to be moved in any
direction. A radiograph of the hip is normal.
Which one of the following would be most appropriate at this time?
a) A CBC and an erythrocyte sedimentation rate
b) A serum antinuclear antibody level
c) Ultrasonography of the hip
d) MRI of the hip
e) In-office aspiration of the hip
The correct answer is a)
Explanation:
This presentation is typical of either transient synovitis or septic arthritis of the hip. Because
the conditions have very different treatment regimens and outcomes, it is important to
differentiate the two. It is recommended that after plain films, the first studies to be
performed should be a CBC and an erythrocyte sedimentation rate (ESR). Studies have
shown that septic arthritis should be considered highly likely in a child who has a fever over
38.7 degrees C (101.7 degrees F), refuses to bear weight on the leg, has a WBC count 3 >
12^9/L, and has an ESR > 40 mm/hr. If several or all of these conditions exist, aspiration of
the hip guided by ultrasonography or fluoroscopy should be performed by an experienced
practitioner. MRI may be helpful in cases that are unclear based on standard data, or if other
etiologies need to be excluded.
Question #130
QID: 16038
Topic: Adverse Drug Effect
Subject: Pediatrics
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 the most likely 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).
Question #131
QID: 16245
Topic: Adverse Drug Effect
Subject: Pediatrics
A 5-year-old child is diagnosed with 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)
c)
d)
e)
Lymphadenopathy
Tinnitus
Edema
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.
Question #132
QID: 18076
Topic: Adverse Drug Effect
Subject: Pediatrics
A 5-year-old boy was rushed to the hospital because his mother strongly believes that he
ingested an unknown large number of Tylenol (acetaminophen) tablets an hour ago. The
child looked well but nauseated. The best action to take at this time is:
a) Draw blood for serum acetaminophen level
b) Emesis induction with ipecac
c) Hospital admission and alkaline diuresis initiation
d) Administration of activated charcoal and intermittent IV infusion of N-acetylcysteine
e) Administration of activated charcoal and oral N-acetylcysteine
The correct answer is e)
Explanation:
In addition to focusing on the ABCs, oral administration of activated charcoal is a useful
course of action for a subject with acetaminophen poisoning during the first two
hours. More important than GI decontamination is the early administration of Nacetylcysteine (NAC). NAC is nearly 100% hepatoprotective when it is given within 8
hours after an acute acetaminophen ingestion. Oral administration is the preferred route for
NAC therapy unless contraindications exist (e.g aspiration, persistent vomiting).
•
•
•
•
Serum for acetaminophen level should be drawn at least four hours after ingestion of
the drug.
Proof of the syrup of ipecac's efficacy, however, in reducing the risk of poisoning is
limited.
Alkaline diuresis enhances elimination of drugs that are weak acids and that are
normally eliminated through the kidney like salicylates and phenobarbital. On the
other hand, the first step in elimination of acetaminophen is conjugation in the liver.
Intermittent IV NAC infusion may be considered for late-presenting or chronic
ingestion.
When faced with a patient with drug poisoning, the course of action is dictated by the
pharmacokinetics and pharmacodynamics of the drug ingested.
Question #133
QID: 16039
Topic: Gynecomastia
Subject: Pediatrics
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) 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 50 years
c) Spironolactone, cimetidine, and ketoconazole have been associated with gynecomastia
d) Gynecomastia results from an increased estrogen to testosterone ratio
e) Mammography or ultrasonography is not routinely done unless the mass is unilateral,
nontender, and/or fixed.
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. It may be
unilateral or bilateral and is diagnosed on exam as a palpable rubbery or firm mass of tissue
at least 0.5 cm in diameter (usually underlying the nipple). Physiologic gynecomastia,
which resolves spontaneously in most cases, has a trimodal distribution, occurring in
neonatal, pubertal, and older males (choice B).
There are many drugs that have been associated with gynecomastia. Drugs with the best
evidence for an association with gynecomastia include spironolactone, cimetidine,
ketoconazole, recombinant human growth hormone, estrogens, human chorionic
gonadotropin (hCG), anti-androgens, gonadotropin-releasing hormone (GnRH) agonists,
and 5-alpha-reductase inhibitors. (choice C).
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 (choice D) 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.
The diagnosis of gynecomastia is made on physical examination. Imaging is not routinely
recommended unless there is concern for possible breast cancer: unilateral, nontender, and/
or fixed masses found eccentric to the nipple-areolar complex (choice E). Mammography is
the most sensitive imaging modality for detecting malignancy, while ultrasonography is the
most specific.
This patient does not show any warning signs and biopsy is not indicated (choice A).
Question #134
QID: 16438
Topic: Gynecomastia
Subject: Pediatrics
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.
Question #135
QID: 16042
Topic: Exercise-induced Proteinuria
Subject: Pediatrics
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 0.41 g 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
e) Radiography
The correct answer is b)
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.
In an athlete with proteinuria, urinalysis should he repeated after a period of 48 to 72 hours
free from exercise.
Question #136
QID: 16044
Topic: Febrile Illness
Subject: Pediatrics
A concerned father calls your office because his three-week-old son has a fever of 39.5
degrees Celsius (103.1°F) measured axillary. 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).
Question #137
QID: 17667
Topic: Febrile Illness
Subject: Pediatrics
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 8500/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
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
e) Hospital admission and adequate antibiotic treatment and fluid resuscitation
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.
For the management of febrile infants, the most commonly used criteria in practice are the
Rochester criteria. Clinical assessment involves deciding whether a child appears toxic. The
clinical features that define toxicity include irritability, lethargy, and decreased social
interaction.
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 (choice B). Occasionally it may be important 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. For example, if a child has diarrhea, stool studies are usually done.
→ Home care and parental observation only, as long as the temperature remains under
39.0°C (choice A) is incorrect.
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. 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.
→ Oral antibiotics and reevaluation in 24 hours (choice C) is incorrect. This child is
considered low risk, therefore, lumbar puncture or empiric antibiotic therapy are not
recommended. For children whose condition warrants antibiotherapy and re-evaluation in
24 hours, lumbar puncture should be done before antibiotics to avoid affecting sensitivity
studies.
→ A complete sepsis workup, including blood cultures, stool studies, a chest radiograph,
and cerebrospinal fluid studies (choice D) should be done for any infant younger than 29
days, and any infant or child with a toxic appearance regardless of age. They 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.
→ Hospital admission and adequate antibiotic treatment and fluid resuscitation (choice E)
are not recommended in this non-toxic child with initial studies showing no abnormality.
Question #138
QID: 16211
Topic: Dehydration
Subject: Pediatrics
A 12-month-old girl is brought to the emergency department for the second time in two 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.
Question #139
QID: 16258
Topic: Dehydration
Subject: Pediatrics
A 1-year-old child with a rapid pulse, lethargy, oliguria, loss of skin turgor 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.
Question #140
QID: 17421
Topic: Dehydration
Subject: Pediatrics
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 mmol/L. All of the following about hypernatremic dehydration are true, except:
a)
b)
c)
d)
e)
Subdural hematomas may occur as a result of hypernatremia
Hypernatremia may be caused when improperly mixed formulas are used
Normal saline boluses should be given until the infant is stable
Fluid should be given to rapidly reduce the serum Na in less than 24 hours
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 (choice D), due to the risk of cerebral edema and seizures.
→ Subdural hematomas (choice A) may occur due to intracellular fluid loss.
→ Hypernatremia (choice B) may be seen with improperly mixed formulas.
→ 20cc/kg normal saline or lactated ringers fluid boluses (choice C) should be given until
the infant is clinically stable.
→ Hypernatremia (choice E) is seen in 10-15% of patients.
Question #141
QID: 17436
Topic: Dehydration
Subject: Pediatrics
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.
Question #142
QID: 16057
Topic: Hypercholesterolemia
Subject: Pediatrics
A one-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 6.7 mmol/L and her LDL-cholesterol
concentration was 3.37 mmol/L. 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.
Question #143
QID: 17039
Topic: Acne
Subject: Pediatrics
Which one of the following topical agents used in the treatment of acne vulgaris is
principally an antibacterial agent?
a) Tretinoin
b)
c)
d)
e)
Adapalene
Benzoyl peroxide
Tazarotene
Salicyclic acid
The correct answer is c)
Explanation:
Tretinoin, adapalene, and tazarotene are all retinoids and are primarily comedolytic and anticomedogenic 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.
Question #144
QID: 17594
Topic: Acne
Subject: Pediatrics
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) 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.
Question #145
QID: 18068
Topic: Acne
Subject: Pediatrics
A 15-year-old boy visits his pediatrician with a chief complaint of chronic acne of moderate
stage. He denies any allergies and currently takes no oral medications. He denies using any
scented soaps, eats healthy meals and exercises regularly.
He has tried topical benzoyl peroxide with no results. What is the next step in treating his
acne?
a) Benzamycin topical
b) Benzaclin topical
c) Minocycline oral
d) Cephalexin oral
e) Accutane oral
The correct answer is c)
Explanation:
Moderate acne not responsive to basic topical treatments like benzoyl peroxide should be
treated with oral antibiotics such as minocycline.
A) and B) Benzamycin and Benzaclin are topical and his acne needs oral medication since
his acne has been categorized by a physician as being in the moderate state.
D) Cephalexin is more specific for skin infections such as dermatitis and cellulitis, and less
specific for acne.
E) Accutane is reserved for severe cases of acne that are unresponsive to oral antibiotics.
Female patients will also have to use birth control when taking Accutane.
Treatment of acne
Mild Acne: Topical medications like Benzamycin or Benzaclin
Moderate Acne: Oral antibiotics like Minocycline
Severe Acne: Accutane
Question #146
QID: 16104
Topic: Glomerulonephritis
Subject: Pediatrics
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.
Question #147
QID: 16909
Topic: Glomerulonephritis
Subject: Pediatrics
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.
Question #148
QID: 16154
Topic: Down Syndrome
Subject: Pediatrics
An 8-month-old infant with trisomy 21 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.
Question #149
QID: 16174
Topic: Central Venous Line
Subject: Pediatrics
A diabetic and obese 11-year-old boy 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. The left femoral vein gets
catheterized percutaneously because of the difficulty in obtaining satisfactory peripheral
venous access. Six hours later, his mental status is improved, blood pressure is 120/70 mm
Hg and serum glucose concentration is 13.9 mmol/L. At that time, physical examination
discloses a cold left foot with diminished pulses compared with those of the right foot. The
most likely explanation for this finding 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.
Question #150
QID: 16184
Topic: Diabetes Mellitus
Subject: Pediatrics
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 mmol/L
K+ 4.1 mmol/L
Cl 92 mmol/L
HCO3 6.6 mmol/L
Glucose 45 mmol/L
The boy is treated with intravenous insulin and isotonic saline solution. Several hours later,
he is improved and his serum glucose concentration is 25 mmol/L. 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
e) Watchful waiting
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.
Question #151
QID: 17236
Topic: Diabetes Mellitus
Subject: Pediatrics
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:
The Canadian Diabetes Association recommends that 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.
Question #152
QID: 17364
Topic: Diabetes Mellitus
Subject: Pediatrics
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 dependent 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.
Question #153
QID: 17375
Topic: Diabetes Mellitus
Subject: Pediatrics
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.
Question #154
QID: 17815
Topic: Diabetes Mellitus
Subject: Pediatrics
Which one of the following injection sites for insulin administration is best for preventing
hypoglycemia in a 14-year-old male with diabetes mellitus who wishes to participate in
track and field running events?
a) Arm
b) Abdomen
c) Hip
d) Calf
e) Thigh
The correct answer is b)
Explanation:
The use of a nonexercised injection site for insulin administration, such as the abdomen
(choice B), may reduce the risk of exercise-induced hypoglycemia.
If the leg is used as an injection site, exercise may accelerate insulin absorption, resulting in
increased levels of plasma insulin. However, leg exercise has no effect on insulin
disappearance from the arm and may actually reduce the rate of insulin disappearance from
abdominal injection sites. Compared with leg injection, arm or abdominal injection reduces
the hypoglycemic effect of exercise by approximately 60% and 90%, respectively.
Question #155
QID: 17877
Topic: Diabetes Mellitus
Subject: Pediatrics
An overweight 11-year-old male with acanthosis nigricans is found to have a fasting plasma
glucose level of 9.8 mmol/L on two occasions. Over the next 6 months, despite reasonable
adherence to a diet and exercise regimen, he has preprandial and bedtime finger-stick blood
glucose levels that average 10 mmol/L. His hemoglobin A1C is 9.0%.
Which one of the following oral agents would be most appropriate at this time?
a) Metformin
b) Glyburide
c) Sitagliptin
d) Pioglitazone
e) Acarbose
The correct answer is a)
Explanation:
Metformin and insulin are the only agents approved for treatment of type 2 diabetes mellitus
in children.
Question #156
QID: 17044
Topic: Cause of Death
Subject: Pediatrics
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.
Question #157
QID: 16719
Topic: Celiac Disease
Subject: Pediatrics
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.
Question #158
QID: 17569
Topic: Celiac Disease
Subject: Pediatrics
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 µg/L. 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).
Question #159
QID: 17570
Topic: Celiac Disease
Subject: Pediatrics
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 µg/L. 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.
Question #160
QID: 16746
Topic: Failure to Thrive
Subject: Pediatrics
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). Your 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) Abnormal liver function tests
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.
Question #161
QID: 17369
Topic: Failure to Thrive
Subject: Pediatrics
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.
Question #162
QID: 17422
Topic: Failure to Thrive
Subject: Pediatrics
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 11.5 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 the mother 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 (choice D) 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.
→ According to the history, this child is meeting his developmental milestones
appropriately (choice A).
→ A 3-day food diary (choice B) is an important component of an FTT workup, but FTT
must be established first.
→ The child’s previous illness are minor and would not result in growth problems or
warrant an immune workup (choice C).
→ Cystic fibrosis (choice E) is one cause of FTT, but this is not the initial step.
Question #163
QID: 16256
Topic: Abdominal Pain
Subject: Pediatrics
Organic causes in the differential diagnosis of recurrent abdominal pain in children include:
a) UTI
b)
c)
d)
e)
Lactose intolerance
Chronic giardiasis
Inflammatory bowel disease
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 (diseasebased). 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.
Question #164
QID: 17391
Topic: Abdominal Pain
Subject: Pediatrics
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.
Question #165
QID: 18071
Topic: Abdominal Pain
Subject: Pediatrics
A 15-year-old female presents with sudden onset of mild left lower quadrant pain. She
denies any history of trauma or fever or sexual activity. There is no loss of appetite and no
change in bowel habit. She is in the middle of her menstrual cycle. Physical exam is
unremarkable. What is the most likely diagnosis?
a) Appendicitis
b) Ectopic pregnancy
c) Ovarian torsion
d) Mittelschmerz
e) Pelvic Inflammatory Disease (PID)
The correct answer is d)
Explanation:
Given this patient history and presentation the most likely cause of her abdominal pain is
Mittelschmerz or midcycle pain. One-sided pain that is lasting minutes to a few hours which
is usually sharp, cramping and distinctive that may switch sides from month to month or
from one episode to another and begins midway through the menstrual cycle suggests
mittelschmerz.
→ Patients with appendicitis classically present with visceral, vague, poorly localized,
periumbilical pain. Within 6 to 48 hours, the pain becomes parietal as the overlying
peritoneum becomes inflamed; the pain then becomes well localized and constant in the
right iliac fossa. Note: bilateral pelvic pain suggests PID, but nausea and vomiting and pain
migration from periumbilical area to right lower quadrant of abdomen suggests appendicitis.
→ Use of an IUD and a history of PID or tubal ligation increase the risk of ectopic
pregnancy. If a postmenarcheal girl presents with abnormal vaginal bleeding and adnexal
mass and hypotension, ectopic pregnancy should be suspected but this patient's physical
exam is unremarkable.
→ A patient who develops sudden onset of severe, intermittent, and unilateral pain
associated with nausea and vomiting may have ovarian torsion.
→ PID is unlikely to be diagnosed in this patient due to lack of risk factors for PID such as
multiple sexual partners, multiple sexual partners, a history of prior STIs, a history of sexual
abuse, and IUD use.
Question #166
QID: 16227
Topic: Diarrhea
Subject: Pediatrics
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
e) Allergic gastroenteropathy
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.
Question #167
QID: 18055
Topic: Diarrhea
Subject: Pediatrics
An outbreak of pediatric diarrhea has swept your community. You evaluate a 20-month-old
male who developed diarrhea yesterday. He is still breastfed. He is alert, his mucous
membranes are moist, and his skin turgor is good. He passes a liquid stool in your office.
Which one of the following would be the best advice with regard to his diet?
a) The mother should withhold breastfeeding
b) He should consume a normal age-appropriate diet, and continue breastfeeding
c) Fasting will promote intestinal mucosal recovery
d) Oral intake should be limited to clear fluids, bananas, rice, applesauce, and toast
The correct answer is b)
Explanation:
Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be
given. Breastfeeding or regular formula should be continued.
Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean
meats, yogurt, fruits, and vegetables are well tolerated. Foods high in simple sugars (e.g.,
juices, carbonated sodas) should be avoided because the osmotic load can worsen the
diarrhea. Fatty foods should be avoided as well. The BRAT diet has not been shown to be
effective.
Question #168
QID: 16229
Topic: Growing Pains
Subject: Pediatrics
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 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.
Question #169
QID: 17170
Topic: Growing Pains
Subject: Pediatrics
A 6-year-old female is brought to your office for recurring limb pain. For the past two 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) Erythrocyte sedimentation rate
c) Complete Blood Count
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.
Question #170
QID: 17940
Topic: Growing Pains
Subject: Pediatrics
During a preparticipation examination of a 5-year-old male for summer soccer camp, his
mother states that he frequently awakens during the night with complaints of cramping pain
in both legs, and that he seems to experience this after a day of heavy physical activity. She
says that he appears to drag his legs at times, but she has never noticed a definite limp. A
physical examination of the hips, knees, ankles, and leg musculature is entirely normal.
Which one of the following would be the most appropriate next step in the evaluation and
management of this patient?
a) Plain films of both hips and knees
b) Serum electrolyte levels
c) Recommending that he not participate in running sports
d) Reassurance, with no activity restrictions or treatment
e) Referral to a pediatric orthopedist
The correct answer is d)
Explanation:
Benign nocturnal limb pains of childhood (growing pains) occur in as many as one-third of
children, most often between 4 and 6 years of age. The etiology is unknown, but the course
does not parallel pubescent growth, as would be expected if bone growth was the source of
pain. The pain often awakens the child within hours of falling asleep following an active
day. The pain is generally localized around the knees, most often in the shins and calves, but
also may affect the thighs and the upper extremities. A characteristic history coupled with a
normal physical examination will confirm the diagnosis. Reassurance that no additional tests
or treatments are necessary and that the condition is self-limiting is the most appropriate
response.
Question #171
QID: 16233
Topic: Cat-scratch Disease
Subject: Pediatrics
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)
c)
d)
e)
Sarcoptes scabiei
Chlamydia psittaci
Bartonella henselae
Toxoplasma gondii
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.
Question #172
QID: 16237
Topic: Apnea in Infants
Subject: Pediatrics
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.
Question #173
QID: 17028
Topic: Apnea in Infants
Subject: Pediatrics
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) Order detailed laboratory work-up
b) The infant should be started on 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 lifethreatening events such as this. It is generally advised, however, that for a short, selfcorrecting episode associated with feeding, hospital admission is not always necessary.
Otherwise, the child should be admitted for observation and evaluation.
→ If the infant is truly afebrile and appears well, laboratory results are likely to be within
the reference ranges.
→ Many groups recommend home apnea monitoring after discharge for those with more
severe or undiagnosed cases.
→ 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.
Question #174
QID: 17371
Topic: Apnea in Infants
Subject: Pediatrics
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.
Question #175
QID: 16240
Topic: Gene Transmission
Subject: Pediatrics
Which of the following genetic diseases is incorrectly linked with its transmission pattern?
a)
b)
c)
d)
e)
Duchenne muscular dystrophy - X-linked recessive
Achondroplasia - autosomal dominant
Cystic fibrosis - autosomal recessive
Hemophilia - X-linked dominant
Neurofibromatosis type 1 - autosomal 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.
Question #176
QID: 16248
Topic: Genu Varum
Subject: Pediatrics
Which of the following congenital anomalies usually resolves spontaneously?
a) Clubfoot
b) Genu varus
c) Developmental dysplasia of the hip
d) Rigid flat feet
e) Cleft lip
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.
→ Clubfoot is treated with manipulation, serial casting or surgery if it doesn't respond to
nonsurgical treatments
→ Developmental dysplasia of the hip must be treated, to prevent the development of
degenerative arthritis of the hip (Pavlik harness or surgery).
→ Cleft lip (cheiloschisis) is a failure of fusion of maxillary and medial nasal processes.
The repair of a cleft lip requires surgery.
→ Rigid flatfeet are uncommon and may be due to abnormal connections between the bones
in the foot. Symptoms (pain) can often be relieved using orthotics as the first line of
treatment. Occasionally, surgery may be needed to relieve pain symptoms.
Question #177
QID: 16251
Topic: Guillain-Barré Syndrome
Subject: Pediatrics
A 5-year-old girl presents to the ED 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
e) Multiple sclerosis
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.
Guillain-Barré syndrome
Question #178
QID: 16254
Topic: DiGeorge Syndrome
Subject: Pediatrics
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 1.1 mmol/L. 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.
Question #179
QID: 16259
Topic: Duodenal Atresia
Subject: Pediatrics
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.
Duodenal Atresia
Question #180
QID: 16261
Topic: Botulism
Subject: Pediatrics
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.
Botulism
Question #181
QID: 16622
Topic: Botulism
Subject: Pediatrics
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.
Botulism
Question #182
QID: 16303
Topic: Chemical Burn
Subject: Pediatrics
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.
Question #183
QID: 16348
Topic: Guttate Psoriasis
Subject: Pediatrics
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 5-10 mm 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 a distinctive,
acute eruption of small, droplike, 1-10 mm in diameter, salmon-pink papules, usually with a
fine scale on the trunk and proximal extremities. The onset frequently follows a
streptococcal respiratory infection.
→ Scarlet fever (choice A) usually accompanies streptococcal paryngitis and the rash is red,
punctate, and often felt more readily than seen.
→ Atopic dermatitis (choice C) is characterized by chronic dry skin which is pruitic.
→ Scabies (choice D) is not related to streptococcal infection and is a papular, itchy rash
seen on the finger webs, axillae, belt line, and genital areas.
→ Erythema marginatum (choice E) is a manifestation of rheumatic fever and is a
nonspecific macular lesion of the trunk with central blanching that appears serpiginous.
Psoriasis
Question #184
QID: 16384
Topic: Haemophilus Influenzae
Subject: Pediatrics
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.
Question #185
QID: 17035
Topic: Haemophilus Influenzae
Subject: Pediatrics
Nontypeable Haemophilus influenzae is frequently responsible for:
a) Recurrent otitis media in children
b) Epiglottitis in older children
c) Meningitis in college students
d) Cellulitis in toddlers
e) Septic arthritis in young children
The correct answer is a)
Explanation:
Nontypeable (unencapsulated strains) Haemophilus influenzae is a significant pathogen in
children, causing otitis media, sinusitis, conjunctivitis, pneumonia, and occasionally
invasive infections. H. influenzae type b conjugate vaccines have no effect on infections
caused by nontypeable strains because nontypeable strains are nonencapsulated.
Approximately, one-third of episodes of otitis media are caused by nontypeable H.
influenzae, which is the most common cause of recurrent otitis media.
→ Epiglottitis is classically associated with Haemophilus influenzae type b (Hib) infection.
→ Bacterial meningitis in college students is typically caused by Neisseria meningitides.
→ The most common bacterial causes of cellulitis include: Group A beta-hemolytic
streptococcus, Streptococcus pneumoniae, Staphylococcus aureus, and Methicillin-resistant
staphylococcus aureus (MRSA).
→ Children with septic arthritis are more likely than adults to be infected with Group B
streptococcus or Haemophilus influenza, if they have not been vaccinated.
Note: In infants and young children, H. influenzae type b (Hib) causes bacteremia,
pneumonia, epiglottitis and acute bacterial meningitis. Unencapsulated H. influenzae strains
are unaffected by the Hib vaccine and cause otitis media, conjunctivitis, and sinusitis in
children, and are associated with pneumonia.
Question #186
QID: 16403
Topic: Death of Loved One
Subject: Pediatrics
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.
Question #187
QID: 16418
Topic: Atopic Dermatitis
Subject: Pediatrics
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.
Question #188
QID: 17805
Topic: Atopic Dermatitis
Subject: Pediatrics
A 6-month-old Hispanic female has had itching and irritability for 4-5 weeks. There is a
family history of atopy and asthma. Physical examination reveals an excoriated dry rash
bilaterally over the antecubital and popliteal fossae, as well as some involvement of the
face. In addition to maintenance therapy with an emollient, which one of the following
topical medications would be appropriate first-line treatment for flare-ups in this patient?
a) A calcineurin inhibitor such as pimecrolimus
b) An anesthetic cream
c) An antihistamine cream
d) An antibiotic ointment
e) A low potency corticosteroid cream
The correct answer is e)
Explanation:
This child has atopic dermatitis (eczema). The infantile stage may present with pruritic, red,
scaly, and crusted lesions on the extensor surfaces and cheeks or scalp. The childhood stage
is characterized by less exudation and often demonstrates lichenified plaques in a flexural
distribution, especially of the antecubital and popliteal fossae, volar aspect of the wrists,
ankles, and neck. There often is a family history of atopy or allergies. In addition to the
regular use of emollients, the mainstay of maintenance therapy, topical low potency
corticosteroids have been shown to be the best first-line treatment for flare-ups of atopic
dermatitis.
→ Topical calcineurin inhibitors (choice A) should be second-line treatment for flare-ups,
but are not recommended for use in children under 2 years of age.
→ There is no evidence to support the use of topical anesthetics or analgesics (choice B) in
the treatment of this disorder.
→ Antihistamines (choice C) provide symptomatic relief of pruritus; may be added to
treatment, if needed, but not considered first line treatment in atopic dermatitis.
→ Antibiotics (choice D) should be reserved for the treatment of acutely infected lesions.
Question #189
QID: 16426
Topic: Breath Holding Spells
Subject: Pediatrics
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.
Question #190
QID: 18192
Topic: Bullous Impetigo
Subject: Pediatrics
A 6-month-old white male is brought to your office because he has “blisters” in his diaper
area, neck, axilla, and face. On examination, 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 medication in the management of this
condition at this point?
a) A topical antifungal agent
b) Mupirocin ointment
c) Topical tetracycline and silver sulfadiazine
d) Oral cephalexin
e) Oral trimethoprim-sulfamethoxazole
The correct answer is d)
Explanation:
Bullous impetigo is a localized skin infection characterized by large bullae; it is caused by
phage group II Staphylococcus aureus. Cultures of fluid from an intact blister will reveal the
causative agent. The lesions are caused by exfolatin, a local toxin produced by the S. aureus,
and develop on intact skin. The bullae initially contain a clear, yellow fluid that
subsequently turns cloudy and dark yellow. Bullae rupture easily, within 1-3 days, leaving a
rim of scale around an erythematous moist base. After desiccation, the lesion has a brownlacquered or scalded-skin appearance, with a collarette of scale or a tubelike rim at the
periphery. Removal of the crust reveals a moist, red base. Central healing results in circinate
lesions.
Diagnosis of impetigo is usually based solely on history and clinical appearance. Bacterial
culture and sensitivity are recommended (1) to identify possible methicillin-resistant
Staphylococcus aureus (MRSA), (2) if an outbreak of impetigo has occurred, or (3) if
poststreptococcal glomerulonephritis is present.
Infections that are widespread, complicated, or are associated with systemic manifestations
are usually treated with antibiotics that have gram-positive bacterial coverage. Systemic
therapy is also recommended if multiple incidents of pyoderma occur within daycare,
family, or athletic team settings. Beta-lactamase resistant antibiotics (eg, cephalosporins,
amoxicillin-clavulanate, cloxacillin, dicloxacillin) are recommended. Cephalexin (choice D)
appears to be the drug of choice for oral antimicrobial therapy in children. If MRSA is
suspected, alternative antibiotics include clindamycin, trimethoprim-sulfamethoxazole, and
vancomycin.
→ Topical anfungal therapy (choice A) is useless agaist bacterial infections.
→ Topical antibiotic therapy (choice B) is considered the treatment of choice for individuals
with uncomplicated localized impetigo. Topical therapy eradicates isolated disease and
limits the individual-to-individual spread. Mupirocin ointment (Bactroban) has been used
for both the lesions and to clear chronic nasal carriers.
→ Tetracycline (choice C) has been used for localized impetigo. It is not widely prescribed
because of the potential risk of skin photosensitivity reactions and because it is
contraindicated in children younger than 8 years. Drugs such as sulfanilamide,
nitrofurazone, and silver sulfadiazine, which are widely used for the treatment of burns, are
not currently used for the treatment of impetigo.
→ MRSA (choice E) is not supected at this point and culture results have not been done
(clinical vignette).
Question #191
QID: 16478
Topic: Duchenne's Muscular Dystrophy
Subject: Pediatrics
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 creatine 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 (CK) 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 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 (choice A) and phenylketonuria (choice C) 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 (choice B) present in the newborn period with
failure to thrive, poor feeding, and lethargy.
→ Gross chromosomal abnormalities (choice E) would usually be incompatible with a
normal physical examination at 18 months.
Question #192
QID: 16519
Topic: Hypertrophic Cardiomyopathy
Subject: Pediatrics
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.
Question #193
QID: 16533
Topic: Bulimia Nervosa
Subject: Pediatrics
A 17-year-old white female is brought in by her parents because of concern about her recent
behaviour and weight loss obsession discussions. Her past medical history is unremarkable.
Physical examination is notable for a body mass index of 25 m/kg², 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.
Question #194
QID: 16608
Topic: Acneiform Lesions
Subject: Pediatrics
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.
Question #195
QID: 16693
Topic: Acneiform Lesions
Subject: Pediatrics
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
e) Oral hormonal therapy
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 isotretinoin is used in severe nodular acne, but also
must be used with extreme caution in females who may become pregnant. Oral hormonal
therapy is an alternative to oral antibiotic therapy in postmenarchal females with moderate
to severe acne.
Question #196
QID: 16626
Topic: Basilar Skull Fracture
Subject: Pediatrics
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 (choice A). This finding is frequently noted on cervical spine films.
→ Orbital floor fractures (choice B) may be associated with double vision, fluid in the
maxillary sinus, an air-fluid level in the maxillary sinus, and diplopia.
→ Epidural hematomas (choice C) are more frequently associated with skull fractures in the
area of the meningeal artery.
→ Zygomatic arch fractures (choice D) are more visible on Towne’s view. Characteristic
swelling and lateral orbital bruising are typically present.
→ Mandible fractures (choice E) may be associated with dental misalignment or bleeding.
Panoramic views are often diagnostic.
Question #197
QID: 16634
Topic: Genital Warts
Subject: Pediatrics
Imiquimod (Aldara) use in patients 12 years of age and over is approved 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.
Genital Warts (Condylomata Acuminata)
Question #198
QID: 16667
Topic: Anterior Fontanelle Closure
Subject: Pediatrics
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.
Question #199
QID: 16670
Topic: Animal Bite
Subject: Pediatrics
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 primary closure
b) Allow healing by secondary intention
c) Culture for aerobic and anaerobic organisms
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. In dog/cat bites, only consider
primary closure for bite wounds on the face; otherwise primary closure is contraindicated.
→ 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.
Question #200
QID: 16689
Topic: Chlamydial infection
Subject: Pediatrics
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.
Question #201
QID: 16732
Topic: Cytomegalovirus
Subject: Pediatrics
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 leading infectious cause of congenital sensorineural
deafness 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.
Question #202
QID: 17411
Topic: Cytomegalovirus
Subject: Pediatrics
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 (choice D) 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.
Question #203
QID: 16735
Topic: Herpes Gladiatorum
Subject: Pediatrics
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
(choice C) caused by the herpes simplex virus.
→ Molluscum contagiosum (choice A) causes keratinized plugs.
→ Human papillomavirus (choice B) causes warts.
→ Tinea corporis (choice D) is ringworm, which is manifested by round to oval raised areas
with central clearing.
→ Mat burn (choice E) is an abrasion.
Question #204
QID: 16778
Topic: Childhood Bullying
Subject: Pediatrics
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
e) Parents should be advised to confront bullies
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.
Question #205
QID: 16832
Topic: Flexible Flat Feet
Subject: Pediatrics
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. What would you do next?
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.
Question #206
QID: 17027
Topic: Fetal Alcohol Syndrome
Subject: Pediatrics
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.
Fetal Alcohol Syndrome
Question #207
QID: 17030
Topic: Dental Injury
Subject: Pediatrics
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.
Question #208
QID: 17038
Topic: Alport's Syndrome
Subject: Pediatrics
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.
Question #209
QID: 17043
Topic: Compartment Syndrome
Subject: Pediatrics
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.
Question #210
QID: 17112
Topic: Constipation
Subject: Pediatrics
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) Rectal biopsy
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.
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.
→ A CT scan (choice A) and a barium enema (choice C) are not as helpful.
→ Rectal biopsy (choice B) is the definitive means of establishing or excluding
Hirschsprung disease. This procedure is to invasive for this patient's clinical picture and
would not be part of initial management
→ Functional constipation can be managed without colonoscopy (choice E).
Question #211
QID: 17143
Topic: Bacterial Conjunctivitis
Subject: Pediatrics
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.
Question #212
QID: 17181
Topic: Breast Milk
Subject: Pediatrics
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 4 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) CCOHS 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 4 hours at room temperature, up to
48h in the refrigerator, and up to 3 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 CCOHS standards.
Question #213
QID: 16175
Topic: Diabetic Ketoacidosis
Subject: Pediatrics
An obese 11-year-old boy with diabetes mellitus is admitted to the hospital because of
severe ketoacidosis and cardiovascular collapse. Which of the following electrolyte deficits
would most likely cause death in this patient?
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, a potentially fatal condition.
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.
Question #214
QID: 17360
Topic: Diabetic Ketoacidosis
Subject: Pediatrics
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.
Question #215
QID: 17374
Topic: Diabetic Ketoacidosis
Subject: Pediatrics
What is the immediate goal in the treatment of new onset insulin dependent diabetes
mellitus (IDDM) and diabetic ketoacidosis (DKA)?
a)
b)
c)
d)
e)
Start administration of dextrose intravenously
Treat the acidosis with sodium bicarbonate
Restore fluid and electrolyte losses and reverse the catabolic state
Start antibiotics to treat any underlying infection that may have precipitated the DKA
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.
Question #216
QID: 17366
Topic: Coma
Subject: Pediatrics
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.
Question #217
QID: 17367
Topic: Erb's Palsy
Subject: Pediatrics
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:
In Ebr's palsy, 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.
Question #218
QID: 17382
Topic: Congenital Cataract
Subject: Pediatrics
While examining a 3-day-old infant born at term by normal spontaneous vaginal delivery to
a 19-year-old primigravida mother without any perinatal infection or complications, you
notice an absence of red reflex in the left eye. Upon closer examination, the pupil in the
right eye was clear, but the pupil in the left eye had a milky appearance.
What is the most common cause of this condition?
a) Retinoblastoma
b) Congenital cataract
c) Retinopathy of prematurity
d) Congenital glaucoma
e) Ocular toxoplasmosis
The correct answer is b)
Explanation:
Congenital cataract (choice B) is the most common cause of leukocoria (white pupil) in an
otherwise healthy, full term newborn.
→ Retinoblastoma should (choice A) always be considered in the differential of an
asymmetric red reflex. Although uncommon, this diagnosis requires early intervention.
→ Retinopathy (choice C) of prematurity is not seen in full term infants.
→ Congenital glaucoma (choice D) is an uncommon but important diagnosis in infants with
an asymmetric red reflex. Tearing, irritability, and a large pupil may also be seen.
→ Ocular toxoplasmosis (choice E) may occur in infants with maternal exposure to
Toxoplasma gondii. Infants with severe disease may have chorioretinitis, intracranial
calcifications, and mental retardation.
Question #219
QID: 17386
Topic: Eisenmenger Syndrome
Subject: Pediatrics
An 7-year-old boy, who was adopted from a poor family from South Korea recently, 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 a
heart murmur. He also admits to not being overly physically active as he prefers playing
video games.
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
increase 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 syndrome 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-toleft 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.
Question #220
QID: 17387
Topic: Chylothorax
Subject: Pediatrics
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 tachypneic. On exam, the patient has diminished breath
sounds on the left 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.
Question #221
QID: 17388
Topic: Eczema
Subject: Pediatrics
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 PO
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.
Question #222
QID: 17389
Topic: Diabetes Insipidus
Subject: Pediatrics
A 7-year-old girl remains hospitalized following surgical removal of a craniopharyngioma.
On post-operative day one, 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.
Note: Hemoconcentration - decrease of the fluid content of the blood, with increased
concentration of formed elements (increase in both hemoglobin and hematocrit levels).
Question #223
QID: 17390
Topic: Hemolytic Uremic Syndrome
Subject: Pediatrics
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 mmol/L.
Management of this patient 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 patient 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 (choice E).
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.
Hemolytic Uremic Syndrome
Question #224
QID: 17392
Topic: Acute Lymphocytic Leukemia
Subject: Pediatrics
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 104 g/L, platelet count of 85 x 10^9/L, and WBC is 28 x 10^9/L, with 80%
lymphocytes and 10% blast forms. A diagnosis of leukemia is made. Further testing is
consistent with L2 morphology and is PAS negative.
Favourable prognostic factors for this disease include all of the following, except:
a) Early attainment of complete remission
b) Young age
c) Complete remission within 4 weeks
d) Presence of Ph chromosome
e) WBC < 30 x 10^9/L
The correct answer is d)
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.
Good prognostic factors: young, WBC < 30 x 10^9/L, T-cell phenotype, absence of Ph
chromosome, early attainment of complete remission, complete remission within 4 weeks.
Question #225
QID: 17398
Topic: Amblyopia
Subject: Pediatrics
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 this 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.
Question #226
QID: 17414
Topic: Conjuctivitis
Subject: Pediatrics
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) Bacterial conjunctivitis
The correct answer is e)
Explanation:
Bacterial conjunctivitis, as long as the cornea is not affected, seldom leads to complications.
General concerns include membrane formation and subsequent scarring of the punctum;
corneal ulcer when the epithelium is not intact; and symblepharon from severe
inflammation.
→ Family history of amblyopia is a risk factor for amblyopia.
→ Premature infants are at risk for retinopathy of prematurity.
→ Patients with cerebral palsy are at risk for strabismus.
→ Maternal intrauterine TORCH infections may result in cataracts or chorioretinitis.
Question #227
QID: 17416
Topic: Hyperoxia Test
Subject: Pediatrics
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:
FiO2 = 0.21, PaO2 = 30
FiO2 = 1.00, PaO2 = 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 PaO2 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 PaO2 with the administration of oxygen issued as a guide to determine the
etiology of the cyanosis. A PaO2 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 PaO2. A PaO2 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 PaO2 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 PaO2 on 100% oxygen was less than 50, suggesting
restricting pulmonary blood flow or a separate circulation.
Question #228
QID: 17418
Topic: Hemangioma
Subject: Pediatrics
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 1.5 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.
Question #229
QID: 17424
Topic: Fragile X Syndrome
Subject: Pediatrics
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)
b)
c)
d)
e)
Both parents are gene carriers for this condition
He has small genitalia and undescended testicles
His mother is a gene carrier for this condition
The parents have a 50% recurrence risk for any future pregnancy
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.
→ Both parents are gene carriers only in autosomal recessive conditions.
→ Boys with fragile X syndrome have normal genitalia and may develop macroorchidism at
puberty.
→ In an X-linked condition, there is a 50% recurrence risk for brothers to be affected, but a
much lesser risk for sisters.
→ 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.
Question #230
QID: 18028
Topic: Fragile X Syndrome
Subject: Pediatrics
Fragile X syndrome is associated with each of the following characteristics, except:
a) More common in females
b) Most common form of inherited mental retardation
c) Involves the long arm of the X chromosome
d) Can be diagnosed with a blood test
e) Treatment is limited to symptomatic management
The correct answer is a)
Explanation:
Fragile X syndrome is more common in males than females, affecting 1 in 2000 and 1 in
4000, respectively. It is the most common inherited form of mental retardation and second
only to Down’s syndrome as a cause of mental impairment. As the name implies, the
syndrome is the result of a fragile site on the long arm of the X chromosome attributed to
the excess amplification of the trinucleotide CGG sequence. It is thought that the protein
produced by this gene is responsible for guiding the connections between neurons involved
in learning and memory. The symptoms of this pervasive developmental disorder include
mental retardation ranging from learning disabilities to severe intellectual impairment,
hyperactivity, unstable mood, and autistic-like behaviors. The diagnosis can now be made
by a DNA probe to pinpoint the defective gene. Presently gene repair is not possible, so
treatments include behavioral and pharmacologic management of the symptoms.
Question #231
QID: 17439
Topic: Hand Foot And Mouth Disease
Subject: Pediatrics
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 38.3˚C (101˚F). 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)
b)
c)
d)
e)
Paramyxovirus
Rubella virus
Herpes virus 6
Parvovirus B-19
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.
Question #232
QID: 17759
Topic: Hand Foot And Mouth Disease
Subject: Pediatrics
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.
Question #233
QID: 18296
Topic: Hand Foot And Mouth Disease
Subject: Pediatrics
An 8-year-old female presents to the clinic with painful blisters covering her hands and feet.
She is also complaining of headaches and fatigue. She is running a low grade fever of
37.2°C. Upon examination of the child's mouth, small ulcerations are found in the back of
the mouth around epiglottis. Her blood results show elevated reactive lymphocytes.
What is the most likely cause of this patient's clinical presentation?
a) Varicella zoster
b) Physical abuse
c) Herpes simplex
d) Coxsackie virus type A
e) Treponema pallidum
The correct answer is d)
Explanation:
These are typical signs and symptoms of hand foot and mouth disease (HFMD) caused by
the Coxsackie virus type A. HFMD typically presents with fever, poor appetite, malaise, and
sore throat. One or two days after fever starts, painful sores usually develop in the mouth
(herpangina). They begin as small red spots that blister and that often become ulcers. The
sores are often but not limited to the back of the mouth. A skin rash develops over 1 to 2
days. The rash has flat or raised red spots, sometimes with blisters. The rash is usually on
the palms of the hands and soles of the feet; it may also appear on the knees, elbows,
buttocks or genital area. Rarely HFMD is associated with meningitis and encephalitis, and
on occasion can cause severe complications, including neurological, cardiovascular and
respiratory problems.
Coxsackie virus is a single strand RNA virus belonging to the Picornaviridae family,
enterovirus genus. HFMD usually occurs in children under 10 years of age but has been
known to occur in adults as well. The clinical symptoms usually resolve without treatment
in approximately 10 days with no scarring, however the virus can be shed for several weeks.
The virus is most commonly spread via hand-feces-mouth contamination route. Diagnosis is
usually based solely on clinical features without further laboratory testing.
→ Varicella zoster (chicken pox) (choice A) usually affects the head and trunk (not hand
and feet). However, mouth ulcerations and elevated reactive lymphocytes are commonly
observed.
→ Physical abuse (choice B) such as burning the child's hands and feet is inconsistent with
the clinical presentation however in cases of electrocution mouth ulcerations and blistering
may occur.
→ Herpes simplex (choice C) usually affects oral cavity but not hands and feet.
→ Treponema pallidum (choice E) presents with similar signs and symptoms however T.
pallidum is a bacterial infection and would show elevated neutrophils and reactive
lymphocytes.
Key point:
The Coxsackie virus is an RNA virus most commonly infecting children resulting in Hand
Foot and Mouth Disease, which usually resolves spontaneously within 10 days.
Question #234
QID: 17599
Topic: Hip Dysplasia
Subject: Pediatrics
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.
Question #235
QID: 17649
Topic: Cutaneous Larva Migrans
Subject: Pediatrics
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)
b)
c)
d)
Dog or cat hookworm (Ancylostoma species)
Dog or other canid tapeworm (Echinococcus granulosus)
Cat protozoa (Toxoplasma gondii)
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 (choice A). 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 (choice B) 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 slowgrowing cysts in the liver or lungs, and occasionally in the brain, bones, or heart.
→ Toxoplasmosis is caused by the protozoa Toxoplasma gondii (choice C), 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 (choice D) 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.
Question #236
QID: 17670
Topic: Depression
Subject: Pediatrics
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
b) Amitriptyline
c) Lithium
d) Paroxetine
e) Fluoxetine
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.
Question #237
QID: 17672
Topic: Foreign Body Removal
Subject: Pediatrics
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.
Question #238
QID: 17693
Topic: Femoral Anteversion
Subject: Pediatrics
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.
Question #239
QID: 17852
Topic: ACL injury
Subject: Pediatrics
A 16-year-old high-school football player plants his left foot to make a cut and feels his left
leg give way. He feels a pop in the knee, followed by acute pain. He is evaluated on the
field, and examination with the knee flexed 20° reveals that the tibia can be displaced farther
anteriorly than with the uninvolved knee.
Which one of the following conditions is most likely?
a) Patellar tendon rupture
b) Posterior cruciate ligament tear
c) Anterior cruciate ligament tear
d) Tibial plateau fracture
e) Patellar dislocation
The correct answer is c)
Explanation:
Anterior cruciate ligament (ACL) tears are the most common ligament injury requiring
surgery. Females have a significantly higher rate of ACL tears, with the majority of tears in
both men and women occurring without physical contact. In addition to the immediate
problems, there is a significant increase in premature osteoarthritis of the knee.
Approximately 50% of patients with this injury develop osteoarthritis in 10-20 years.
Findings that help make the diagnosis of ACL tear include a noncontact mechanism of
injury, an audible popping sound, early swelling of the joint, and the inability to participate
in the game after the injury. Many patients can walk normally and can perform such
straight-plane activities as climbing stairs, biking, or jogging. Physical examination using
the Lachman test or pivot shift test can be used to further assess whether the ligament is
torn. MRI can be used to confirm the diagnosis, although it is not needed if the diagnosis is
clear from the history and examination. The other conditions listed are also sports-related
knee injuries, but have different mechanisms of injury or physical findings. Patients with
patellar tendon rupture are unable to fully extend their knee and examination shows a
palpable defect in the patellar ligament and a high-riding patella. While the mechanism of
injury in patients with posterior cruciate ligament tears may be similar to that of ACL injury,
the examination would show posterior rather than anterior displacement of the tibia when
the knee is flexed at 90° (the posterior drawer sign). The mechanism of injury of tibial
plateau fractures in a healthy young male generally involves a high- energy collision
causing a valgus force with axial loading. Patients with patellar dislocations have symptoms
similar to those of an ACL injury, including an audible crack or pop and the feeling of the
knee giving way after a twisting motion. Immediately following the injury, however,
examination would show an obvious deformity, but the patella may spontaneously relocate
prior to the on-field exam. There would be no instability on the Lachman maneuver.
Question #240
QID: 17807
Topic: Allergic Rhinitis
Subject: Pediatrics
You are treating an 18-year-old white male college freshman for allergic rhinitis. It is
September, and he tells you that he has severe symptoms every autumn that impair his
academic performance. He has a strongly positive family history of atopic dermatitis.
Which one of the following medications is considered optimal treatment for this condition?
a) Intranasal glucocorticoids
b) Intranasal cromolyn sodium
c) Intranasal decongestants
d) Intranasal antihistamines
e) Oral antihistamines
The correct answer is a)
Explanation:
Topical intranasal glucocorticoids are currently believed to be the most efficacious
medications for the treatment of allergic rhinitis. They are far superior to oral preparations
in terms of safety.
→ Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is
more effective if started prior to the season of peak symptoms.
→ Because of the high risk of rhinitis medicamentosa with chronic use of topical
decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.
→ Azelastine, an intranasal antihistamine, is effective for controlling symptoms but can
cause somnolence and a bitter taste.
→ Oral antihistamines are not as useful for congestion as for sneezing, pruritus, and
rhinorrhea. Overall, they are not as effective as topical glucocorticoids.
Question #241
QID: 17910
Topic: Hypercalcemia
Subject: Pediatrics
A 14-year-old female sees you for follow-up after hypercalcemia is found on a chemistry
profile obtained during a 5-day episode of vomiting and diarrhea. She is now asymptomatic,
but her serum calcium level at this visit is 2.75 mmol/L. Her aunt underwent unsuccessful
parathyroid surgery for hypercalcemia a few years ago.
Which one of the following laboratory findings would suggest a diagnosis other than
primary hyperparathyroidism?
a) Low 24-hour urine calcium
b) Decreased serum phosphate
c) High-normal to increased serum chloride
d) Elevated alkaline phosphatase
e) Elevated parathyroid hormone
The correct answer is a)
Explanation:
Low urine 24-hour calcium levels or a low urine calcium to urine creatinine ratio is not
characteristic of primary hyperparathyroidism. This finding should suggest familial
hypocalciuric hypercalcemia (FHH). Awareness of this condition is important to avoid
unnecessary surgery.
→ Serum chloride (choice C) tends to be high normal or mildly elevated.
→ Alkaline phosphatase (choice D) may be elevated in more severe cases, while serum
phosphate levels (choice B) tend to be low.
→ The parathyroid hormone level (choice E) may be mildly elevated. Parathyroid hormone
is elevated in hyperparathyroidism.
Question #242
QID: 17933
Topic: Counseling
Subject: Pediatrics
The physician 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.
Question #243
QID: 17953
Topic: Crohn's Disease
Subject: Pediatrics
A 16-year-old male presents with history of weight loss, abdominal pain and bloody
diarrhea. Investigation shows a normal upper endoscopy, inconclusive abdominal x-rays and
an ultrasonography report reveals the GI wall thickness about 3mm with several hypoechoic
areas. What is the most appropriate next step?
a) Colonoscopy with biopsy
b) CT of abdomen
c) Stool studies
d) CBC and reticulocyte count
e) Abdominal Ultrasound
The correct answer is a)
Explanation:
Crohn's disease is a chronic transmural inflammatory disease that usually affects the distal
ileum and colon but may occur in any part of the GI tract. Symptoms include diarrhea and
abdominal pain. Abscesses, internal and external fistulas, and bowel obstruction may arise.
Extraintestinal symptoms, particularly arthritis, may occur.
Diagnosis is by colonoscopy and barium contrast studies. If initial presentation is less acute,
an upper GI series with small-bowel follow-through and spot films of the terminal ileum is
recommended. Treatment is with 5-aminosalicylic acid, corticosteroids, immunomodulators,
anticytokines, antibiotics, and often surgery.
Question #244
QID: 18079
Topic: Drug intoxication
Subject: Pediatrics
A 4-year-old boy was brought to the hospital with confusion and seizures for the last two
hours. While being evaluated he went into coma. According to his mother, he was fine until
about 8 hours ago when he started complaining of feeling tired and nauseated. On
examination, the child was in coma with Glasgow coma scale of 9 but he did not look ill
and was not febrile. Severe bradycardia and hypotension were found. His mother recalls that
she saw him playing with her beta-blocker bottle this morning. Although she does not
remember the number of the tablets left in her bottle, she was almost sure that many of the
tablets were missing. Blood glucose was found to be low and IV glucose was given. The
best antidote to be given to this child is:
a) Epinephrine
b) Norepinephrine
c) Glucagon
d) Charcoal
e) Atropine
The correct answer is c)
Explanation:
Glucagon (choice C) is the antidote of choice for beta-blocker poisoning because it
increases intracellular levels of cyclic AMP independent of the beta receptors that are
blocked.
→ Epinephrine (choice A) and norepinephrine (choice B) are not effective antidotes for
beta-blocker poisoning. Beta-blockers are drugs that bind to beta-adrenoceptors and thereby
block the binding of norepinephrine and epinephrine to these receptors.
→ Prehospital administration of charcoal (choice D) is indicated when there are no
contraindications and the patient is alert and cooperative.
→ Atropine (choice E) can improve the bradycardia but it does not alleviate the
hypotension, hypoglycemia or the CNS effects.
Glucagon can enhance myocardial contractility, heart rate, and atrioventricular conduction;
many authors consider it the drug of choice for beta-blocker toxicity. Because a glucagon
bolus can be diagnostic and therapeutic, the clinician can empirically administer glucagon
and check for a response.
Question #245
QID: 18427
Topic: Female Athlete Triad
Subject: Pediatrics
A 17-year-old gymnast is training for one year and is scheduled to participate in a national
gymnastics event in three weeks. She presents for pre-participation physical evaluation. She
reports that her last menstrual period was six months ago; prior to which she used to have
normal menstruation. She had reported having missed periods for two months to her family
physician, who had reassured her that amenorrhea in an athlete, is a normal phenomenon.
She has lost 7 kilograms in past 12 months, which she says is because of six hours of daily
training. She reports that generally she restricts consumption of food containing
carbohydrates and fats; but occasionally binges on Pizza and ice cream. However, she
manages to keep her weight under control by using laxatives.
On examination her body mass index is 19 kg/m². Her pulse rate is 54 bpm and her blood
pressure is 90/65 mm Hg.
Which one of the following conditions, if present, will indicate diagnosis of female athlete
triad in this case?
a)
b)
c)
d)
e)
Anemia
Polycystic ovary
Cardiac arrhythmia
Osteoporosis
Depression
The correct answer is d)
Explanation:
Female athlete triad is a syndrome of three interrelated conditions associated with intense
athletic training and energy deficient diet. It is defined as presence of disordered eating,
amenorrhea and osteoporosis (choice D). The patient described in the stem has disordered
eating as suggested by food restriction and use of laxatives. She also has amenorrhea.
Unbalanced diet and inadequate caloric intake relative to body needs are predisposing
factors for amenorrhea. Amenorrhea in athletes is due to hormonal imbalance caused by
changes in hypothalamus and decreased levels of oestrogen. Osteoporosis develops due to
low oestrogen levels and other hormonal changes.
Amenorrhea is common in athletes. However, it should not be discounted as a benign
consequence of athletic training. Risk of bone loss increases with the duration of
amenorrhea. A dual energy X-ray absorptiometry (DEXA) scan should be ordered in
athletes with amenorrhea lasting at six months or more to detect osteoporosis.
→ Anemia (choice A) is commonly associated with disordered eating. However, female
athlete triad may be present in absence of anemia.
→ Polycystic ovary syndrome (choice B) is a common disorder associated with
amenorrhoea. It is characterized by hyper-androgenic state and anovulation. It does not
occur with higher frequency in female athletes and is not a part of female athlete triad.
→ Severely disordered eating associated with self-induced vomiting and purging can cause
electrolyte imbalance and cardiac arrhythmia (choice C). However, presence of these
conditions is not essential for diagnosis of female athlete syndrome.
→ Depression (choice E) and anxiety are common associations with disordered eating in
women. This is thought to be due to low self-esteem and associated compulsive behavior. It
is not a part of female athlete triad.
Key point:
Osteoporosis in young female athletes can be associated with many skeletal complications
and possibility of permanent loss of bone mass. Thus it is essential to diagnose female
athlete triad early in its course.
Question #246
QID: 17766
Topic: Child Safety Seat
Subject: Pediatrics
A married couple brings 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:
a) Weighs 10 kg (22 lb)
b) His height reaches 90cm (35inch)
c) Weighs 18kg (40lb)
d) Is 10 months old
e) Is 15 months old
The correct answer is a)
Explanation:
A child can start riding facing forward when he or she is at least 10 kg (22 lb.).
To prevent the car seat from moving forward and causing injury in a collision, it is
important to use the tether strap exactly as the manufacturer recommends.
The shoulder straps should be at or above the child's shoulders. Straps should be snug, with
only one finger width between the strap and the child's chest. Using aftermarket car seat
products should be avoided. They can become projectiles or may have hard or sharp
surfaces that can hurt the child in a collision.
Infants who weigh less than 10 kg at one year of age should continue to ride in the rearfacing position.
Question #247
QID: 18144
Topic: Dermatomyositis
Subject: Pediatrics
The mother of an 8-year-old female is concerned about purple “warts” on her daughter’s
hands. The mother explains that the lesions started a few months ago on the right hand along
the top of most of the knuckles and interphalangeal joints, and she has recently noticed them
on the left hand. The child has no other complaints and the mother denies any unusual
behaviors. A physical examination is unremarkable except for the slightly violaceous, flattopped lesions the mother described.
What is the most likely cause for this patient’s finger lesions?
a)
b)
c)
d)
e)
Dermatomyositis
Aggressive warts
Rubbing/wringing of the hands
Bulimia nervosa
Child abuse
The correct answer is a)
Explanation:
One of the most characteristic findings in dermatomyositis is Gottron’s papules, which are
flat-topped, sometimes violaceous papules that often occur on most, if not all, of the
knuckles and interphalangeal joints.
Question #248
QID: 18199
Topic: Dermatomyositis
Subject: Pediatrics
A 6-year-old boy was brought to the hospital because of a two-month history of lassitude
and weakness. At first, he had difficulty climbing stairs. For the last two months, he had to
roll over on his side to get off the bed and use his hands on thighs to stand from the sitting
position. For the last two weeks he asked for help to comb his hair. There are no other
complaints and the family history was unremarkable. Routine vaccination was up to date.
On examination, the child looked well, not pale, jaundiced or cyanosed and he was afebrile.
His upper eye lids had purplish colored macules and the dorsal surface of his
interphalangeal joints had flat-topped pinkish papules. His cheeks, forehead and the dorsal
surfaces of the forearms were erythematous. Positive Gower sign was confirmed. Slight
tenderness was also noted over the hamstring and quadriceps muscles. Tendon reflexes were
normal and sensations were intact. Electromyography showed increased insertional activity,
fibrillation potentials, sharp waves and decreased duration and amplitude of action potential.
Motor and sensory conduction velocities were however, normal. Creatine kinase was 3000
U/L.
Given this patient's presentation, what would be the most likely diagnosis?
a) Acute intermittent porphyria
b) Duchenne muscular dystrophy
c) Guillain-Barré syndrome
d) Dermatomyositis
e) Myasthenia gravis
The correct answer is d)
Explanation:
Dermatomyositis, an inflammatory disorder of muscle, is a rare condition affecting 3 per
1,000,000 children with peak onset between 4 and 10 years. It is relatively more common in
girls.
Dermatomyositis presents with skin rash or insidious onset weakness or both. The typical
rash is heliotrope rash, a blue-violet discoloration of the upper eyelids. Another typical type
of rash is the flat topped pinkish classic Gottron’s papules on the back of the interphalangeal
joints. The weakness usually affects proximal muscles such as neck flexors, shoulder girdle
and hip flexors. Patients may thus, have difficulty in climbing stairs, standing from the
sitting position, combing hair or getting out of bed. These children may be observed to use
hands on thighs to stand from the sitting position (Gower sign). Tenderness of muscle is one
sign of muscle inflammation in patients with dermatomyositis. Lab findings include high
serum creatine kinase and myopathy EMG changes (increased insertional activity,
fibrillation potentials, sharp waves and decreased duration and amplitude of action
potential). Motor and sensory conduction velocities are typically normal in patients with
dermatomyositis. Our patient has most of these findings.
→ In acute intermittent porphyria (AIP), in addition to muscle weakness, there is also
sensory involvement that might be described by patients as "muscle pain." The muscle
weakness of AIP is neuropathic in nature. Thus, EMG is expected to show either low motor
and sensory conduction velocities or low amplitude of action over muscle. Increased
insertional activity, fibrillation potentials, and sharp waves typical of myopathy do not
develop in AIP. Creatine kinase is expected to be normal in this condition.
→ The main findings against the diagnosis of Duchenne muscular dystrophy (DMD) in this
patient are the cutaneous manifestations and muscle tenderness. In addition, in children with
DMD, symptoms and signs of muscle weakness are observed during infancy and certainly
by the age of 3. By the age of 6 these children usually have muscle contractures and lordotic
posture when walking. Furthermore, serum creatine kinase would be much higher (>15000
U/L) in DMD.
→ In Guillain-Barré syndrome (GBS) weakness usually begins in the lower limbs and
progresses to the trunk, upper limbs and bulbar muscles. In addition, unlike the case of our
patient, the weakness of GBS affects both proximal as well as distal muscles. Reflexes are
either reduced or absent in this disorder and sensory complaints, in the form of paraesthesia,
are common. Both motor and sensory conduction velocities are reduced in GBS. Cutaneous
symptoms do not accompany this disorder and creatine kinase is normal.
→ Although any muscle can be affected, the weakness of Myasthenia gravis (MG)
characteristically affects the ocular and bulbar muscles presenting as diplopia and
dysphagia, respectively. In addition, MG has no known cutaneous manifestations. The
typical electromyography finding of MG is the decremental response to repeated nerve
stimulation. Furthermore, the weakness of MG waxes and wanes and is usually more
marked towards the end of the day.
Key point:
Differentiation between different causes of muscle weakness in children.
Question #249
QID: 18155
Topic: Bullied Children
Subject: Pediatrics
A 16-year-old male is brought to your office by his mother for “stomachaches.” On the
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. When you discuss these
problems with him, he admits to being teased and called names 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 more serious problems such as suicide, substance abuse, and victim-tobully transformation. These are not signs or symptoms of thyroid disease.
The Olweus Bullying Prevention Program developed in Norway is a well documented,
effective program for reducing bullying among elementary and middle-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 more likely to carry weapons to school, be in
frequent fights, and eventually be injured.
Question #250
QID: 18198
Topic: Acute Rheumatic Fever
Subject: Pediatrics
A 7-year-old boy was brought to the hospital because of pain and swelling of his right knee
and right wrist. His mother thought he was 'slightly feverish' and gave him Tylenol. The
mother relates that a few days ago first his right ankle and then left wrist were similarly
affected but the swelling and pain subsided over several days. About a month ago the patient
had sore throat for which he received an antibiotic.
On examination, the patient was not pale, jaundiced, or cyanosed and he was febrile. His
heart rate was 106 beats per minute, respiratory rate 22 resp/min and blood pressure was
within normal range. The right knee and right wrist appeared red and swollen. All other
joints were normal. The rest of the examination was unremarkable. Acute rheumatic fever
was suspected and a couple of investigations were ordered. Anti-streptolysin O titer was
positive.
In additon to the above clinical presentation which of the following would establish this
diagnosis according to the revised Duckett Jones criteria?
a) Positive throat culture
b) High erythrocyte sedimentation rate (ESR)
c) Rumbling mid-diastolic apical murmur
d) Echocardiographically elicited systolic apical murmur
e) Diffuse erythematous papular rash around the neck with flushed cheeks
The correct answer is b)
Explanation:
Rheumatic fever is one of the suppurative complications of group A streptococcal infection
of the pharynx. Although there is a dramatic decline in its incidence in developed countries,
rheumatic fever is still a significant problem because of its grave effects on the heart.
Because of absence of any pathognomonic clinical or laboratory features for rheumatic
fever, the revised Jones criteria are used for its diagnosis. The diagnosis can be established
when a patient fulfills two major criteria or one major and two minor criteria plus an
absolute requirement for evidence of recent group A streptococcal (GAS) infection. The
major criteria include polyarthritis, carditis, subcutaneous nodules, erythema marginatum
and chorea. The minor criteria include arthralgia, fever, high ESR, high C-reactive protein
and prolonged PR interval. Noteworthy is the fact that these criteria should be used for the
diagnosis of the initial acute attack only and not for recurrences.
This patient fulfills one major criterion (polyarthritis) and one minor criterion (fever; note
that we cannot use arthralgia). An additional minor criterion is required to establish the
diagnosis of acute rheumatic fever. High ESR (choice B) would thus be sufficient to
establish the diagnosis of acute rheumatic fever.
→ Positive antistreptolysin O titer (choice A) is sufficient evidence for recent GAS
infection. Positive throat culture will only strengthen this evidence and is not in itself a
required criterion for diagnosis of acute rheumatic fever.
→ Mitral stenosis causing a rumbling mid-diastolic apical murmur (choice C) is a known
complication of rheumatic heart disease. However, mitral stenosis usually develops years or
decades after an acute attack of rheumatic fever. For this reason mitral stenosis does not
signify acute carditis, a major criterion of diagnosis of acute rheumatic fever.
→ In contrast to mitral stenosis, mitral regurgitation (indicated by apical systolic murmur)
might occur during an acute attack of rheumatic fever and is an evidence of acute carditis.
For mitral regurgitation to be accepted as evidence of acute carditis, its murmur must be
detected clinically. Subclinical or echocardiographically elicited systolic apical murmur
(choice D) is so far not accepted as a conclusive evidence of rheumatic carditis.
→ The only erythematous rash (choice E) accepted as a criterion for diagnosis of rheumatic
fever is erythema marginatum which occurs in the form of erythematous, serpiginous
macular lesions with pale centers. It occurs primarily on the trunk and spares the face.
Diffuse rash on the neck with flushed cheeks is characteristic of scarlet fever and not
rheumatic fever.
Rheumatic Fever
Question #251
QID: 18217
Topic: Genetics
Subject: Pediatrics
A couple of Jewish descent comes to the hospital for evaluation. They have had four
children and two of them (a boy and a girl) have died of a disease. Neither parent has the
disease.
What is the most likely mode of inheritance of the disease?
a) Autosomal dominant inheritance
b) Autosomal recessive inheritance
c) X-linked dominant inheritance
d) X-linked recessive inheritance
e) Mitochondrial inheritance pattern
The correct answer is b)
Explanation:
Both children who died were most likely affected by a genetic disease. We are also given
information about the health status of the parents, therefore this makes our ability to deduce
the mode of inheritance much easier. Since none of the parents has the disease, it is clear
that the disease is of an autosomal recessive inheritance pattern and the parents are simply
carriers (choice B).
→ Autosomal dominant (choice A) is incorrect. At least one of the parents would have to be
affected for this to be an autosomonal dominant inheritance. It is transmitted by both sexes,
all generations are affected, and there's no carrier state. Examples include polycystic kidney
disease, Marfan syndrome,neurofibromatosis, and osteogenesis imperfecta.
→ X-linked dominant (choice C) is associated with manifested disease in females but is
usually lethal in males. Examples include hypophosphatemic rickets and the majority of
Alport syndrome cases. In this question X-linked dominant inheritance is incorrect because
the mother is not affected by the disease.
→ X-linked recessive (choice D) is incorrect as only males would be affected.
→ Mitochondrial inheritance (choice E) is incorrect as the mother is not
affected. Mitochondria are inherited only in the maternal ova and not in sperm.
Key point:
If 2 children of opposite sex have been affected by a genetic disease in a family, the mode of
inheritance could be autosomal recessive, autosomal dominant, or X-linked dominant. If
parents are free of the disease, it is most likely to be a case of autosomal recessive
inheritance pattern with parents being carriers of the gene.
Question #252
QID: 18237
Topic: bone tumors in children
Subject: Pediatrics
A 12-year-old boy presents to the emergency room complaining of pain and swelling at the
left mid-femur area for approximately two weeks. On review of systems, he has had on/off
low-grade fever for the last month, and the mother says it looks like he has lost some
weight, but she had attributed this to a recent growth spurt. You perform an X-ray and notice
a bizarre periosteal reaction, which the radiologist describes as "onion skinning." The
following day, a biopsy is performed and shows small, round blue cells.
Given this history and these findings, what is the most likely diagnosis?
a) Osteosarcoma
b)
c)
d)
e)
Osteoid osteoma
Ewing's sarcoma
Chondroblastoma
Nonossifying fibroma
The correct answer is c)
Explanation:
Ewing sarcoma is the correct answer in this case. It is a malignant, small round blue cell
tumor. It is the second most common malignant bone tumor (after osteosarcoma). It tends to
peak between 10-20 years of age. Symptoms typically include pain and swelling, usually
involving the midshaft of long bones, flat bones of the ribs and pelvis. Constitutional
symptoms or signs, such as fever, fatigue, weight loss, or anemia, are present in about 10 to
20 percent of patients at presentation. Radiograph studies have typical features of multiple
layers of periosteum around the tumor site described as "onion-skinning" pattern (see
image).
→ Osteosarcoma (choice A), while it is the most common malignant bone tumor, it typically
does not present with systemic symptoms and radiographs typically show a "sunburst"
pattern (soft tissue mass with radial calcifications).
→ Osteoid osteoma (choice B) is a benign bone-forming tumor, which produces high levels
of prostaglandins (pain typically responds to NSAIDs). The lower extremity is most
frequently affected; the proximal femur is the most common site. Boys are affected two to
three times as often as girls. On plain radiographs, osteoid osteoma appears as a small,
round lucency (nidus) with a sclerotic margin.
→ Chondroblastoma (choice D) is a benign cartilage-forming tumor that usually arises in
the epiphyses of long bones and typically presents during the teenage years. On plain
radiographs, chondroblastomas appear as small, well-defined lesions with a sclerotic border
that may cross the physis (growth plate).
→ Nonossifying fibroma (choice E) is a benign fibrous lesion that is also known as
metaphyseal cortical defect. It is a developmental defect in which areas that normally ossify
are filled with fibrous connective tissue. On plain radiographs, nonossifying fibromas appear
as small, well-defined, eccentric, expansile, lytic lesions located in the metaphysis with
scalloped sclerotic borders
Key point:
When benign bone tumors are symptomatic, they may present with localized pain, swelling,
deformity, or pathologic fracture. Malignant bone tumors include the same symptoms, but
also usually accompanied by systemic symptoms (fever, weight loss, night sweats).
Question #253
QID: 18247
Topic: Bronchiolitis Obliterans
Subject: Pediatrics
A 16-month-old male is brought to the emergency department by his mother because of
coughing and severe shortness of breath. The cough is described as nonproductive. He was
born at 40 weeks gestation with 3.4 kg and he has been meeting all developmental
milestones. The mother denies any recent family travel or exposure to any toxic gases. She
reports that the child’s 3-year-old sister had flu, conjunctivitis, and hemorrhagic cystitis 3
weeks ago. Around the same time the boy had what seemed to be common cold for 2 days
but it had resolved spontaneously.
On physical examination the child has intercostal retractions, wheezes, and fine crackles.
Chest X-ray reveals peribronchial thickening, lowered diaphragm, increased air contrast of
the lungs, and right lower lobe atelectasis. Which of the following is most likely to occur as
a result of this condition?
a) Intraluminal polyploid plug of fibrotic tissue and obliteration of airways
b) Progressively worsening emphysema and development of liver cirrhosis
c) Bronchiectasis and pancreatic enzyme insufficiency with fat malabsorption
d) Bronchogenic adenocarcinoma at the periphery of the lungs
e) Systemic dissemination with nodules consisting of central caseating necrosis
The correct answer is a)
Explanation:
The child’s clinical picture is suggestive of bronchiolitis obliterans secondary to adenovirus
respiratory infection. Adenovirus infections commonly affect children between 1 and 3
years of age and besides respiratory infection it may cause follicular conjunctivitis,
gastroenteritis, intussusception, hemorrhagic cystitis, and myocarditis. Adenovirus
pneumonitis is associated with the development of bronchiolitis obliterans.
The diagnosis of bronchiolitis obliterans can be made based on history, physical
examination, imaging and ventilation/perfusion scan. Initial symptoms may be cough, chest
pain, or hemoptysis. After the initial episode a clinical plateau ensues that may last several
days to one month during which symptoms appear to abate. However, following this period
dyspnea worsens and cough becomes more frequent. Chest X-ray findings are non-specific
and include peri-bronchial thickening and hyperinflation. The latter is characterized by
lowered diaphragm, increased air contrast of the lungs, and increased retro-sternal space in
the lateral view. Atelectasis is also a common finding. Ventilation/Perfusion scans show the
distinctive pattern of a matched ventilation-perfusion defects and the segmental or lobar
distribution of post-infectious bronchiolitis obliterans. This provides an assessment of the
distribution pattern of the compromised areas of the lung. On histo-pathology, early lesions
of bronchiolitis obliterans demonstrate submucosal lymphocytic inflammation and
disruption of the epithelium of small airways, followed by an ingrowth of fibromyxoid
granulation tissue (polyploid plug of fibrotic tissue) into the airway lumen, resulting in
partial or complete obstruction (choice A).
→ Progressively worsening emphysema and development of liver cirrhosis (choice B)
would occur in a patient with anti-trypsin deficiency.
→ Bronchieactasis and pancreatic enzyme insufficiency with fat malabsorption (choice C)
would be seen in a patient with cystic fibrosis.
→ Bronchogenic adenocarcinoma at the periphery of the lungs (choice D) is incorrect as
there’s no association between adenovirus pneumonitis and lung cancer.
→ Systemic dissemination with nodules consisting of central caseating necrosis (choice E)
would be seen in miliary tuberculosis. This child’s clinical picture is more consistent with
adenovirus infection.
Key point:
In pediatric patients bronchiolitis obliterans is often a complication of adenovirus infection
of lower respiratory tract. In later stages, its histopathology is characterized by fibromyxoid
granulation tissue in the airway lumen, resulting in partial or complete obstruction.
Question #254
QID: 18276
Topic: Biliary atresia management
Subject: Pediatrics
A 6-week-old infant is brought to your department because of yellow skin. He also has dark
urine and light stools. Physical examination reveals icteric sclera and hepatosplenomegaly.
Laboratory studies are significant for conjugated bilirubin. Ultrasonography reveals
shrunken gallbladder and liver biopsy reveals portal fibrosis and bile duct proliferation.
What is the most appropriate next step in management?
a) Roux-en-Y hepatoportojejunostomy
b) Pancreaticoduodenectomy
c) Liver transplantation
d) Ursodeoxycholic acid
e) Observation until 1 year
The correct answer is a)
Explanation:
This child has elevated direct bilirubin, ultrasonography shows a shrunken gall bladder, and
biopsy reveals portal fibrosis and bile duct proliferation, which all point to a diagnosis of
biliary atresia. It is characterized by obliteration or discontinuity of the extrahepatic biliary
system. Once the diagnosis is confirmed with biopsy, the most appropriate initial treatment
is a Kasai procedure, the most successful version being a Roux-en-Y
hepatoportojejunostomy (choice A). It has been observed that prognosis is significantly
improved if surgery is done before 8 weeks of age.
→ Pancreaticoduodenectomy (choice B) also known as Whipple’s procedure is the
treatment of choice for pancreatic cancer. It is not appropriate for biliary atresia.
→ Liver transplantation (choice C) is successful as the definitive treatment of biliary atresia
in one third of biliary atresia patients. But the Kasai procedure is usually done as the initial
treatment to allow biliary drainage.
→ Ursodeoxycholic acid (choice D) has been shown to promote bile flow in cholestatic
conditions associated with a patent extrahepatic biliary system. It is used to enhance biliary
drainage after a Kasai procedure has been performed, but it would not be helpful before the
procedure.
→ Observation until 1 year (choice E) is incorrect. Studies have shown that children who
have the Kasai procedure before 60 days of age have a better prognosis, while those who are
operated later than 90 days of age are at disadvantage.
Key point:
Conjugated bilirubinemia, shrunken gall bladder on ultrasonography, and a biopsy that
reveals portal fibrosis and bile duct proliferation are suggestive of biliary atresia. Kasai
procedure is the best initial treatment in children with biliary atresia and is most beneficial
when performed before 60 days of age.
Question #255
QID: 18329
Topic: Cellulitis management
Subject: Pediatrics
An 8-year-old girl presents to the emergency department with a poorly healing wound on
the lateral side of her right leg 5 cm below the knee. She was injured when she fell down
while playing with her friends. Her mother cleaned the area and it has been conservatively
managed at home for the last 4 days. Her mother noted that the site has become very warm
to touch, the child is becoming anxious and it has affected the way she walks so she decided
to bring her for evaluation. Past medical history is not remarkable. Her immunizations are
uptodate.
On physical examination, her temperature 38.8°C, Pulse is 105 bpm, respirations 23/min,
BP is 110/65 mmHg. A poorly healing excoriation of the skin that contains some pus is
noted. The area is tender to touch, hot, and swollen. While limited range of motion is noted
because of pain, joints are not involved. 1 cm lymphadenopathy is palpable in the right
popliteal area. Incision and drainage are done at the office and bacterial culture is
performed. Based on the most common infections and antibiotic sensitivities, which of the
following medications are most appropriate to prescribe?
a) IV Vancomycin and topical fluticasone
b) Clindamycin and topical mupirocin
c) Doxycycline and topical nystatin
d) Erythromycin and topical neomycin
e) Amoxicillin-clavulanate and topical neomycin
The correct answer is b)
Explanation:
This child has cellulitis of her lower extremity. Risk factors include cracks or peeling of
skin, peripheral vascular disease, injury or trauma, insect bites and stings, diabetesassociated ulcers, immunosuppressive drugs use, and recent surgery. The most common
causative organisms are Streptococcus pyogenes and Staphylococcus aureus, but other
organisms may be involved if cellulitis originates from animal or human bites, is hospitalacquired, or occurs in an immunocompromised host. Tests are ordered depending on the
severity of the infection. Most cases of early or mild cellulitis, especially those without
fever, do not require laboratory testing. If there is an abscess or pustule, incision and
drainage with a wound culture of the purulent discharge can be helpful for focused and
appropriate antibiotic therapy.
While group A Streptococcus is sensitive to penicillin and cephalosporins, community
acquired methicillin resistant Staphylococcus aureus is quite common, therefore, the
selected antibiotics should take into account this reality. There’s less community acquired
Staphylococcus aureus resistance to clindamycin and trimethroprim-sulfamethoxazole.
Topical mupirocin is effective in managing Streptococcus pyogenes associated cellulitis.
Therefore, the best choice in this scenario is clindamycin and topical mupirocin (choice B).
→ IV vancomycin (choice A) is indicated for severely ill patients with MRSA infections,
those who are unable to tolerate oral medications, or those whose conditions worsen despite
empirical antibiotic therapy.
→ Doxycycline and topical nystatin (choice C) is used in aquatic in lacerations and
puncture wounds sustained in an aquatic environment; nystatin is an anti-fungal and this
child’s wound infection is most likely bacterial.
→ Erythromycin and topical neomycin (choice D) both are known to have high resistance.
→ Amoxicillin-clavulanate (choice E) is indicated in cellulitis caused by Pasteurela
multocida after a dog bite. For topical medications, mupirocin is the most effective with
efficacy considered equivalent to oral systemic antibiotics. There’s much resistance against
topical neomycin.
Key point:
Cellulitis is a nonnecrotizing inflammation of the skin and subcutaneous tissues, usually
from acute infection. There's little resistance against clindamycin and TMP-SMX, and they
are effective in treating this condition. Topical mupirocin is more effective than neomycin
and bacitracin.
Question #256
QID: 18326
Topic: Glucose-6-Phosphate dehydrogenase deficiency
Subject: Medicine
An 18-year-old sexually active black male presents to your department feeling weak, tired,
and a bit confused. He was seen 2 days earlier for burning on urination and treated with
TMP-SMX and phenazopyridine. Laboratory studies reveal hemoglobin of 95 g/L and
reticulocytes 21%. Rapid fluorescent blood spot test fails to fluoresce under ultraviolet light.
Which one of the following is most likely to be the cause of this clinical presentation?
a)
b)
c)
d)
e)
Sickle Cell Disease
Thrombotic Thrombocytopenic Purpura
Beta Thalassemia
Hemolytic Uremic Syndrome
Glucose-6-Phosphate Dehydrogenase Deficiency
The correct answer is e)
Explanation:
This patient’s clinical presentation is suggestive of hemolytic anemia. The patient has an
acute presentation with hemoglobin of 95 g/L and reticulocytes 21%. He is also black and
was recently treated with TMP-SMX and pyridium (phenazopyridine) - two drugs known to
cause oxidative stress in patients with glucose-6-phosphate dehydrogenase deficiency
(choice E). The G6PD enzyme catalyzes the oxidation of glucose-6-phosphate to 6phosphogluconate while concomitantly reducing the oxidized form of nicotinamide adenine
dinucleotide phosphate (NADP+) to nicotinamide adenine dinucleotide phosphate
(NADPH).This is why this condition can be confirmed by a positive rapid fluorescent spot
test, as seen in this patient. This test detects the generation of NADPH from NADP and is
positive if the blood spot fails to fluoresce under ultraviolet light.
→ Sickle cell disease (choice A) is also increased in blacks. It is not associated with high
risks of hemolytic anemia after treatment with TMP-SMX or phenazopyridine such as seen
in G6PD patients.
→ Thrombotic thrombocytopenia purpura (choice B) presents with classic pentad of
thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, kidney
failure, and fever.
→ Beta thalassemia (choice C) is caused by mutations in the globin genes. It affects 1 or
both of the beta-globin genes. Hemolytic anemia seen after treatment with TMP-SMX in
this patient is not commonly seen in beta-thalassemia; besides the results of the rapid
fluorescent blood spot test point to G6PD.
→ Hemolytic uremic syndrome (choice E) is characterized by the involvement of
widespread occlusive microvascular thromboses resulting in thrombocytopenia,
microangiopathic hemolytic anemia, and variable signs and symptoms of end-organ
ischemia. E. coli serotype O157:H7 has been associated with more than 80% of infections
leading to hemolytic uremic syndrome. The rapid fluorescent blood spot test that is positive
in this patient points to a diagnosis of G6PD deficiency.
Key point:
TMP-SMX can cause oxidative stress in G6PD deficiency patients leading to hemolytic
anemia.
Question #257
QID: 15954
Topic: Heart Murmur, innocent
Subject: Pediatrics
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) Extra sound/click is present
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. Murmurs which are attenuated with
changing body position are usually innocent.
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.
Question #258
QID: 16061
Topic: Heart Murmur, innocent
Subject: Pediatrics
During a routine physical examination of a 2-year-old child, a grade 3/6 early systolic
vibratory murmur is heard. The mother reports no signs or symptoms of illness. The child is
otherwise asymptomatic. Physical examination is normal. The most appropriate next step is
to:
a) Additional testing is not needed at this point
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 a)
Explanation:
This patient most likely has Stillʹ′s murmur, which is tthe most common innocent murmur in
children between the ages of 2 and 6 years, though it may be present at extremes of age
(adolescence and infancy). It is an early systolic, grade 1 to 3 (usually grade 2), low to
medium pitched murmur, best heard at the lower left sternal edge and extending to the apex
and loudest in the supine position. It changes on sitting or standing. It has a distinctive
vibratory quality or a twanging sound, which gives it a musical character.
The origin of the murmur is not clear. This has been attributed to various causes including
vibration of the pulmonary valves during systolic ejection, physiologic narrowing of the left
ventricular outflow tract and presence of ventricular false tendons.
Still’s murmur is diagnosed by physical examination. Additional testing is not necessary in
absence of additional siigns and symptoms. Still’s murmur is not associated with any sort of
cardiovascular pathology.
Question #259
QID: 18336
Topic: Galactosemia
Subject: Pediatrics
A six-day-old boy was brought to hospital because of episodes of vomiting, cyanosis, and
jitteriness and hepatomegally. His mother was not diabetic and he was a full-term baby of
normal birth weight and he was exclusively breast-fed. With appropriate work-up, the
diagnosis of hypoglycemia was established. Urinalysis showed presence of reducing
substance but no ketonuria.
Which of the following disorders is the most likely cause of hypoglycemia in this patient?
a) Transient neonatal hypoglycemia
b) Galactosemia
c) Type I Glycogen Storage Disease (Glucose-6-Phosphatase deficiency, Von Gierke
Disease)
d) Hereditary Fructose Intolerance (HFI)
e) Hyperinsulinism
The correct answer is b)
Explanation:
Galactosemia (choice B) typically presents in the second half of the first week of life with
features of hypoglycemia including vomiting, jaundice, cyanosis, jitteriness, and seizures.
The liver is usually enlarged. Urine of patients with galactosemia usually contains reducing
substances (galactose) but is devoid of ketone bodies. Our patient showed most of these
features and galactosemia is the most likely cause of hypoglycemia.
→ Transient neonatal hypoglycemia (choice A) is not the correct choice. Hepatomegally and
demonstration of reducing substance in urine make the diagnosis of transient neonatal
hypoglycemia unlikely. Urine of patients with transient neonatal hypoglycemia is not
expected to contain any reducing substance (sugars) because blood glucose is low i.e. much
lower than renal threshold for glucose reabsorption. Also hepatomegaly is not a feature of
transient neonatal hypoglycemia because the basic etiology of this disorder is reduced liver
glycogen stores due to immaturity of the responsible enzyme systems.
→ Type I Glycogen Storage Disease (choice C) is not the correct choice. Type I glycogen
storage disease usually presents at the age of three to four months. Urine of patients with
this disease is not expected to contain reducing substances because blood glucose is low i.e.
much lower than renal threshold for glucose reabsorption.
→ Hereditary Fructose Intolerance (HFI) (choice D) is not the correct choice. Patients with
HFI remain asymptomatic until foods containing fructose like table sugar or fruits are
introduced. Our patient is exclusive breast-fed.
→ Hyperinsulinism (choice E) is not the correct choice. Hepatomegaly and presence of
reducing substances in urine make hyperinsulinism an unlikely cause of hypoglycemia in
this patient. Urine of patients with this disorder is not expected to contain reducing
substances because blood glucose is low i.e. much lower than renal threshold for glucose
reabsorption.
Key point:
Demonstration of a reducing substance in urine of a neonate with hypoglycemia makes
galactosemia a highly likely diagnosis.
Question #260
QID: 18439
Topic: Galactosemia
Subject: Pediatrics
A woman brings her one-week-old son to the pediatrician because of vomiting and poor
weight gain. The neonate is exclusively breastfed and frequently vomits after feeding. His
mother also notes that his stools are almost always loose.
Physical exam reveals jaundice, a slightly sunken anterior fontanelle, and bilateral
opacification of the lenses.
Which of the following enzymes is likely deficient in this patient?
a) Glucose-6-phosphatase
b) Fructokinase
c) Fructose-1-phosphate aldolase
d) Galactokinase
e) Galactose-1-phosphate uridyltransferase
The correct answer is e)
Explanation:
The presence of jaundice, cataracts, vomiting, diarrhea, and poor weight gain in a breastfed
neonate is highly suggestive of classic galactosemia.
Galactosemia is caused by a deficiency of the enzyme galactose-1-phosphate
uridyltransferase (choice E). This enzyme converts galactose-1-phosphate to uridine
diphosphate (UDP) galactose, which can then either be converted to glucose, or used for
biosynthesis of glycolipids, glycoproteins, or glycosaminoglycans. When this enzyme is
deficient, there is an excess of galactose-1-phosphate. The only other pathway for
galactose-1-phosphate is conversion to galactitol via aldose reductase, since the addition of
phosphate to galactose traps it inside the cell.
The excess galactose-1-phosphate and galactitol accumulates in liver, kidney, lens, and
nervous tissue, causing cirrhosis, cataracts, mental retardation, and failure to thrive.
The source of galactose in this patient is from lactose, which is broken down into glucose
and galactose. Breastfeeding is contraindicated in patients with galactosemia for this reason.
Rapid diagnosis, and removal of galactose is the best treatment for galactosemia, but
neonatal screening can prevent it.
→ Glucose-6-phosphatase (choice A) is incorrect, since a deficiency in this enzyme would
cause Von Geirke's disease, a glycogen storage disease characterized by fasting
hypoglycemia, hepatosplenomegaly, lactic acidosis, and hyperuricemia.
→ Fructokinase (choice B) is incorrect. A fructokinase deficiency leads to essential
fructosuria, a clinically benign condition resulting in fructosuria without major symptoms.
→ Fructose-1-phosphate aldolase deficiency (choice C) is incorrect. Deficiency of this
enzyme causes Hereditary fructose intolerance, resulting in severe hepatotoxicity, since
causes accumulation of fructose-1-phosphate by preventing it's conversion to
glyceraldehyde and dihydroxyacetone. While jaundice, vomiting, and hepatomegaly are
expected, cataracts are not, and this disease usually manifests after switching from breast
milk to formula, as that is when fructose is often introduced to the diet for the first time.
→ Galactokinase (choice D) is incorrect. Galactokinase deficiency results in the
accumulation of galactose. However, since galactose cannot be phosphorylated, it is not
trapped inside of cells, and can leave, being excreted in the urine (galactosuria). While it is
possible that it can cause cataracts by way of conversion of galactose to galactitol, it does
not affect other tissues. This disease mechanism is similar to fructokinase deficiency. Both
of these diseases result in excretion of their respective sugar in the urine without major
systemic symptoms.
Key point:
Galactosemia is caused by a deficiency of galactose-1-phosphate uridyltransferase, and can
be recognized by vomiting, diarrhea, jaundice, cataracts and failure to thrive in a neonate.
Rapid removal of galactose is essential for treatment.
Question #261
QID: 18393
Topic: Becker muscular dystrophy
Subject: Pediatrics
A 6-year-old boy is brought to his family physician because he was observed to fall
frequently and has difficulty getting up from the floor. Physical exam shows no
abnormalities other than positive Gower sign and a heart rate of 115 bpm.
With appropriate work-up, neuropathies and inflammatory and metabolic myopathies are
excluded. The family physician suspects Duchenne or Becker muscular dystrophy.
Which of the following pieces of history or lab results would support the diagnosis of
Becker muscular dystrophy (BMD) rather than Duchenne muscular dystrophy (DMD)?
a) A male sibling without any obvious health problems, who has normal serum creatine
kinase at the age of 17 years
b) A female sibling without any obvious health problems, who has normal serum creatine
kinase at the age of 8 years
c) A father without any obvious health problems at the age of 35 years
d) A maternal uncle who has muscle dystrophy but is ambulatory at the age of 17 years
e) A paternal uncle without any obvious health problems at the age of 17 years
The correct answer is d)
Explanation:
Becker muscular dystrophy (BMD), is a mild form of X-linked muscle dystrophy with late
onset. Patients with this disease usually remain ambulatory beyond the age of 15 to 20
years. Like BMD, Duchenne muscular dystrophy (DMD) is also X-linked but has an early
onset and patients with this disease are usually confined to wheel chair by the age of 7 years.
A maternal uncle who has muscle dystrophy but is ambulatory at the age of 17 (choice D)
would favor the diagnosis of BMD rather than DMD. A maternal uncle with dystrophy
suggests the X-linked transmission of dystrophy and the fact that the maternal uncle is
ambulatory at the age of 17 years suggest the milder form or BMD. Thus, if there is a family
history of maternal uncle with dystrophy and who is ambulatory beyond the age of 15 years,
BMD rather than DMD is the likely diagnosis.
→ A male sibling without any obvious health problems who has normal serum creatine
kinase at the age of 17 years (choice A) can be a sibling to a patient with Duchenne
muscular dystrophy (DMD) or Becker muscular dystrophy (BMD). Both diseases are
transmitted as x-linked recessive and only 50% of male off-spring of female carriers
develop the diseases. The other 50% might inherit the normal X chromosome from the
female carrier and might thus, be normal. So, a normal male sibling cannot differentiate
between DMD and BMD.
→ A female sibling without any obvious health problems who has normal serum creatine
kinase at the age of 8 years (choice B) can be a sibling to a patient with DMD or BMD.
Both diseases are transmitted as x-linked recessive and only 50% of female off-springs of
female carriers would be carriers and have high serum creatine kinase. The other 50% might
inherit the normal X chromosome from the female carrier and are thus, not carriers and have
normal serum creatine kinase. So, a normal female sibling cannot differentiate between
DMD and BMD.
→ A father without any obvious health problems at the age of 35 years (choice C) could a
father to a patient with DMD or BMD. Fathers give their Y chromosomes to their sons and
cannot transmit X-linked recessive diseases like DMD or BMD.
→ A paternal uncle without any obvious health problems at the age of 17 years (choice E)
could be an uncle to a patient with DMD or BMD. Both disease are transmitted as x-linked
recessive and are not transmitted from the paternal side.
Key point:
A patient with muscular dystrophy who has a maternal uncle with dystrophy who is
ambulatory beyond the age of 15 years, most likely has Becker muscular dystrophy rather
than Duchenne muscular dystrophy.
Question #262
QID: 18304
Topic: Congenital Heart Diseases
Subject: Pediatrics
A mother brings her 4-month-old baby because she thinks he looks a little “blue” and seems
to be a bit short of breath when feeding him. He has no significant perinatal or other history,
and neither does his mother or father.
On examination, you confirm that the baby is cyanotic and seems to have severe respiratory
distress, especially when attempting to bottle-feed him. There is a hyperactive right
ventricle impulse, quadruple rhythm, fixed and widely split S2, a systolic ejection murmur
and a mid-diastolic rumble on the left lower sternal border. The blood pressure appears
normal and equal in all extremities.
His ECG reveals a right ventricle hypertrophy and right axis deviation. The X-ray shows an
enlarged right heart and an increased pulmonary vascular markings and the radiologist
reports a “classic pattern of a snowman in a storm.”
Which of the following is your presumptive diagnosis before obtaining an echocardiogram?
a) Tetralogy of Fallot
b) Ticuspic Atresia
c) Total Anomalous Pulmonary Venous Return
d) Coarctation of the Aorta
e) Patent Ductus Arteriosus
The correct answer is c)
Explanation:
Total anomalous pulmonary venous return is a congenital heart disease in which, instead of
draining into the left auricle, the pulmonary vein drains into any of the following locations:
Supracardiac (most common, Superior Vena Cava), Cardiac (coronary sinus or Right
Auricle), Subdiaphragmatic (Inferior Vena Cava, Portal Vein, Ductus Venosus, or hepatic
vein), or mixed site.
The examination findings are a hyperactive RV impulse, quadruple rhythm, S2 fixed and
widely split, 2-3/6 systolic ejection murmur at the left upper sternal border and mid-diastolic
rumble at the left lower sternal border. The ECG reports right axis deviation and right
ventricle hypertrophy, and may come with right atrial enlargement. The X-ray shows
cardiomegaly at expense of the right heart and the classic finding of “snowman in a storm,”
which is due to enlargement of the heart and the presence of a dilated right superior vena
cava, innominate vein, and left vertical vein.
→ Tetralogy of Fallot (choice A) will have a loud systolic ejection murmur at the left midsternal border and left upper sternal border, and a loud, single S2. The ECG will show right
axis deviation and right ventricle hypertrophy. A boot-shaped heart with normal heart size
and decreased pulmonary venous markings will appear on the chest x-ray.
→ Tricuspid Atresia (choice B) will show a single S2 with a 2-3/6 systolic regurgitation
murmur at the left lower sternal border if a ventricular septal defect is present. The ECG
will show a superior axis deviation and a right auricle enlargement or common atrial
enlargement and left ventricle hypertrophy. The heart will appear of normal or slightly
enlarged size in the chest x-ray and have a boot shape.
→ Coarctation of the aorta (choice D) usually presents with a 2-3/6 systolic ejection
murmur at the left upper sternal border radiating to the interescapular area. Classically, the
lower extremities will have a lower BP than the upper extremities, and this may be
accompanied by a discrepancy of > 5% discrepancy between upper and lower extremities
pulse oximetry.
→ Patent Ductus Arteriosus (choice E) usually exhibits a 1-4/6 continuous machinery
murmur that is loudest at the left upper sternal border and a wide pulse pressure.
Key point:
Careful clinical examination and x-ray of the newborn and infant with suspected congenital
heart disease can point towards the diagnosis before obtaining an Echocardiogram.
Question #263
QID: 18421
Topic: Acute Otitis Media
Subject: Pediatrics
A 3-year-old boy presents to your walk-in clinic with a 4-day history of fever, decreased
appetite and irritability. His mother adds that he has been pulling his right ear for the last
four days. He has normal urine output and energy. He is otherwise healthy.
Vital signs: temperature: 38.4°C, BP: 90/50 mmHg, HR: 120 bpm, RR: 30 rpm. On
examination you see an energetic boy. Otoscopic examination reveals a red, bulging
tympanic membrane on the right side. The opposite ear is normal. Examination of the
oropharynx is normal. There is no head or neck lymphadenopathy.
What is your next step in the immediate management of this patient?
a) Reassurance and follow-up with primary care provider in 2 weeks
b) Treat with amoxicillin-clavulanate 80 mg/kg/d for 7 days.
c) Treat with amoxicillin 40 mg/kg/d for 7 days.
d) Treat with amoxicillin 80 mg/kg/d for 7 days.
e) Counsel that often no antibiotic treatment is required and 90% of children improve
spontaneously by 5 days.
The correct answer is d)
Explanation:
The high spontaneous recovery rate (80-90%) of acute otitis media may warrant watchful
waiting for 48-72 hours before starting antibiotic therapy. However, in cases where there is
prolonged fever such as in this boy, treatment with antibiotics is clinically warranted. The
treatment of choice for acute otitis media is currently amoxicillin at a dose 80-90 mg/kg/d
divided into two doses for 7 days (choice D). Amoxicillin is favoured for its low cost,
narrow coverage spectrum, and side effect profile. Further cases where treatment with
antibiotics is suggested include:
•
children < 6 months of age
•
children between 6 months and 2 years of age with symptoms > 3 days
•
children over 2 years who appear sick, bilateral otalgia or cannot be followed up in
48 hours
Generally speaking, treatment with antibiotics occurs in the above conditions as well as in
clinical settings where follow-up may be uncertain. Treatment of otitis media with
antibiotics does have the following benefits over conservative treatment:
•
reduced pain at 2-3 days
•
reduced tympanic membrane perforations
•
reduced incidence of bilateral disease
•
serious complications including mastoiditis and meningitis were equally rare in the
group receiving antibiotics and the group receiving symptomatic treatment.
→ While reassurance and follow-up (choice A) are reasonable options, closer follow-up
period of 48-72 hours would be advisable for this patient with fever.
→ Amoxicillin-clavulanate (choice B) is often reserved as second-line treatment or in cases
where there has been recent antibiotic use in the last three months.
→ Amoxicillin 40 mg/kg/d for 7 days (choice C) has fallen out of favour due to increasing
resistance by Streptococcus pneumoniae.
→Typically, spontaneous recovery (choice E) is seen in 50% of patients by 3 days and 90%
of patients by 7 days.
Key point:
Acute otitis media has a high spontaneous recovery rate, however in select cases including
age less than two, and cases where follow-up is uncertain, first line treatment for otitis
media is amoxicillin 80-90 mg/kg daily divided into two doses for 7 days.
Otitis Media
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Question Count: 268
Question #1
QID: 15636
Topic: Neurofibromatosis
Subject: Pediatrics
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.
Question #2
QID: 15889
Topic: Neurofibromatosis
Subject: Pediatrics
A 7-year-old girl presents with multiple hyperpigmented 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)
b)
c)
d)
e)
Tuberous sclerosis
Sturge-Weber disease
Neurofibromatosis
Ataxia telangiectasia
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.
Question #3
QID: 15407
Topic: Osgood-Schlatter disease
Subject: Pediatrics
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) Septic arthritis
d) Slipped capital femoral epiphysis
e) Osgood-Schlatter disease
The correct answer is e)
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.
Question #4
QID: 17141
Topic: Osgood-Schlatter disease
Subject: Pediatrics
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, antiinflammatory medications, a rehabilitation program, and an infrapatellar strap during
activities. Casting and corticosteroid injections are not indicated.
Question #5
QID: 16210
Topic: Pneumonia
Subject: Pediatrics
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.
Question #6
QID: 16800
Topic: Pneumonia
Subject: Pediatrics
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 9.8 x 10^9/L 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
e) Antitussives
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 6year-old is more likely to have mycoplasmal disease.
Antitussives should be avoided as none have been found to be effective in pneumonia.
Question #7
QID: 16846
Topic: Pneumonia
Subject: Pediatrics
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 37.9°C (100.2°F), 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.
Question #8
QID: 16859
Topic: Pneumonia
Subject: Pediatrics
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.
Question #9
QID: 17042
Topic: Pneumonia
Subject: Pediatrics
The most common cause of pneumonia in preschool-age (3 months - 4 years) 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.
Question #10
QID: 17394
Topic: Pneumonia
Subject: Pediatrics
A 10-year-old female presents to your office with a 4-day history of non-productive cough,
low grade fever of 38.1°C (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 37.7°C (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.
Question #11
QID: 15409
Topic: Nephritic Syndrome, acute
Subject: Pediatrics
A 5-year-old boy is brought to the ED with swollen eyelids, loss of appetite, nausea and
vomiting. His blood pressure is high and urine tests show RBC casts. Valuable treatment for
his acute nephritic syndrome will include all of the following, except:
a) Loop diuretic
b) Salt restriction
c) Penicillin
d) Glucocorticoids
e) Calcium channel blocker
The correct answer is d)
Explanation:
Glomerulonephritis generally presents as a set of findings that includes hematuria, edema,
and often hypertension. It is caused by a number of disorders that are all characterized by
glomerular injury accompanied by inflammation. In some cases, it may progress to renal
failure. Treatment is mainly supportive, because there is no specific therapy for renal
disease. When acute glomerulonephritis is associated with chronic infections, the underlying
infections must be treated.
→ Nephritis treatment involves a diet that is low in protein and sodium (choice B), and may
be necessary until kidney function recovers.
→ Diuretics (choice A) may be prescribed to help the kidneys excrete excess sodium and
water and to treat high blood pressure.
→ Other agents useful in treating hypertension include calcium channel blockers (choice E)
and nitroprusside and angiotensin converting enzyme inhibitors.
→ Most of acute glomeulonephritis patients have a recent streptococcal infection and are
treate with penicillin (choice C), even though this antibiotic doesn't reduce the risks of
glomerulonephritis development after 36 hours of clinical presentation, it is still useful to
control symptoms of the throat and to prevent spread of infection to close contacts.
Glucocorticoids (choice D) are usually not indicated for acute glomerulonephritis and are
only used in rare cases that develop into rapidly progressive glomerulonephritis. Therefore,
glucocorticoids was the only treatment that is not generally indicated for patients with acute
glomerulonephritis.
Question #12
QID: 15427
Topic: Juvenile Rheumatoid Arthritis
Subject: Pediatrics
A 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: (+)
ANA: (-)
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.
Question #13
QID: 15741
Topic: Juvenile Rheumatoid Arthritis
Subject: Pediatrics
What is the most common complication of juvenile rheumatoid arthritis?
a) Iridocyclitis
b) Hepatitis
c) Nephritis
d) Vasculitis
e) Macrognathia
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.
Question #14
QID: 16228
Topic: Juvenile Rheumatoid Arthritis
Subject: Pediatrics
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.
Question #15
QID: 16600
Topic: Juvenile Rheumatoid Arthritis
Subject: Pediatrics
Which one of the following is a manifestation of pauci-articular juvenile rheumatoid
arthritis?
a) Uveitis
b) Splenomegaly, but not hepatomegaly
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.
Question #16
QID: 15454
Topic: Vesicoureteral Reflux
Subject: Pediatrics
A 2-year-old boy has developed grade 4 vesicoureteral reflux. What is the most appropriate
management?
a) Intermittent prophylactic antibiotic
b) Continuous prophylactic antibiotic
c) Observation
d) Surgery
e) Treatment with pyridium
The correct answer is b)
Explanation:
Vesicoureteral reflux (VUR) is the backup of urine from bladder into the ureter during
urination. VUR may result in urine reflux into the renal pelvis, causing 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 patients with grades III to V VUR regardless of age receive antibiotic
prophylaxis (choice B). Although no large randomized trials have been conducted
establishing the efficacy of prophylactic antibiotics in prevention of either urinary
tract infection (UTI) or renal scarring, several decades of clinical practice have
demonstrated that antibiotic prophylaxis is usually well-tolerated, and clinicians are
reluctant not to offer some treatment. The typical dose is one fourth of the therapeutic dose.
→ Intermittent prophylactic antibiotic (choice A) and observation (choice B) in a child with confirmed VUR
grade IV are not preferred as they are not considered protective enough against recurrent
infection.Prophylaxis should be started once a child has completed treatment of the
initial UTI and continues at least until imaging reveals vesicoureteral reflux. If no vesicoureteral is seen,
prophylaxis is discontinued. If vesicoureteral reflux is present, prophylactic antibiotics are continued until (1)
vesicoureteral reflux resolves, (2) vesicoureteral reflux is surgically corrected, or (3) the child grows old
enough that prophylaxis is deemed no longer necessary.
→ At this time surgery (choice D) is not indicated in this child. Accepted indications for surgical treatment
include the following: (1) breakthrough febrile UTIs despite adequate antibiotic prophylaxis; (2) severe reflux
(grade V or bilateral grade IV) that is unlikely to spontaneously resolve, especially if renal scarring is present;
(3) mild or moderate reflux in females that persists as the patient approaches puberty, despite several years
of observation; (4) poor compliance with medications or surveillance programs; and (5) poor renal growth or
function or appearance of new scars.
→ Pyridium (choice E) is often used to alleviate the pain, irritation, discomfort, or urgency
caused by urinary tract infections, surgery, or injury to the urinary tract. While children with
VUR are at increased risks of UTI, pyridium is not given simply for confirmed VUR
without an infection and the symptoms that warrant its use.
Question #17
QID: 15584
Topic: Vesicoureteral Reflux
Subject: Pediatrics
A 10-month-old child presents for the 5th time with symptoms of pain when he urinates,
fever, and abdominal tenderness. What is the most likely underlying cause of his recurrent
UTIs?
a) Ureteropelvic junction obstruction
b) Vesicoureteral reflux
c) Potter's syndrome
d) Cryptorchidism
e) Nephroblastoma
The correct answer is b)
Explanation:
Vesicoureteral reflux (choice B) 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.
→ Ureteropelvic junction obstruction (choice A) is the most common cause of neonatal and
antenatal hydronephrosis. Prior to the use of prenatal ultrasonography, most patients with
this condition presented with pain, hematuria, urosepsis, failure to thrive, or a palpable
mass. It is found in approximately 50% of patients diagnosed with antenatal hydronephrosis.
→ Potter's Syndrome (bilateral renal agenesis) (choice C) - would have been diagnosed
in his antepartum or neonatal period.
→ Cryptorchidism (choice D) is the most common genital problem encountered in
pediatrics. It presents with an empty and hypoplastic or poorly rugated scrotum or
hemiscrotum.
→ Nephroblastoma (Wilms tumor) (choice E) presents as a large, solid tumor (abdominal
mass) of renal origin. Average age of incidence is 3 years.
Question #18
QID: 16011
Topic: Vesicoureteral Reflux
Subject: Pediatrics
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.
Question #19
QID: 16365
Topic: Vesicoureteral Reflux
Subject: Pediatrics
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
c) Voiding cystourethrography
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.
Question #20
QID: 15457
Topic: Scarlet Fever
Subject: Pediatrics
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 most 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.
Question #21
QID: 15459
Topic: Seborrheic Dermatitis
Subject: Pediatrics
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
e) Tinea versicolor
The correct answer is c)
Explanation:
Seborrhoeic dermatitis (choice C) 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.
→ Atopic dermatitis, eczema (choice A and choice D) occurs in the first year of life in 60%
of cases. The infantile stage may present with pruritic, red, scaly, and crusted lesions on the
extensor surfaces and cheeks or scalp. There is usually sparing of the diaper area. Acute
lesions can include vesicles, and there can be serous exudates and crusting in severe cases.
→ Psoriasis (choice B) is characterized by scaling erythematous macules, papules, and
plaques. Typically, the macules are seen first, and these progress to maculopapules and
ultimately well-demarcated, noncoherent, silvery plaques overlying a glossy homogeneous
erythema.
→ Tinea versicolor (choice E) is a common, benign, superficial cutaneous fungal infection
usually characterized by hypopigmented or hyperpigmented macules and patches on the
chest and the back.
Question #22
QID: 15942
Topic: Seborrheic Dermatitis
Subject: Pediatrics
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.
Although this condition usually resolves without treatment, it may require treatment in some
cases. Suggestions for treatment include:
-Shampoo frequently with baby shampoo (choice D) and gently remove scaly skin with a
soft brush or fine-tooth comb after shampooing.
-Apply a small amount of an emollient (white petroleum jelly, vegetable oil, mineral oil,
baby oil) (choice C) to the scalp (overnight, if necessary) to loosen the scaly patches,
followed by gentle scalp massage with a soft brush (to lift the scale), then shampoo with a
nonmedicated baby shampoo.
If it persists despite these measures, mild topical corticosteroids (choice A) or a prescription
antifungal (not antibacterial) shampoo may be used.
Question #23
QID: 15479
Topic: Turner Syndrome
Subject: Pediatrics
A 16-year-old girl is brought in for evaluation. See picture:
She has short stature, no sexual development, no pubic hair, no breast development. What is
the most appropriate test to reach the diagnosis?
a) Karyotype
b) FSH and LH
c) TSH and GH
d) CT of head
e) Glucose tolerance test
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.
Question #24
QID: 15788
Topic: Turner Syndrome
Subject: Pediatrics
All of the following are associated with Turner syndrome, except:
a) Short stature
b) Amenorrhea
c) Coarctation of the aorta
d) Hirsutism
e) Webbed neck
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.
Question #25
QID: 17408
Topic: Turner Syndrome
Subject: Pediatrics
All of the following are appropriate steps in managing the patients in following figures,
except:
a)
b)
c)
d)
e)
Echocardiogram
Renal ultrasonography
Chromosome analysis
Brain MRI
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.
Question #26
QID: 18213
Topic: Turner Syndrome
Subject: Pediatrics
A 15-year-old female is brought to the hospital by her mother because she has never had
menstrual periods and the mother is concerned. On physical examination the girl appears
short, has a webbed neck. Four-limb blood pressures were also evaluated: higher blood
pressures were noted in the arms while the ones of the lower extremities were normal.
Which of the following is the best way to confirm this girl’s diagnosis?
a) Echocardiography
b) FSH, LH, and Estrogen levels
c) Karyotype
d) Brain MRI
e) Bone age assessment
The correct answer is c)
Explanation:
This girl has primary amenorrhea, a webbed neck, and a significant difference between the
blood pressure in the upper and lower extremities (suggesting possible coarctation of the
aorta). These findings suggest Turner syndrome as the most likely diagnosis. The best way
to confirm this diagnosis is a standard 30 cell Karyotype, which in Turner syndrome would
reveal 45, XO cell line or a cell line with deletion of the short arm of the X chromosome.
→ An echocardiography (choice A) is useful in evaluating cardiovascular abnormalities of
Turner syndrome such as the coarctation of the aorta; while this is an important
characteristic of Turner syndrome, it is not the best way to confirm it.
→ FSH, LH, and Estrogen (choice B) are likely to be abnormal in this patient. With
estrogen being low while FSH and LH are elevated; this, however, is not the best way to
confirm Turner syndrome.
→ Brain MRI (choice D) would be useful in cases of amenorrhea caused by pituitary
pathology such as craniopharyngioma, it is not the best way to confirm Turner syndrome.
→ Bone age assessment (choice E) will be useful in the management of this patient as
hormone therapy is being considered; however, this is not the best way to confirm Turner
syndrome.
Key point:
When Turner syndrome is suspected, karyotype is the best way to confirm it.
Question #27
QID: 15494
Topic: Mesenteric Lymphadenitis
Subject: Pediatrics
What is the condition most commonly mistaken for appendicitis in children?
a) Mesenteric lymphadenitis
b) Meckel's 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.
Question #28
QID: 17163
Topic: SIDS
Subject: Pediatrics
Which one of the following is associated with a reduction in risk for sudden infant death
syndrome?
a) Avoiding excessively soft or padded sleep surface
b) Keeping a stuffed toy in a crib for baby's comfort
c) Putting the baby to sleep in a prone position
d) Putting the baby to sleep on his or her side
e) Bed-sharing with parents or siblings
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. Avoid
excessively soft or padded sleep surfaces, including pillows, comforters, and waterbeds.
Keep soft objects and loose bedding out of the crib.
→ 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. Bed-sharing may lead to compromise of the
infants' airway. Sleeping in a separate bed or crib in the same room with the parents may be
a safer alternative
Question #29
QID: 17379
Topic: SIDS
Subject: Pediatrics
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.
Question #30
QID: 15532
Topic: Patent Ductus Arteriosus
Subject: Pediatrics
A baby born prematurely develops tachypnea, tachycardia, bounding peripheral pulses,
and a machine like murmur. What is the most likely cause of this?
a) Infective endocarditis
b) Heart failure with Ventricular septal defect
c) Patent ductus arteriosus
d) Atrial septal defect
e) Mitral regurgitation
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.
Question #31
QID: 15613
Topic: Patent Ductus Arteriosus
Subject: Pediatrics
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
e) Mid-systolic ejection 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.
Question #32
QID: 15900
Topic: Patent Ductus Arteriosus
Subject: Pediatrics
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.
Question #33
QID: 16224
Topic: Otitis Media
Subject: Pediatrics
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
e) Breastfeeding
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.
Question #34
QID: 16430
Topic: Otitis Media
Subject: Pediatrics
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.
Question #35
QID: 18119
Topic: Otitis Media
Subject: Pediatrics
Which one of the following is the most common cause of recurrent and persistent acute
otitis media in children?
a) Haemophilus influenzae
b) Moraxella catarrhalis
c) Penicillin-resistant Streptococcus pneumoniae
d) Pseudomonas aeruginosa
e) Staphylococcus aureus
The correct answer is c)
Explanation:
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most
common bacterial isolates from the middle ear fluid of children with acute otitis media.
Penicillin-resistant S. pneumoniae is the most common cause of recurrent and persistent
acute otitis media.
Question #36
QID: 15567
Topic: Infantile spasms
Subject: Pediatrics
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.
Question #37
QID: 15568
Topic: Selective Mutism
Subject: Pediatrics
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 be associated with anxiety
d) Has a communication disorder (eg stuttering)
e) The mutism has persisted for at least one week
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).
Question #38
QID: 15569
Topic: Shaken Baby Syndrome
Subject: Pediatrics
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)
b)
c)
d)
e)
Idiopathic thrombocytopenic purpura
Keratitis
Accidental injury
Non-accidental injury
Pigment epithelial detachment
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.
Shaken Baby Syndrome
Question #39
QID: 16045
Topic: Shaken Baby Syndrome
Subject: Pediatrics
The emergency department 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.
Shaken Baby Syndrome
Question #40
QID: 17774
Topic: Shaken Baby Syndrome
Subject: 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.
Shaken Baby Syndrome
Question #41
QID: 15570
Topic: MMR vaccine
Subject: Pediatrics
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
c) Give the child the MMR vaccine under medical supervision
d) Do not give if the child is allergic to egg proteins
e) Delay the MMR vaccination
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.
Question #42
QID: 15579
Topic: Laryngotracheobronchitis
Subject: Pediatrics
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 department 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.
Question #43
QID: 15805
Topic: Laryngotracheobronchitis
Subject: Pediatrics
A 2-year-old girl is brought to the ED by her parents. 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.
Question #44
QID: 16231
Topic: Laryngotracheobronchitis
Subject: Pediatrics
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.
Question #45
QID: 16691
Topic: Laryngotracheobronchitis
Subject: Pediatrics
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
The correct answer is a)
Explanation:
Croup is a viral illness and is not treated with antibiotics. Racemic epinephrine may be used
acutely, but rebound can occur. Albuterol has not been shown to be helpful. Oral or
intramuscular dexamethasone, 0.6 mg/kg as a single dose, and nebulized budesonide have
been shown to reduce croup scores and shorten hospital stays.
Question #46
QID: 17763
Topic: Laryngotracheobronchitis
Subject: Pediatrics
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.
Question #47
QID: 17809
Topic: Laryngotracheobronchitis
Subject: Pediatrics
Which one of the following is true concerning the use of dexamethasone to treat acute
laryngotracheitis (croup)?
a) A single dose is adequate for treatment
b) Single dose treatment frequently leads to a secondary bacterial infection due to
immunosuppression
c) It increases the need for hospitalization
d) It is indicated only for patients with severe croup
The correct answer is a)
Explanation:
Treatment with corticosteroids is now routinely recommended for acute laryngotracheitis
(croup). A single dose of dexamethasone, either orally or intramuscularly, is appropriate.
Prolonged courses of corticosteroids provide no additional benefit and may lead to
secondary bacterial or fungal infections. Secondary infections rarely occur with single-dose
treatment. Corticosteroid therapy shortens emergency department stays and decreases the
need for return visits and hospitalizations. It is indicated for patients with croup of any
severity.
Question #48
QID: 17932
Topic: Laryngotracheobronchitis
Subject: Pediatrics
A 2-year-old Hispanic male with a 3-day history of nasal congestion presents with a barking
cough and hoarseness. He is afebrile. The examination reveals tachypnea, inspiratory and
expiratory stridor, noticeable intercostal retractions, and good color.
Which one of the following is indicated?
a) Albuterol syrup and the use of a humidifier
b) Inhaled albuterol (Proventil, Ventolin)
c) Aerosolized epinephrine and intramuscular dexamethasone
d) Visualization of the epiglottis, and ceftriaxone (Rocephin)
The correct answer is c)
Explanation:
This child has a history and physical findings typical of viral laryngotracheobronchitis, or
croup. In rare instances, this illness can be complicated by critical upper airway obstruction.
The symptoms of cough, respiratory stridor, and distress result from edema of the subglottic
portion of the upper airway. Humidification of inspired air is sometimes beneficial, but the
child should not be sent home until improvement is demonstrated. Because this child has
stridor and intercostal retractions, aerosolized epinephrine is indicated, along with
intramuscular dexamethasone, and hospitalization may be required for observation and
continued treatment. Antibiotics do not have a role in the treatment of viral croup, and
attempted visualization of the epiglottis is not indicated since it will increase the child’s
anxiety and worsen the symptoms.
Question #49
QID: 15589
Topic: Slipped Capital Femoral Epiphysis
Subject: Pediatrics
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-Calvé-Perthes disease
e) Distal femur fracture due to child abuse
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.
Question #50
QID: 15720
Topic: Slipped Capital Femoral Epiphysis
Subject: Pediatrics
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.
Question #51
QID: 17754
Topic: Slipped Capital Femoral Epiphysis
Subject: Pediatrics
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.
Question #52
QID: 17835
Topic: Slipped Capital Femoral Epiphysis
Subject: Pediatrics
A 13-year-old male presents with a 3-week history of left lower thigh and knee pain. There
is no history of a specific injury, and his past medical history is negative. He has had no
fevers, night sweats, or weight loss, and the pain does not awaken him at night. He tried out
for the basketball team but had to quit because of the pain, which was worse when he tried
to run.
Which one of the following physical examination findings would be pathognomonic for
slipped capital femoral epiphysis?
a) Excessive forward passive motion of the tibia with the knee flexed
b) Lateral displacement of the patella with active knee flexion
c) Limited internal rotation of the flexed hip
d) Reduced hip abduction with the hip flexed
e) Inability to extend the hip past the neutral position
The correct answer is c)
Explanation:
Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents during the
growth spurt. Physical activity, obesity, and male gender are predisposing factors for the
development of this condition, in which the femoral head is displaced posteriorly through
the growth plate. There is pain with physical activity, most commonly in the upper thigh
anteriorly, but one-third of patients present with referred lower thigh or knee pain, which
can make accurate and timely diagnosis more difficult. The hallmark of SCFE on
examination is limited internal rotation of the hip. Specific to SCFE is the even greater
limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has
this physical finding, which makes the maneuver very useful in children with lower
extremity pain. Orthopedic consultation is advised if SCFE is suspected. Hip extension and
abduction are also limited in SCFE, but these findings are nonspecific. The knee findings in
this patient are not associated with SCFE.
Question #53
QID: 15603
Topic: Scoliosis
Subject: Pediatrics
A 13-year-old girl sustains a minor injury to the left side of her back in a school basketball
game. On examination little is found except for asymmetric shoulder levels. While she
bends over, the right posterior chest is elevated. Which of the following are these findings
most readily suggestive of?
a) An accessory rib
b) An iliopsoas muscle spasm
c) Rhabdomyosarcoma
d) Scoliosis
e) Hematoma
The correct answer is d)
Explanation:
Scoliosis is lateral curvature of the spine. It can be detected in 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.
Muscular backaches in areas of strain (eg, in the lumbosacral angle) may follow.
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.
The greater the curve, the greater the likelihood that it will progress after the skeleton
matures. Curves > 10° are considered significant. Prognosis depends on site and severity of
the curve and age at symptom onset. Significant intervention is required in < 10% of
patients.
Question #54
QID: 16054
Topic: Scoliosis
Subject: Pediatrics
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.
Question #55
QID: 15615
Topic: Wilms Tumor
Subject: Pediatrics
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)
c)
d)
e)
Polycystic kidney
Transitional cell carcinoma
Wilms tumour
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 younger than 5 years but occasionally in older
children and rarely in adults. Wilms' tumor accounts for about 6% of cancers in children <
15 years.
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.
Wilms Tumor
Wilms Tumor
Question #56
QID: 15617
Topic: Puberty
Subject: Pediatrics
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.
Question #57
QID: 15779
Topic: Puberty
Subject: Pediatrics
Which of the following is typically the first sign of puberty in girls?
a) Breast budding
b) Menarche
c) Underarm hair
d) Leukorrhea
e) Ovulation
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.
Question #58
QID: 18011
Topic: Puberty
Subject: Pediatrics
In normal female pubertal development, which of the following is true?
a) Adrenarche usually precedes thelarche
b) Menarche usually precedes adrenarche
c) Menarche usually precedes peak height velocity
d) Regular ovulatory cycles occur about 2 years after menarche
e) Ovulation must occur before menses can begin
The correct answer is d)
Explanation:
The normal stages of female pubertal development in order are: thelarche (breast budding),
adrenarche (pubic and axillary hair), peak height velocity, and menarche.
The age of pubertal change has been getting earlier, with breast development starting
between the ages of 10 and 11 and menarche between the ages of 12 and 13. The mean
interval from thelarche to menarche is 2.3 years, with a standard deviation of 1 year. If there
is an absence of secondary sexual characteristics by age 14 with no menarche or normal
secondary sexual characteristics but no menarche by 16, then the diagnostic workup of
primary amenorrhea is necessary.
A. Thelarche is before adrenarche.
B. Menarche is the final event in the process.
C. Peak height velocity is about 1 year before the onset of menarche.
E. Often the first bleeding is not ovulatory.
Question #59
QID: 15618
Topic: Neonatal Conjunctivitis
Subject: Pediatrics
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 presents during the first month of life. It may be aseptic or
septic. Aseptic neonatal conjunctivitis most often is a chemical conjunctivitis that is induced
by silver nitrate solution, which is used for prophylaxis of infectious conjunctivitis.
Chemical conjunctivitis is less common owing to the use of erythromycin ointment in place
of silver nitrate solution for the prophylaxis of infectious conjunctivitis. Bacterial and viral
infections are major causes of septic neonatal conjunctivitis, with Chlamydia being the most
common infectious agent. Infants may acquire these infective agents as they pass through
the birth canal during the birth process. 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.
→ Neisseria gonorrhoeae (choice A) is a gram-negative diplococcus and is potentially the
most dangerous and virulent infectious cause of neonatal conjunctivitis. However, it's not
the most common cause of neonatal conjunctivitis.
→ Herpes simplex virus (choice B) can cause neonatal keratoconjunctivitis, but it is rare
and can be associated with a generalized herpes simplex infection.
→ The most commonly identified gram-positive organisms include Staphylococcus aureus
(choice C), Streptococcus pneumoniae, Streptococcus viridans, and Staphylococcus
epidermidis. These bacteria make up 30-50% of all cases of neonatal conjunctivitis.
→ Silver nitrate (choice D) is a surface-active chemical, facilitating agglutinate gonococci
and inactivating them. Ironically, silver nitrate was later found to be toxic to the conjunctiva,
potentially causing a sterile neonatal conjunctivitis (which less common than the infectious
neonatal conjunctivitis).
Question #60
QID: 15626
Topic: Lead Poisoning
Subject: Pediatrics
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
e) Encephalitis
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.
Question #61
QID: 15792
Topic: Lead Poisoning
Subject: Pediatrics
A child who lives in an old building with his mother 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
e) Vitamin B12 deficiency
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 µg/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
µg/dL (> 2.4 mmol/L). Encephalopathy is likely if lead is > 100 µg/dL (> 4.8 mmol/L).
Lead poisoning will show a microcytic anemia with an MCV < 80.
Lead Poisoning
Question #62
QID: 16034
Topic: Lead Poisoning
Subject: Pediatrics
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 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.
Question #63
QID: 16125
Topic: Lead Poisoning
Subject: Pediatrics
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.
Lead Poisoning
Question #64
QID: 17395
Topic: Lead Poisoning
Subject: Pediatrics
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 μg/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 μg/dl, chelation treatment is usually needed (choice D). No
treatment is recommended for blood lead levels below this threshold. This child's lead level
is 50 microgram/dl which is higher than the threshold for treatment. If oral chelation with
succimer is used as an outpatient, there must be assurance that the home environment is free
of lead.
→ A repeat lead level (choice A) within 3 months is acceptable for children with lead levels
between 10 and 14 μg/dl, but is not adequate management for a lead level this high. Action
should be taken within 48 hours.
→ 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
(choice B). Lead can also come from pottery, soil, home remedies, plumbing, automobile
repair supplies, batteries, and various solvents.
→ Any patient who has a blood lead level over 20 μg/dl needs careful evaluation and
repeated blood lead levels (choice C).
→ Emergency hospitalization (choice E) and intravenous chelation is usually reserved for
children with lead levels over 70 μg/dl.
Question #65
QID: 17803
Topic: Lead Poisoning
Subject: Pediatrics
A father brings in his 5-year-old boy who complains of fatigue, terrible stomach aches and
weakness in his right hand (wrist drop). His blood results will likely reveal:
a) Microcytic anemia
b) Macrocytic anemia
c) Normocytic anemia
d) Pancytopenia
e) Polycythemia
The correct answer is a)
Explanation:
Lead poisoning.
High levels of lead in the body are toxic to bone marrow, the central and peripheral nervous
system, the kidneys, heart, intestinal tissue, and reproductive system. Symptoms can include
abdominal pain, headaches, vomiting, confusion, muscle weakness, seizures, hair loss and
anemia.
A particularly vulnerable patient population are children younger than 6 years of age.
Canadian homes, in particular those built prior to 1960, do contain lead paint so it is
conceivable that lead dust from paint poses an on-going risk to children.
The CDC recommends: 1) screening virtually all children for lead exposure at 12 and 24
months; 2) screening children at high risk every 6 months beginning at 6 months of age; and
3) using direct measurement of BPb (annual blood lead levels) rather than erythrocyte
protoporphyrin (EP) to screen.
PEARL: Lead poisoning presents with neurologic deficits, abdominal pain and microcytic
anemia.
Lead Poisoning
Question #66
QID: 15635
Topic: Salicylate Poisoning
Subject: Pediatrics
A 3.5-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 in adults and children > 4 years old.
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. Respiratory alkalosis occurs in this age group
because aspirin stimulates the respiratory center
ASA toxicity in children < 4 years of age leads to high anion gap metabolic acidosis with
compensation (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).
→ High HCO32- (choice B) is seen in metabolic alkalosis. Aspirin toxicity primarily causes
metabolic acidosis in children < 4 years old.
→ pH low; HCO3 low; pCO2 high (choice C) shows metabolic acidosis compounded with
respiratory acidosis.
→ pH low; HCO3 high; pCO2 low (choice D) is not a feature of any known acid-base
disturbance because pH low signifies acidosis, this should be accompanied by either low
HCO3 to suggest metabolic acidosis or high pCO2 to suggest respiratory acidosis; it is very
unlikely to see an acidic pH, while both the HCO3 and pCO2 point to alkalosis.
→ pH high; HCO3 high; pCO2 high (choice E) shows a metabolic alkalosis compounded
with respiratory compensation.
Question #67
QID: 15657
Topic: Intussusception
Subject: Pediatrics
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 palpable mass in right
hypochondrium. 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. The hallmark physical findings in intussusception are a
right hypochondrium sausage-shaped mass and emptiness in the right lower quadrant
(Dance sign).
Intussusception
Question #68
QID: 15693
Topic: Intussusception
Subject: Pediatrics
A 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) Meckel's diverticulum
b) Appendicitis
c) Pyloric stenosis
d) Intussusception
e) Tracheoesophageal fistula
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.
Intussusception
Question #69
QID: 16515
Topic: Intussusception
Subject: Pediatrics
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.
Intussusception
Question #70
QID: 15666
Topic: Impetigo
Subject: Pediatrics
A child presents with the following rash:
You diagnose her with impetigo. What is the most appropriate treatment?
a) Oral trimethoprim/sulfamethoxazole
b) Oral dicloxacillin
c) Cefuroxime
d) Topical clotrimazole
e) Vancomycin
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.
Question #71
QID: 17138
Topic: Impetigo
Subject: Pediatrics
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
c) Mupirocin cream
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.
Question #72
QID: 17687
Topic: Impetigo
Subject: Pediatrics
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
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.
Question #73
QID: 17857
Topic: Impetigo
Subject: Pediatrics
A 4-year-old male presents with a 3-day history of sores on his right leg. The sores began as
small red papules but have progressed in size and now are crusting and weeping. Otherwise
he is in good health and is up to date with immunizations.
On examination he has three lesions on the right anterior lower leg that are 0.5-1.5 cm in
diameter, with red bases and honey-colored crusts. There is no regional lymphangitis or
lymphadenitis.
Which one of the following is the preferred first-line therapy?
a) Oral erythromycin
b) Oral penicillin V
c) Topical hexachlorophene
d) Topical mupirocin
e) Topical hydrogen peroxide
The correct answer is d)
Explanation:
The lesions described are nonbullous impetigo, due to either Staphylococcus aureus or
Streptococcus pyogenes. Topical antibiotics, such as mupirocin, but not compounds
containing neomycin, are the preferred first-line therapy for impetigo involving a limited
area.
→ Oral antibiotics are widely used, based on expert opinion and traditional practice, but are
usually reserved for patients with more extensive impetigo or with systemic symptoms or
signs. Penicillin V and hexachlorophene have both been shown to be no more effective than
placebo.
→ Topical antibiotics have been shown to be as effective as erythromycin, which has a
common adverse effect of nausea.
→ Topical disinfectants are not useful in the treatment of impetigo.
Question #74
QID: 15699
Topic: Myopathies
Subject: Pediatrics
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)
b)
c)
d)
e)
Creatine phosphokinase (CPK)
Muscle biopsy
Nerve biopsy
Electromyogram (EMG)
MRI
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.
Creatine 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.
Question #75
QID: 15704
Topic: Tanner Stages
Subject: Pediatrics
A 15-year-old girl who is at Tanner stage 3 is concerned because she has still not had her
first menses. Patient denies abdominal pain or other concerning symptoms. Physical
examination reveals no abnormalities. The most appropriate management at this time is:
a) Pelvic ultrasound
b) Chromosome analysis
c) Progesterone withdrawal test
d) Reassurance
e) Thyroid stimulating hormone and T4 levels
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
contours
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. This patient denies symptoms of abdominal pain which are often seen
in cases of imperforate hymen and her physical examination reveals no abnormalities.
Reassurance (choice D) is appropriate at this time. The average age for menarche is 12, but
can vary between 9 and 16.
→ Pelvic ultrasound (choice A) could reveal abnormalities in anatomic structures of the
pelvis but is not indicated at this point.
→ Chromosomal analysis (choice B) would be useful in a case that suggests Turner
syndrome. This patient's physical examination reveals no abnormalities, which can be found
in in Turner syndrome. Reassurance is appropriate at this point.
→ Progesterone withdrawal test (choice C) is useful in the work up of amenorrhea and can
predictably induce bleeding if the circulating serum estradiol level is at least 50 pg/mL. This
patient's is still 15 years old and is Tanner stage 3, reassurance is appropriate at this point.
→ Thyroid stimulating hormone (choice E) along with FSH, LH measurements are always
first line testing in the work up of amenorrhea. In this patient, at this point, reassurance is
appropriate.
Question #76
QID: 16114
Topic: Tanner Stages
Subject: Pediatrics
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.
Question #77
QID: 16242
Topic: Tanner Stages
Subject: Pediatrics
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. Most
boys reach adult height during the latter half of puberty (Tanner stage 4).
Question #78
QID: 15710
Topic: Juvenile Polyposis
Subject: Pediatrics
A child has juvenile polyposis. What is the most common symptom to be seen in this
patient?
a) Diarrhea
b) Painless bleeding
c) Painful bleeding
d) Constipation
e) Fever
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.
Question #79
QID: 15916
Topic: UTI, recurrent
Subject: Pediatrics
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. In children < 5 years
old with recurrent UTI diagnostic workup should include ultrasound and voiding
cystourethrogram (choice B).
→ Renal ultrasonography (choice A) is the best initial imaging in this child with recurrent
UTI to assess the kidneys for size, parenchymal thickness, and collecting system dilation.
However, it is not sufficient to exclude vesicoureteral reflux.
→ Intravenous pyelogram only (choice C) and (choice E) are incorrect. Renal ultrasound
has largely replaced intravenous pyelogram as the screening test of choice for the upper
urinary tract because of the absence of radiation, elimination of contrast reaction risk, and
noninvasive technique
→ Voiding cystogram only (choice D) is recommended as the initial study in boys. For
girls, renal ultrasound is done first.
Question #80
QID: 15722
Topic: Radial Head Subluxation
Subject: Pediatrics
A child is brought into the ED by his mother. She states "he screamed and started crying
when I pulled his arms up (holding hands) to make him fly since he likes that a lot. He has
never cried before when we played like this."
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
e) Hand soft tissue injury
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.
Question #81
QID: 16345
Topic: Radial Head Subluxation
Subject: Pediatrics
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
e) Refer to an orthopedist
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. After several failed attempts at reduction, radiographs of the arm should be
obtained to evaluate for fractures of the radius or ulna. The child with normal radiographs
who refuses to use the arm should be referred to an orthopedist.
Question #82
QID: 17440
Topic: Radial Head Subluxation
Subject: Pediatrics
A toddler presents to your office with his left arm held semi flexed, adducted, and pronated.
The lateral elbow has mild tenderness, and attempts to pronate or supinate the forearm cause
pain. His parents don't remember any unusual recent events that could have caused this and
they report that this has never happened before. 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 always requires casting
d) This almost certainly is subluxation of the radial head
e) This is caused by partial dislocation of the ulnar head
The correct answer is d)
Explanation:
This is ordinary “nursemaid's elbow” (or pulled elbow), which is a subluxation of the radial
head. It is usually an innocent injury, which typically results from a quick pull on a child's
arm.
→ Radiographs (choice A) are usually not typically necessary, provided no history of
significant trauma and no deformity or local tenderness (apart from at the radial head) are
noted.
→ Upon presentation of any injured child, the physician must consider possible abuse
(choice B), especially in cases of recurrent subluxation. However, this patient presents with
the diagnosis for the first time and no other compaints, which makes child abuse unlikely.
→ Supination technique is the classic method of reduction (80-92% success rate)
- Begin with the arm in pronation and the elbow in 90° of flexion.
- Place pressure over the patient's radial head.
- Next, firmly supinate the wrist, keeping pressure on the radial head
- Then, flex the elbow completely. A click is often felt over the radial head when the arm has
reached full supination
If multiple reduction attempts prove unsuccessful, a sling or posterior long arm splint may
be applied for comfort (choice C), and the child can be referred to an orthopedist.
→ When longitudinal axial traction is placed on an extended pronated arm, the radial head
(not ular head, choice E) may therefore slip or tear through the weak annular ligament into
the radiocapitellar articulation. This results in entrapment of the annular ligament and a
subluxation (or partial dislocation) of the radial head.
Question #83
QID: 15739
Topic: Stuttering
Subject: Pediatrics
What is the most appropriate management for a 2-year-old boy with stuttering without
behavioral changes?
a) Reassurance
b) Speech therapy
c) Referral to ENT specialist
d) Referral to neurologist
e) Antidepressant
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 at the of age of 3-8 years, the stuttering
eventually resolves within 4 years in 75% of cases, 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 speechlanguage therapist to evaluate your child before he or she is 3 years old.
Normal Stuttering:
•
Onset age 1.5 to 3 years old
•
Repeated syllables and sounds at the begining of sentences
•
Children have no awareness of their stuttering
Mild Stuttering:
•
Onset age 3 to 5 years old
•
Similar to normal stuttering but more frequent, associated with secondary behaviors
Severe Stuttering:
•
Onset age 1-7 years
•
Stuttering occurs in most phrases and sentences
→ Refer mild and severe stuttering to speech pathology.
→ There's no need for ENT of neurology referral, as this patient suffers from developmental
stuttering; not neurogenic stuttering (acquired stuttering due to neurologic trauma).
→ In a recent study, researchers concluded that drug therapy has been largely ineffective in
controlling stuttering.
Question #84
QID: 16221
Topic: Stuttering
Subject: Pediatrics
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 50% of children who stutter recover spontaneously
e) More severe stuttering requires speech therapy
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% 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.
Question #85
QID: 18333
Topic: Post Streptococcal Glomerulonephritis
Subject: Pediatrics
A 6-year-old female patient is brought in by her mother because the girl’s urine has been red
since this morning. She refers to you that the patient had an upper respiratory tract infection
1 week ago, from which she seemed to have recovered. She also reports noticing that the
girl seems to have gained weight in the past day.
On physical examination her vital signs are: blood pressure of 150/90 mmhg, and heart and
respiratory rate within the normal range for her age. As you examine her, you notice that she
has lower limb edema, that seems to extend to the abdominal area. You also find facial
edema. With these findings you decide to order a urinalysis which reveals hematuria with
red blood cell casts and proteinuria (+). Her blood creatinine is slightly elevated.
Which of the following patterns would you expect to find in her serum complement levels?
a) Normal C3 level and normal C4 level
b) Low C3 level and low C4 level
c) Normal C3 level and low C4 level
d) Low C3 level and normal C4 level
e) Very high C3 level
The correct answer is d)
Explanation:
The clinical scenario described above would point to a diagnosis of Nephritic Syndrome.
The most likely cause of it in this particular patient would be Postinfectious
Glomerulonephritis, which is caused by prior infection with specific nephritogenic strains of
group A beta-hemolytic streptococcus. This disease tends to affect children between 5 and
12 years old, as well as adults over 60 years of age.
Typically, it would take between 1 and 3 weeks to develop postinfectious
glomerulonephritis after having pharyngitis, while it would take between 3 and 6 weeks
after having a skin infection.
The clinical manifestations usually include, gross hematuria, edema and hypertension.
Laboratory findings include: hematuria with or without red cell cast and non-nephrotic
range proteinuria in the urinalysis; increase in creatinine level; and low C3 and normal C4
complement levels (choice D). Anti-streptolysin (ASO), Anti-hyaluronidase (AHase), Antistreptokinase (ASKase), Anti-nicotinamide-adenine dinucleotidase (anti-NAD) and AntiDNAse B antibodies are also positive in most of the cases 90 percent in pharyngitis and 80
percent in skin infection).
→ Normal C3 level and normal C4 level (choice A) could be found in IgA nephropathy.
→ Low C3 level and low C4 level (choice B) could be found in Systemic Lupus
Erythematous.
→ Normal C3 level and low C4 level (choice C) could be found in Membranoproliferative
glomerulonephritis.
→ Very high levels of C3 (choice E) can be found in hematologic malignancies, although it
is not common.
Out of these, the only pattern that could rarely be found in a patient with Postinfectious
glomerulonephritis is Normal C3 and Normal C4. However, 90 percent of the cases show
low C3 and normal C4.
Key point:
Due to the immunologic nature of postinfectious glomerulonephritis, complement levels are
commonly affected showing low C3 level and normal C4 level. This aids in the differential
diagnosis of a patient with clinical manifestations of Nephritic Syndrome.
Question #86
QID: 15743
Topic: Kawasaki Disease
Subject: Pediatrics
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.
Question #87
QID: 16021
Topic: Kawasaki Disease
Subject: Pediatrics
A 4-year-old girl has marked cervical adenopathy, conjunctival injection without exudate,
red cracked lips, and a macular exanthem on palms and soles. Her mother reports a 6-day-
history of high fever which failed to respond to penicillin. What your presumptive diagnosis
in this patient?
a) Stevens-Johnson syndrome
b) Kawasaki syndrome
c) Adenoviral conjunctivitis
d) Rocky Mountain spotted fever
e) Infectious mononucleosis
The correct answer is b)
Explanation:
Kawasaki disease (KD) is one of the most common vasculitic syndrome of childhood.
Although it is typically a self-limited condition, can lead to death from coronary artery
aneurysm in a very small percentage of patients. The clinical characteristics of KD are
bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa (strawberry
tongue and lip fissures), polymorphous rash, peripheral extremity changes (erythema of
palms or soles, edema of hands or feet (acute phase), and periungual desquamation
(convalescent phase)), and cervical lymphadenopathy, which typically develop after a brief
nonspecific prodrome of respiratory or gastrointestinal symptoms. Fever is the most
consistent manifestation of KD. Fever is minimally responsive to antipyretic agents, and it
typically remains above 38.5°C (101.3°F) during most of the illness.
Approximately 85-90% of Kawasaki disease cases occur in children younger than 5 years;
90-95% of cases occur in children younger than 10 years.
→ Stevens-Johnson syndrome (choice A) is characterized by bullous or vesicular rash, not
commonly found in KD.
→ A highly contagious acute red eye infection caused by adenovirus (choice C) is exudative
conjunctivitis. This patient's eye infection shows absence of the exudate.
→ Rocky Mountain spotted fever (choice D) is unlikely in this patient. Typically, headache
and gastrointestinal complaints are prominent features of this infection.
→ Epstein-Barr virus infectious mononucleosis (choice E) presents with generalized
lymphadenopathy.
Question #88
QID: 16860
Topic: Kawasaki Disease
Subject: Pediatrics
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 2 x 2 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.
Question #89
QID: 17437
Topic: Kawasaki Disease
Subject: Pediatrics
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 39.5°C. 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 38.5°C. 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.
Question #90
QID: 18075
Topic: Kawasaki Disease
Subject: Pediatrics
A 4-year-old boy was brought to hospital with fever for the last 6 days. The boy looked ill
but not pale or jaundiced and his body temperature was 38.6°C. Examination of the mouth
showed generalized erythema of oropharynx, strawberry tongue and red fissured lips.
Polymorphous, confluent maculo-papular erythematous skin rash was noted. Two enlarged
cervical lymph nodes could be palpated. Laboratory examination showed mild anemia and
raised ESR. Kawasaki disease was strongly suspected. Although, scarlet fever and toxic
shock syndrome should be considered in the differential diagnosis of this presentation, they
are less likely because of:
a) The type of the rash
b) Fissuring of the lips
c) The mild anemia
d) The ill look of the patient
e) The raised ESR
The correct answer is b)
Explanation:
Fissuring of the lips is a strong clue for differentiating Kawasaki disease from scarlet fever
and toxic shock syndrome.
→ Scarlet fever and toxic shock syndrome might have the same type of scarlatiniform rash
as Kawasaki disease described in this case.
→ Mild anemia, the ill look and high ESR might all accompany severe scarlet fever and
toxic shock syndrome.
Careful physical examination (fissuring of the lips in this case) is a strong tool in
differentiating between diseases with similar presentations.
Question #91
QID: 15746
Topic: Idiopathic Thrombocytopenic Purpura
Subject: Pediatrics
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
e) Anticoagulation
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.
Question #92
QID: 17423
Topic: Idiopathic Thrombocytopenic Purpura
Subject: Pediatrics
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 120 g/L, WBC is 12.5 x 10^9/L, and the platelet count is 45 x 10^9/
L. Large platelets are seen on the smear. Prothrombin time and activated partial
thromboplastin time (APPT) are normal. Treatment of this child should include:
a) Splenectomy
b) Platelet transfusion
c) Aspirin
d) Reassure the parents that no specific treatment is needed at this time
e) Administer intravenous immunoglobulin and glucocorticoids
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. Children
who have platelet counts > 30 x 10^9/L and are asymptomatic or have only minor purpura
do not require routine treatment. Children who have platelet counts < 20 x 10^9/L and
significant mucous membrane bleeding and those who have platelet counts < 10x10^9/L and
minor purpura should receive specific treatment.
Usually choose to treat because spontaneous recovery takes a few months, and risk of
bleeding (especially intracranial hemorrhage with platelets < 20 x10^9 /L).
-IVIG or oral prednisone (mainstays of treatment),
-IV anti-D (if blood group Rh positive).
-Splenectomy only for life-threatening bleeding.
-Platelet transfusion is indicated for controlling severe hemorrhage.
-Avoid ASA/NSAIDS.
-No contact sports.
-Reassurance: very low risk of serious hemorrhage (3%) and CNS hemorrhage rare (<
0.5%).
Question #93
QID: 15767
Topic: Von Willebrand's Disease
Subject: Pediatrics
Which of the following would be the most likely presenting symptom of a patient with Von
Willebrand disease during the onset on menstruation?
a) Dyspareunia
b) Dysmenorrhea
c) Infertility
d) Menorrhagia
e) Fatigue
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.
Question #94
QID: 15967
Topic: Von Willebrand's Disease
Subject: Pediatrics
A 4-year-old boy has a history of nosebleeds and easy bruising. There is a similar history
among female and male family members. Laboratory investigations show prolonged APTT
and normal INR. 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) Wiskott-Aldrich syndrome
The correct answer is d)
Explanation:
Von Willebrand's disease (choice D) 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 (choice A) and hemophilia B (Christmas disease) (choice B) 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.
→ Activated partial thromboplastin time (aPTT) and international normalized ratio (INR)
assessments are normal in factor XIII deficiency (choice C).
Wiskott-Aldrich syndrome (choice E) is an X-linked recessive disorder, which is
characterized by immunodeficiency, severely dysfunctional platelets, and thrombocytopenia
with microthrombocytes. INR and PTT are normal.
Question #95
QID: 17956
Topic: Von Willebrand's Disease
Subject: Pediatrics
A child is noted to develop easy bruising and excessive bleeding from small skin cuts. Tests
show bleeding time is increased and a deficiency of von Willebrand's factor. What is the
appropriate treatment?
a) Factor 7
b) Factor 9
c) Platelet transfusion
d) DDAVP
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 (DDAVP) (choice
D).
Question #96
QID: 16727
Topic: Proteinuria
Subject: Pediatrics
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.
Question #97
QID: 16219
Topic: Physiologic Jaundice
Subject: Pediatrics
Which of the following is false about neonatal physiologic jaundice?
a) Presentation is on the second or third day of life
b) It almost always causes kernicterus
c) It usually does not continue beyond the first 1-2 weeks of life
d) It is mainly due to temporarily impaired hepatic clearance of bilirubin
e) Medications are not usually administered in infants with physiologic neonatal jaundice
The correct answer is b)
Explanation:
Physiologic jaundice is caused by a combination of increased bilirubin production
secondary to accelerated destruction of erythrocytes, decreased excretory capacity
secondary to low levels of ligandin in hepatocytes, and low activity of the bilirubinconjugating enzyme uridine diphosphoglucuronyltransferase.
Physiological jaundice occurs in approximately 50% of newborns. Its onset is on 2 to 3 days
of age, with a peak on day 4 to 5, then improves. It disappears usually without treatment by
1 to 2 weeks of age. It almost never causes kernicterus. Jaundice that is visible during the
first 24 hours of life is likely to be nonphysiologic; further evaluation is suggested.
Medications are not usually administered in infants with physiologic neonatal jaundice.
However, in certain instances, phenobarbital, an inducer of hepatic bilirubin metabolism,
has been used to enhance bilirubin metabolism.
Question #98
QID: 17222
Topic: Strep Pharyngitis
Subject: Pediatrics
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 headache. On examination
you note a tonsillar exudate and anterior cervical lymphadenopathy. A rapid antigen
detection test for group A beta-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 beta-hemolytic streptococcal pharyngitis
by rapid antigen detection testing or throat culture prior to initiation of treatment.
Question #99
QID: 18095
Topic: Strep Pharyngitis
Subject: Pediatrics
A 7-year-old male presents with a fever of 38.5°C (101.3°F), a sore throat, tonsillar
swelling, and tender anterior cervical adenopathy. He does not have a cough or a runny
nose. His younger sister was treated for streptococcal pharyngitis last week and his mother
would like him to be treated for streptococcal infection.
Which one of the following is true concerning this situation?
a) Empiric antibiotic treatment for streptococcal pharyngitis is warranted
b) The chance of this patient having a positive rapid antigen detection test for
Streptococcus is < 50%
c) There is a generalized consensus among the various national guidelines for management
of pharyngitis
d) The patient should have a tonsillectomy when he recovers from this infection
e) The family dog should be treated for streptococcal infection
The correct answer is a)
Explanation:
The patient has a score of 5 under the Modified Centor scoring system for management of
sore throat. Patients with a score of 4 and 5 are at highest risk (at least 50%) of having group
A beta-hemolytic streptococcal (GABHS) pharyngitis, and empiric treatment with
antibiotics is warranted. Various national and international organizations disagree about the
best way to manage pharyngitis, with no consensus as to when or how to test for GABHS
and who should receive treatment. The minimal benefit seen with tonsillectomy in reducing
the incidence of recurrent GABHS pharyngitis does not justify the risks or cost of surgery.
Treatment of pets for the prevention of GABHS infection has proven ineffective.
Centor Criteria - The patients get one point for each positive criterion:
- History of fever
- Tonsillar exudates (exudate or swelling)
- Tender anterior cervical adenopathy
- Absence of cough
The Modified Centor Criteria add the patient's age to the criteria:
- Age < 15 add 1 point
- Age > 44 subtract 1 point
Question #100
QID: 15821
Topic: Scabies
Subject: Pediatrics
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)
e) Folliculitis
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.
Question #101
QID: 16400
Topic: Scabies
Subject: Pediatrics
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 from neck down to soles of feet
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.
5% permethrin cream is the most common treatment for scabies. It is safe for children as
young as 1 month old and women who are pregnant.
→ Lindane may be hazardous to young infants because of its percutaneous absorption and
potential neurotoxicity.
→ 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.
Question #102
QID: 16809
Topic: Scabies
Subject: Pediatrics
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
e) Topical lindane
The correct answer is b)
Explanation:
5% permethrin cream is the drug of choice for scabies treatment, especially in infants over
age 2 months and small children. It is more effective than crotamiton in treating symptoms
and reducing chances of secondary bacterial infection. This agent is highly effective,
minimally absorbed, and minimally toxic.
Question #103
QID: 17142
Topic: Scabies
Subject: Pediatrics
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.
Question #104
QID: 15829
Topic: Ventricular Septal Defect
Subject: Pediatrics
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.
Eisenmenger's syndrome or Eisenmenger's reaction is defined as the process in which a leftto-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.
Question #105
QID: 16220
Topic: Ventricular Septal Defect
Subject: Pediatrics
Which of the following is true regarding prophylactic antibiotic therapy use for tooth
extraction in a patient with a prosthetic heart valve?
a) Therapy is started 48 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) Macrolide is usually used in those patients who are 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 (1h) 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.
Antimicrobial prophylaxis is recommended for patients at high risk of an adverse outcome
from infective endocarditis. Such patients include those with:
•
Prosthetic heart valves
•
Previous infective endocarditis
•
Certain congenital heart diseases (CHD): Unrepaired cyanotic CHD (including
palliative shunts and conduits), completely repaired CHD during the first 6 mo after
surgery if prosthetic material or device was used, repaired CHD that has residual
defects at or adjacent to the site of repair
•
Heart transplant recipients with valvulopathy
Drug treatment in patients allergic to penicillin is with clindamycin or a macrolide such as
erythromycin, clarithromycin or azithromycin.
Question #106
QID: 16234
Topic: Ventricular Septal Defect
Subject: Pediatrics
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) Atrial septal defect
b) Ventricular septal defect
c) Patent ductus arteriosus
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.
Question #107
QID: 15842
Topic: Testicular Torsion
Subject: Pediatrics
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
e) Varicocele
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.
Question #108
QID: 17384
Topic: Testicular Torsion
Subject: Pediatrics
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 in prepubertal males, antibiotics are most commonly
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 in epididymitis and orchids but not improve
torsional pain
C. Only a few hours remain for intervention before irreversible damage occurs.
D. In this patient orchitis is most likely caused by viral infections, which would not respond
to antibiotic treatment.
(In mumps orchitis, 4 out of 5 cases occur in prepubertal males (younger than 10 years). In
bacterial orchitis, most cases are associated with epididymitis (epididymo-orchitis), and they
occur in sexually active males older than 15 years or in men older than 50 years with benign
prostatic hypertrophy)
E. As mumps is a primary cause of orchitis, the widespread use of this vaccine has
decreased the number of cases of orchitis.
Question #109
QID: 15865
Topic: Nocturnal Enuresis
Subject: Pediatrics
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 initial method for managing this child?
a) Psychiatric counseling
b) Desmopressin (DDAVP)
c) Waking at night
d) Nightly diapers
e) Limitation of fluid intake before bedtime
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.
Nocturnal Enuresis
Question #110
QID: 16156
Topic: Nocturnal Enuresis
Subject: Pediatrics
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.
Nocturnal Enuresis
Question #111
QID: 16232
Topic: Nocturnal Enuresis
Subject: Pediatrics
A 5-year-old boy frequently wets his bed with foul smelling urine. His parents are
concerned and would like to know what they can do to prevent this. After obtaining a
complete history and physical examination, which were both unremarkable, 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.
During the second year of life, children start to develop the ability to voluntarily relax the
external urethral sphincter and initiate voiding, even in the absence of the desire to void. By
approximately age 4 years, all children with normal bladder function should have acquired
this ability.
The evaluation of nocturnal enuresis requires a thorough history, a complete physical
examination, and urinalysis. Urinalysis is the most important screening test in a child with
enuresis. If the findings of the physical examination and urinalysis are negative and the
history does not suggest a secondary cause of nocturnal enuresis, no further work-up is
needed. If urinalysis reveals evidence of infection, the child should be evaluated for
vesicoureteral reflux. Given our patient's history of present illness (foul smelling urine), UA
(choice A) would be the best answer.
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.
Question #112
QID: 16236
Topic: Nocturnal Enuresis
Subject: Pediatrics
An 8-year-old boy who has been continent of urine between the ages of 4 and 5 years comes
in because of recent onset of enuresis. Which of the following statements is false?
a) It may be precipitated by a family crisis
b) It does not require a specific treatment
c) It can lead to poor self esteem
d) Bed-wetting alarm has the lowest relapse rate
e) It can be secondary to diseases such as diabetes mellitus
The correct answer is b)
Explanation:
Nocturnal enuresis is a common problem that can be troubling for children and their
families. 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.
Question #113
QID: 16773
Topic: Nocturnal Enuresis
Subject: Pediatrics
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%).
Question #114
QID: 17031
Topic: Nocturnal Enuresis
Subject: Pediatrics
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.
Nocturnal Enuresis
Question #115
QID: 17372
Topic: Nocturnal Enuresis
Subject: Pediatrics
A 6-year-old boy comes to your office for a well-child checkup. He has been healthy and
doing well in school, but his mother is concerned about his bedwetting. He has never had a
prolonged period of nighttime dryness, and he currently wets every night, about 2-3 hours
after going to sleep. The patient's father had enuresis until age 9, but he outgrew the
problem without any treatment. The mother has tried restricting fluids prior to bed, but this
has not helped. His urinalysis results are normal.
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 the patient and his mother on the use of a buzzer alarm conditioning device
e) Use negative reinforcement techniques to punish the boy 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 70% of cases.
→ Unless there is a history of urinary tract infection or an abnormal urinary stream, cultures
and radiographic studies (choice A) are not necessary.
→ Intervention (choice B), when enuresis persists beyond 7-8 years of age, may decrease
stress and embarrassment.
→ While medications (choice C) 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 treatment
→ Punishment and restriction of fluid (choice E) have not been shown to be effective
treatments for enuresis.
Question #116
QID: 17786
Topic: Nocturnal Enuresis
Subject: Pediatrics
A very concerned mother tells you that her 5-year-old son is still wetting the bed at night.
The most appropriate next step is to:
a) Perform a urinalysis
b) Prescribe oxybutinin
c) Refer the child for psychiatric counseling
d) Reassure the mother
e) Prescribe imipramine and behavioral extinction therapy
The correct answer is d)
Explanation:
Primary nocturnal enuresis or bed-wetting during sleep is relatively common in children
under the age of 6. Reassuring the parents is appropriate, as many cases of enuresis will
spontaneously resolve. Further investigation is required if the bed-wetting continues beyond
6 years of age, the child experiences dysuria, the enuresis becomes diurnal or if the enuresis
appears after the child has sustained a period of bladder control (secondary enuresis).
First line management includes behaviour modification: limiting nighttime fluids, voiding
prior to sleep and positive reinforcement. Medications and psychosocial therapies are
second line.
Anatomic abnormalities should be considered in cases of diurnal enuresis along with UTI,
constipation and CNS disorders. If the child exhibits secondary enuresis, screening for
diabetes, UTI, diabetes insipidus and psychosocial stresses may be warranted.
PEARL: Nocturnal enuresis is considered normal until the age of 6.
Question #117
QID: 15867
Topic: Sickle Cell Anemia
Subject: Pediatrics
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.
Question #118
QID: 15980
Topic: Immunization
Subject: Pediatrics
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. 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.
Question #119
QID: 16010
Topic: Immunization
Subject: Pediatrics
A 14-month-old infant boy was brought in by his mother for required (routine and nonroutine) vaccination before they leave the country to go to Peru for Easter. The mother tells
you that last week, he tried a small amount of scrambled eggs and developed hives,
wheezing and swelling. He was treated in the emergency room. She has read some stories
about possible immunization complications in children with egg allergy.
Which of the following contains the highest amount of egg protein and should not be given
to persons hypersensitive to eggs?
a) Flu vaccine
b) MMR vaccine
c) DTaP vaccine
d) Yellow fever vaccine
e) Varicella
The correct answer is d)
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 nonroutine vaccines contain egg protein: yellow fever and typhoid vaccines. Yellow fever
vaccine 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.
Diphtheria, tetanus, and pertussis, or DTaP, vaccine does not contain egg proteins (some
contain bovine proteins).
Question #120
QID: 16239
Topic: Immunization
Subject: Pediatrics
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 today's vaccination?
a) Wait until the child is two months older to administer the vaccination
b) Wait until the child is clinically well and then vaccinate
c) Administer the vaccination
d) Consult a pediatrician
e) Skip the vaccination
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
Question #121
QID: 16420
Topic: Immunization
Subject: Pediatrics
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.
Question #122
QID: 17171
Topic: Immunization
Subject: Pediatrics
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.
Question #123
QID: 17668
Topic: Immunization
Subject: Pediatrics
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.
Question #124
QID: 16852
Topic: Seizures, febrile
Subject: Pediatrics
A 15-month-old male is brought to the emergency department following a generalized tonicclonic 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 5.3 mmol/L (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.
Question #125
QID: 17368
Topic: Seizures, febrile
Subject: Pediatrics
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 10 minutes with a short
postictal 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 39°C. 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.
Question #126
QID: 17634
Topic: Seizures, febrile
Subject: Pediatrics
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 (choice E).
→ Lumbar puncture (choice A) is unnecessary in most well-appearing children who have
returned to a normal baseline after a febrile seizure. LP should be performed when there are
meningeal signs or symptoms or other clinical features that suggest a possible meningitis or
intracranial infection or when the patient is on antibiotics because antibiotic treatment can
mask the signs and symptoms of meningitis. It should also be considered in infants between
6 and 12 months if the immunization status for Haemophilus influenzae type b or
Streptococcus pneumoniae is deficient or undetermined.
→ There is no evidence to suggest that routine blood tests (choice D) or neuroimaging
studies (choice C) are useful in a patient following a first simple febrile seizure, and it has
not been shown that electroencephalography (choice B) performed either at the time of
presentation or within the following month will predict the likelihood of recurrence.
Question #127
QID: 15911
Topic: Labial Adhesion
Subject: Pediatrics
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.
Question #128
QID: 16892
Topic: Labial Adhesion
Subject: Pediatrics
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.
Question #129
QID: 15940
Topic: TB
Subject: Pediatrics
A 3-year-old girl presents with a two 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 result 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 is 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.
Question #130
QID: 16243
Topic: TB
Subject: Pediatrics
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. Drug susceptibility studies are negative for drug resistance. 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).
Ethambutol (EMB) is added in the initial phase whenever there is any suspicion of initial
drug resistance and while the results of drug susceptibility testing are pending (which is not
the case in this scenario).
Question #131
QID: 15955
Topic: Neuroblastoma
Subject: Pediatrics
You suspect a neuroblastoma in a 4-year-old boy with headaches and hypertension. 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) Serum alpha-fetoprotein
b) Serum ferritin and lactate dehydrogenase
c) Levels of homovanillic acid and vanillylmandelic acid in the urine
d) Serum catecholamines
e) MRI or CT scan of the involved area of the body
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 metaiodobenzylguanidine (MIBG) scintigraphy for evaluation of bone and soft-tissue
involvement of neuroblastoma are attractive.
Question #132
QID: 15968
Topic: Tinea Capitis
Subject: Pediatrics
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.
Question #133
QID: 15972
Topic: Rectal Prolapse
Subject: Pediatrics
Extrusion of some or all of the rectal mucosa through the external anal sphincter in children
is most commonly associated with:
a) Pyloric stenosis
b) Obesity
c) Cystic fibrosis
d) Trisomy 18
e) Celiac disease
The correct answer is c)
Explanation:
Rectal prolapse seldom occurs in children who do not have an underlying predisposing
condition and usually occurs between infancy and four years of age, with the highest
incidence in the first year of life. The finding of rectal prolapse should be considered as a
symptom of an underlying condition that predisposes to rectal prolapse [1-4,14-16]. These
conditions include:
- Increased intraabdominal pressure
- Diarrheal disease
- Cystic fibrosis
- Malnutrition
- Pelvic floor weakness
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.
Question #134
QID: 16250
Topic: Reye's Syndrome
Subject: Pediatrics
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.
Reye Syndrome
Question #135
QID: 16036
Topic: Tourette's Syndrome
Subject: Pediatrics
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).
Question #136
QID: 16037
Topic: Tourette's Syndrome
Subject: Pediatrics
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)
e) Schizophrenia
The correct answer is c)
Explanation:
People with Tourette's syndrome (TS) often have difficulty functioning and experience
considerable anxiety in social situations. Children with Tourette's syndrome often have
difficulty learning. Behavioral symptoms are common in TS. The two most common
disorders are obsessive-compulsive disorder (OCD) and attention deficit hyperactivity
disorder (ADHD). The symptoms of OCD (as well as ADHD) may be the dominating and
debilitating feature of TS in certain patients.
OCD is the most frequent behavior symptom associated with TS. The rates of OCD in
patients with TS range from 20-60%. Obsessive-compulsive symptoms have an increased
prevalence in first-degree relatives with tics.
Question #137
QID: 16046
Topic: Normal Growth
Subject: Pediatrics
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 two weeks of age. The
infant is being bottle-fed formula. His weight today is identical to birth. Parents say that
they know neonates lose their birth weight and regain it few days later. They ask how much
weight a normal neonate is supposed to be adding on each week if fed appropriately. Which
of the following is the best answer for this question?
a) 50 grams to 80 grams
b) 80 grams to 120 grams
c) 120 grams to 150 grams
d) 150 grams to 200 grams
e) 250 grams to 300 grams
The correct answer is d)
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 7- 14
days after birth in majority of children. If a neonate is fed appropriately, anticipate weight
gain 20-30 grams per day or 150- 200 grams per week (choice D).
→ A neonate gaining 50 grams to 80 grams(choice A), 80 grams to 120 grams (choice B),
and 120 grams to 150 grams (choice C) would be either underfed or having other causes of
failure to thrive.
→ A neonate gaining 250 grams to 300 grams (choice E) each week would be increasing
weight higher than normally anticipated.
Question #138
QID: 16047
Topic: Normal Growth
Subject: Pediatrics
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 two weeks of age. The
baby is being fed infant formula. He is gaining weight appropriately. Considering the
appropriate nutritional management of infants, select the appropriate advice to be given to
new mothers who are thinking about whether they will choose to feed their babies with
breast milk or infant formula exclusively.
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 is regained within 1 week
to 2 weeks after birth in majority of children.
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 (choice C) 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.
→ Avoid feeding newborn infants in the first 12 hours of life in order to prevent aspiration
(choice A) is incorrect. The baby can start to feed shortly after birth and does not need to
wait for 12 hours.
→ Breast milk is deficient in iron and iron supplementation is recommended for breast fed
infants (choice B) is incorrect. Cow's milk is deficient in iron.
→ Institute solid food at three months of age (choice D) is incorrect. Solid food is typically
introduced between 4-6 months of age.
→ Breast milk may causes diarrhea if used exclusively, so formula should be added (choice
E) is incorrect. Breast milk has many benefits for infants and the American Academy of
pediatrics recommends breast feeding for at least the first year of life. There has been no
study that established breast milk causes diarrhea if used exclusively; in fact, it is believed
that breast milk decreases the risks of diarrhea.
Question #139
QID: 16386
Topic: Normal Growth
Subject: Pediatrics
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
e) 40 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.
Question #140
QID: 17767
Topic: Normal Growth
Subject: Pediatrics
Between 7 and 8 years of age, your patient has grown 4.5 cm. His height, however, remains
below and parallel to the 50th 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 50th 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 50th percentile line (meaning growth velocity is normal) or if the child is falling
further behind (which is more concerning).
Question #141
QID: 16090
Topic: Premature Adrenarche
Subject: Pediatrics
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.
Question #142
QID: 16091
Topic: Pityriasis Rosea
Subject: Pediatrics
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
e) Seborrheic dermatitis
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.
Question #143
QID: 16098
Topic: Neonatal Lupus Syndrome
Subject: Pediatrics
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) Neonatal lupus is a much more common cause of heart block presenting after the
neonatal period
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 erythematosus (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.
Congenital complete heart block is the most serious manifestation of NLE. NLE is
responsible for 80 to 95 % of all cases of congenital complete heart block diagnosed in utero
or in the neonatal period. NLE is a much less common cause of heart block presenting after
the neonatal period.
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.
Question #144
QID: 16115
Topic: Iron Deficiency Anemia
Subject: Pediatrics
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 30 g/L
Mean corpuscular volume 48 fL
Platelet count 400 x10^9/L
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 40 g/L, 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.
Question #145
QID: 16257
Topic: Iron Deficiency Anemia
Subject: Pediatrics
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.
Question #146
QID: 16411
Topic: Iron Deficiency Anemia
Subject: Pediatrics
A 1-year-old infant is brought to your office for a well child visit. A screening CBC reveals
her hemoglobin to be 105 g/L with a mean corpuscular volume of 69 fL. Which one of the
following is the most likely cause of her anemia?
a) Iron deficiency
b) Lead poisoning
c) Chronic liver disease
d) Hemolysis
e) Hypothyroidism
The correct answer is a)
Explanation:
This child has evidence of mild microcytic anemia, which is most commonly caused by iron
deficiency related to reduce dietary intake. Less common causes are thalassemia and lead
poisoning. Hemolysis usually causes a normocytic anemia with an elevated reticulocyte
anemias.
Question #147
QID: 16134
Topic: Jaundice
Subject: Pediatrics
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 confirm
your presumptive diagnosis of physiologic jaundice. 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. 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.
Question #148
QID: 16457
Topic: Jaundice
Subject: Pediatrics
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
e) 8 mg/dL at 24 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 newborns. Safe bilirubin levels in preterms vary
according to gestational age.
Anything out of this range is considered pathological jaundice.
Question #149
QID: 17514
Topic: Jaundice
Subject: Pediatrics
A 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 new symptoms were starting to occur.
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)
b)
c)
d)
e)
Look for ABO or Rh incompatibility
Perform CBC, reticulocyte count, and blood smear
Initiate phototherapy when direct bilirubin >24mg/dL
Initiate exchange transfusion
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. We 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
(choice D).This is indicated in all children with bilirubin-induced neurologic
dysfunction(BIND) or those who reach the threshold of >20 mg/dL (340 μmol/L) known as
"vigintiphobia" because of its concerning association with neurological damage.
→ Look for ABO or Rh incompatibility (choice A) might certainly cause jaundice, but the
most likely cause of jaundice in this child is congenital hypothyroidism.
→ Perform CBC, reticulocyte count, and blood smear (choice B) are useful in hemolytic
anemia.
→ Initiate phototherapy when direct bilirubin >24mg/dL(choice C) is incorrect. Direct
bilirubin is not a concern for causing BIND. For children with unconjugated bilirubinemia,
levels >20 mg/dL should prompt exchange transfusion.
→ Urinalysis and urine culture, and assess for sepsis (choice E) is inlikely to reveal the
diagnosis of this child as it is most likely caused by congenital hypothyroidism.
Question #150
QID: 17707
Topic: Jaundice
Subject: Pediatrics
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 222 µmol/L (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.
Question #151
QID: 17041
Topic: Obesity
Subject: Pediatrics
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 kg/m²
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
The correct answer is c)
Explanation:
Childhood obesity is a growing epidemic. Childhood obesity is defined as a BMI above the
95th percentile for age and sex (choice C). Children with a BMI between the 85th and 95th
percentile are considered overweight. In adults, an individual with a BMI > 30 kg/m² is
considered obese.
Question #152
QID: 16152
Topic: Inguinal Hernia
Subject: Pediatrics
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.
Question #153
QID: 16215
Topic: Umbilical Hernia
Subject: Pediatrics
What is true about most umbilical hernias in children?
a) Need strapping
b)
c)
d)
e)
Resolve spontaneously
Require elective surgery
Require immediate surgery
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.
Question #154
QID: 16216
Topic: Volvulus
Subject: Pediatrics
A 3-day-old infant male presents with spiting up his 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) Choledochal 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.
Question #155
QID: 16605
Topic: Volvulus
Subject: Pediatrics
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, and mild
bowel distention. Of the following, which one is the most likely diagnosis?
a)
b)
c)
d)
e)
Duodenal atresia
Intestinal malrotation
Pyloric stenosis
Necrotizing enterocolitis
Jejunoileal atresia
The correct answer is b)
Explanation:
Most individuals with intestinal malrotation develop signs of acute small bowel obstruction
in early infancy. Intestinal malrotation should be considered in any infant with bilious
vomiting and any child with bilious emesis and abdominal pain.
Physical examination may reveal mild distension of the abdomen, diffuse tenderness with or
without signs of peritonitis, and bloody stool on rectal examination. Blood in the stool is a
worrisome sign, since it suggests bowel ischemia and possible necrosis.
→ Both duodenal and jejunoileal atresia most commonly present within the first 24 hours of
life. An infant with duodenal atresia typically has a scaphoid abdomen.
→ 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.
Question #156
QID: 16217
Topic: SSSS
Subject: Pediatrics
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 (choice B) 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.
→ Kawasaki disease (choice A) is characterized with polymorphous rash, usually
generalized but may be limited to the groin or lower extremities. Oropharyngeal changes
include erythema, fissuring, and crusting of the lips; strawberry tongue; diffuse mucosal
injection of the oropharynx (mucous membrane changes, which occur in more than 90% of
patients)
→ Typically, Stevens-Johnson syndrome’s rash (choice C) begins as macules that develop
into papules, vesicles, bullae, urticarial plaques, or confluent erythema. The center of these
lesions may be vesicular, purpuric, or necrotic. The typical lesion has the appearance of a
target; this is considered pathognomonic. Involvement of oral and/or mucous membranes
may be very severe.
→ In toxic epidermal necrolysis (choice D), the cutaneous eruption begins as a poorly
defined, erythematous macular rash with purpuric centers, which later coalesces to form
flaccid blisters and sheetlike epidermal detachment. The lesions predominate on the torso
and face, sparing the scalp. Mucous membrane is not spared.
→ Toxic shock syndrome (choice E) also includes mucosal involvement and is
characterized by high fever, rash, hypotension, multiorgan failure, and desquamation,
typically of the palms and soles.
Question #157
QID: 17380
Topic: Necrotizing Enterocolitis
Subject: Pediatrics
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
Necrotizing Enterocolitis (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.
Question #158
QID: 17396
Topic: Necrotizing Enterocolitis
Subject: Pediatrics
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 necrotizing enterocolitis (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.
Question #159
QID: 16223
Topic: Sexual Abuse
Subject: Pediatrics
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 mother-son incest
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.
Question #160
QID: 17652
Topic: Transient Tachypnea of the Newborn
Subject: Pediatrics
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.
Question #161
QID: 16225
Topic: Microcytic Anemia
Subject: Pediatrics
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.
Question #162
QID: 16226
Topic: Rheumatic Fever
Subject: Pediatrics
Antibiotic therapy can be helpful for prevention of rheumatic fever if initiated up to how
many hours/days following onset of symptoms of Group-A streptococcal throat infection?
a) 24 hours
b) 48 hours
c) 96 hours
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.
Rheumatic Fever
Question #163
QID: 17413
Topic: Rheumatic Fever
Subject: Pediatrics
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.
Rheumatic Fever
Question #164
QID: 16230
Topic: Precocious Puberty
Subject: Pediatrics
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.
Question #165
QID: 16244
Topic: Prematurity
Subject: Pediatrics
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 midline 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.
Question #166
QID: 16246
Topic: Respiratory Distress Syndrome
Subject: Pediatrics
Which of the following is a characteristic chest x-ray appearance of neonatal 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.
Respiratory Distress Syndrome
Question #167
QID: 16312
Topic: Osteomyelitis
Subject: Pediatrics
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 gramnegative 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.
Note: Salmonella osteomyelitis occurs most commonly in children with sickle cell disease,
but is still less common than Staph aureus in these patients
Question #168
QID: 16249
Topic: Measles
Subject: Pediatrics
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.
Question #169
QID: 16252
Topic: Pseudomembranous Colitis
Subject: Pediatrics
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.
Question #170
QID: 16253
Topic: Transposition of the Great Arteries
Subject: Pediatrics
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)
c)
d)
e)
Complete atrioventricular canal defect
Tetralogy of Fallot
Transposition of the great arteries
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.
Question #171
QID: 17397
Topic: Seizures, absence
Subject: Pediatrics
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 daydreaming. 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.
Question #172
QID: 17362
Topic: Shigellosis
Subject: Pediatrics
An 8-year-old boy presents with a 2- to 3-day history of diarrhea, fever of 38.9-39.5°C
(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.
Question #173
QID: 16322
Topic: Laryngomalacia
Subject: Pediatrics
A 4-month-old baby was brought in for a mild inspiratory stridor that has become more
noisy lately, according to the parents. The most likely cause of this is:
a)
b)
c)
d)
e)
Laryngomalacia
Acute epiglottitis
Croup
Tonsillar hypertrophy
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.
In more than 99% of cases, the only treatment necessary for laryngomalacia is time. The
lesion gradually improves, and noises disappear by age 2 years in virtually all infants. The
noise steadily increases over the first 6 months, as inspiratory airflow increases with age.
Question #174
QID: 18446
Topic: Laryngomalacia
Subject: Pediatrics
A 2-month-old male is brought in by his mother who has noted unusual sounds while the
baby is breathing. She states that it started about 2 weeks ago, but yesterday, it sounded like
it was getting worse. The breathing noise is usually heard when the baby is lying on his
back or crying, and it improves when she holds the baby on her shoulder. She also noticed
that the sounds are worse when the baby is breathing in but they get better on exhalation.
The pregnancy and delivery were uneventful and the baby had been growing well since
birth.
On physical examination you note stridor that increases on inspiration heard best just above
the sternal notch. Which of the following is the most likely diagnosis?
a) Airway foreign body
b) Choanal atresia
c) Laryngotracheobronchitis
d) Subglottic stenosis
e) Laryngomalacia
The correct answer is e)
Explanation:
This patient presents with stridor that worsens on inspiration and when he is in the supine
position, which is typical of laryngomalacia (choice E). It is a congenital abnormality of the
laryngeal cartilage, the most common cause of congenital stridor and is the most common
congenital lesion of the larynx. It is a dynamic lesion resulting in collapse of the supraglottic
structures during inspiration leading to airway obstruction. The epiglottis is curled on itself
to form an omega-shaped epiglottis. 90% of cases heal by themselves by the age of 2
without any treatment. Diagnosis is best confirmed with laryngoscopy or bronchoscopy. In
cases with the typical stridor that worsens when the child lies down, it is reasonable to make
the diagnosis based on clinical presentation.
→ Airway foreign body (choice A) is seen in aspiration of objects by toddlers and preschool children. The presentation is acute with a child suddenly coughing or choking. New
abnormal airway sounds are heard and are often unilateral. Stridor is heard during both
phases of respiration, inspiration and expiration.
→ Choanal atresia (choice B) is a supralaryngeal cause of stridor with the back of the nasal
passage blocked by abnormal bony or membranous tissue due to failed recanalization of the
nasal fossae during fetal development. Bilateral choanal atresia is more serious than
unilateral choanal atresia and crying alleviates respiratory distress.
→ Laryngotracheobronchitis (choice C) or Croup as it is commonly called, manifests as
hoarseness, a seal-like barking cough, and a variable degree of respiratory distress.The most
common cause of Croup is parainfluenza infection.
→ Subglottic stenosis (choice D) can be congenital or acquired. Stridor of subglottic
stenosis is typically biphasic. Acquired forms usually arise from endotracheal intubation.
Key point:
Laryngomalacia is characterized by an immature cartilage that leads to collapse of the
supraglottic structures during inspiration, and results in airway obstruction. Stridor that
worsens when the child lies supine is typical and can be used to make a clinical diagnosis.
The diagnosis is confirmed with bronchoscopy and laryngoscopy.
Question #175
QID: 16359
Topic: Vitamin B12 Deficiency
Subject: Pediatrics
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
e) Vitamin D
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.
Vitamin B12 Deficiency
Question #176
QID: 16362
Topic: Posterior Urethral Valves
Subject: Pediatrics
A 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 (choice B) until proven otherwise. These valves consist of folds
of mucosa obstructing the urethra at the prostatic level. A lower abdominal mass may
represent a markedly distended urinary bladder. 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.
Question #177
QID: 16417
Topic: Insect Bite
Subject: Pediatrics
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.
Question #178
QID: 16759
Topic: Insect Bite
Subject: Pediatrics
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.
Question #179
QID: 16468
Topic: Necrotizing Ulcerative Gingivitis
Subject: Pediatrics
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, craterlike 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) Prednisone
The correct answer is b)
Explanation:
This patient has acute necrotizing ulcerative gingivitis (ANUG, known as trench mouth).
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. The causative organisms are mostly anaerobic bacteria.
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.
Question #180
QID: 16528
Topic: Sinusitis
Subject: Pediatrics
You diagnose sinusitis in a 20-month-old boy. He has been in good health otherwise, and
has not been seen by a physician since his last well care visit. Which one of the following is
recommended as initial antibiotic treatment in cases of serious allergic reactions to
penicillins?
a) Clarithromycin
b) Trimethoprim/sulfamethoxazole
c) Cefuroxime
d) Amoxicillin
e) Doxycycline
The correct answer is a)
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. For children younger
than 2 years of age with uncomplicated acute bacterial sinusitis that is mild to moderate in
degree of severity, who do not attend day care, and have not recently been treated with an
antimicrobial, amoxicillin is recommended.
If the patient is allergic to amoxicillin, either cefdinir, cefuroxime, or cefpodoxime can be
used (only if the allergic reaction was not a type 1 hypersensitivity reaction).
In cases of serious allergic reactions, clarithromycin or azithromycin can be used.
Question #181
QID: 16536
Topic: Sinusitis
Subject: Pediatrics
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) Antibiotics should not be used at this time
d) Sinus radiographs should be ordered, and the decision to use antibiotics should be based
on the findings
e) Erythrocyte sedimentation rate and C-reactive protein should be ordered
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. The
erythrocyte sedimentation rate and C-reactive protein level may be elevated in
rhinosinusitis, but these findings are nonspecific.
Question #182
QID: 16560
Topic: Peritonsillar Abscess
Subject: Pediatrics
The mother of a 16-year-old male calls to report that her son has a severe sore throat and has
been running a fever of 38.9°C (102°F). Which one of the following additional findings
would be most specific for peritonsillar abscess?
a) A 1 day duration of illness
b) Ear pain
c) Difficulty opening his mouth
d) Hoarseness
e) Pain with swallowing
The correct answer is c)
Explanation:
Trismus is almost universally present with peritonsillar abscess. Voice change, otalgia, and
odynophagia may or may not be present with peritonsillar abscess. Pharyngotonsillits and
peritonsillar cellulites may also be associated with these complaints. Otalgia is common
with peritonsillar abscess, otitis media, temporomandibular joint disorders, and a variety of
other conditions. Peritonsillar abscess is rarely present without at least a 3 day history of
progressive sore throat.
Question #183
QID: 16566
Topic: UTI
Subject: Pediatrics
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 should be performed to rule out vesicoureteral reflux
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.
→ All children should have urine for culture collected by suprapubic aspiration or urethral
catheterization. The perineal bag has unacceptable rates of contamination (choice A),
especially in girls and uncircumcised boys.
→ A 7- to 14-day course of parenteral or oral antibiotics is recommended (choice B), with
prophylactic oral antibiotics recommended until imaging studies are completed.
→ A voiding cystourethrogram (VCUG) to rule out vesicoureteral reflux (VUR) should not
be performed routinely after the first febrile UTI (choice D). More than 50% of these
children will have some VUR on these studies, and the degree of VUR correlates with renal
parenchymal damage.
→ After a UTI has been diagnosed, meta-analyses have revealed no significant reduction in
symptomatic UTI from prophylactic antibiotics regardless of whether VUR was present
(choice E).
Question #184
QID: 16818
Topic: UTI
Subject: Pediatrics
A 4-year-old female presents with urinary frequency, dysuria, and fever to 38.8°C (101.8°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. She returns after 4 days with no
improvement of her symptoms.
Which of the following is recommended for this patient?
a)
b)
c)
d)
e)
Renal ultrasonography only if she has recurrent infections
Renal scintigraphy only if she has recurrent infections
Renal ultrasonography and cystoscopy only if she has recurrent infections
Renal ultrasonography for this primary episode of infection
VCUG for this primary episode of infection
The correct answer is d)
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. UTI 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. Renal and bladder ultrasonography is a noninvasive test that can demonstrate the size and shape of the kidneys, the presence of
duplication and dilatation of the ureters, and the existence of gross anatomic abnormalities.
It can also identify renal or perirenal abscess or pyonephrosis in children with acute UTI
who fail to improve with antimicrobial therapy. Given the potentially large benefit of
detecting correctible malformations for a small number of children and the low risk of harm,
renal and bladder ultrasound (choice D) is recommended for the following children:
●Children younger than two years of age with a first febrile UTI
●Children of any age with recurrent febrile UTIs
●Children of any age with a UTI who have a family history of renal or urologic disease,
poor growth, or hypertension
●Children who do not respond as expected to appropriate antimicrobial therapy
→ Renal scintigraphy (choice B) using dimercaptosuccinic acid (DMSA) can be used to
detect acute pyelonephritis and renal scarring in the acute and chronic settings. The role of
renal scintigraphy in the management of children with acute UTI is controversial. In
addition, these scans are expensive, invasive, and expose children to radiation.
→ Cystoscopy (choice C) and retrograde pyelography are rarely indicated in the work-up.
→ Perform VCUG (voiding cystourethrogram) (choice E) to diagnose VUR (vesicoureteral
reflux) in children of any age with two or more febrile UTIs and in children of any age with
a first febrile UTI who have any anomalies on renal ultrasound or a family history of renal
or urologic disease; and children with poor growth or hypertension.
Question #185
QID: 17788
Topic: UTI
Subject: Pediatrics
A mother complains that her 4-year-old daughter’s urine smells strange. Her urine dipstick
is positive for leukocytes and nitrates but negative for blood. The most likely causative
organism for her condition is:
a) Klebsiella
b) Proteus
c) Enteroccocus
d) E. coli
e) Pseudomonas
The correct answer is d)
Explanation:
Urinary Tract Infection
This question is testing your knowledge of the epidemiology of childhood UTI’s. Each of
the listed answers causes UTI but E. coli (d) is responsible for 80-90% of UTI’s.
The MCCEE and LMCC exams will very often test this kind of knowledge - listing equally
plausible answers in order to test your command of the statistics regarding a particular
pathology. Whereas, the USMLE will typically give you very long stems with various clues
as to which answers to consider (often listing a few unrelated answers/distractors, e.g. they
may list some viruses or bacteria that do not cause UTI’s).
PEARL: E. coli is responsible for most UTI’s.
Question #186
QID: 16584
Topic: Infectious Enteritis
Subject: Pediatrics
Which one of the following is the most common cause of infectious enteritis in children in
temperate climate areas?
a) Parvo-like virus
b) Cytomegalovirus
c) Campylobacter jejuni
d) Pathogenic Escherichia coli
e) Human rotavirus
The correct answer is e)
Explanation:
Rotavirus (choice E) 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 (choice A) have caused major community outbreaks of acute diarrhea.
→ Cytomegaolvirus (choice B) 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 (choice C) and various strains of Salmonella and Shigella species.
→ Some strains of Escherichia coli (choice D) are pathogenic, causing sporadic cases of
acute enteritis, epidemic diarrhea, and traveler’s diarrhea.
Question #187
QID: 16598
Topic: Menarche
Subject: Pediatrics
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.
Question #188
QID: 17037
Topic: Pertussis
Subject: Pediatrics
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.
Question #189
QID: 16619
Topic: Visual Loss
Subject: Pediatrics
Which one of the following is the most common cause of monocular visual loss in children?
a)
b)
c)
d)
e)
Iritis
Glaucoma
Amblyopia
Eye trauma
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.
Question #190
QID: 16632
Topic: Pharyngitis
Subject: Pediatrics
A 16-year-old male presents with a 3-day history of sore throat, hoarseness, fever of 39°C
(102.2°F), and cough. Examination reveals no tonsilar exudates, no lymphadenopathy, 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) Order chest X-ray
The correct answer is a)
Explanation:
Pharyngitis is a common complaint, and usually has a viral cause. The key factors identified
in the Centor criteria or the McIsaac decision rule in diagnosing streptococcal pharyngitis
are a fever over 38.5°C, 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.
This has led to a modified criteria that adds 1 point for patients < 15 and substracts 1 point
for patients > 44 in predicting streptococcal infection and 0 point added for those between
15-44 years old.The scenario described is consistent with a viral infection, as only one of
the 4 key factors is present in this patient: fever. The patient has no tonsilar exudates, no
lymphadenopathy.
→ Perform a rapid antigen test for streptococcal pharyngitis (choice B) and Perform a throat
culture for streptococcal pharyngitis (choice D), these are done if the patient has 2 or 3
points on the Centor criteria/McIsaac decision rule. If these studies are positive, then
antibiotics can be given.
→ Treat empirically for streptococcal pharyngitis (choice C) is recommended for patients
who have a Centor criteria/McIsaac score ≥ 4.
→ Ordering chest X-ray (choice E) means that pneumonia is suspected. This patient's
condition suggests an uncomplicated upper respiratory infection and chest X-ray is
unnecessary at this point.
Question #191
QID: 16641
Topic: Internal Tibial Torsion
Subject: Pediatrics
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.
Question #192
QID: 16658
Topic: Munchausen Syndrome by proxy
Subject: Pediatrics
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: 123 g/L
Hematocrit : 36%
WBC count: 4.5 x 10^9/L
Platelets: 235 x10^9/L
Prothrombin time: 40 seconds
Partial thromboplastin time: 30 seconds
INR: 3.9
ALT (SGPT) : 18 U/L
AST (SGOT): 16 U/L
Bilirubin: 12.0 µmol/L
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 seconds/3.0, 23
seconds/2.1, and 15 seconds/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) Shaken baby syndrome
The correct answer is c)
Explanation:
Munchausen syndrome by proxy (choice C) is used to describe a behavior pattern in which
a caregiver deliberately exaggerates, fabricates, and/or induces physical, psychological,
behavioral, and/or mental health problems in those who are in their care. It is a covert,
potentially lethal, and frequently misunderstood form of child abuse. Although not
uncommon, this syndrome is difficult to detect and confirm
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 (choice A) of this degree would likely produce transaminase and
bilirubin elevations, as well as mental status changes.
→ Antiphospholopid syndrome (choice B) produces a hypercoagulable state.
→ Henoch-Schönlein purpura (choice D) presents with purpura, joint pain, abdominal pain,
and a normal PT.
→ Traumatic injury (like shaken baby syndrome) (choice E) would not result in PT
elevations.
Munchausen Syndrome
Question #193
QID: 16811
Topic: Munchausen Syndrome by proxy
Subject: Pediatrics
An 18-month-old white male has been brought into your office multiple times over the past
year with a reported fever of over 38°C (101°F). 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)
b)
c)
d)
e)
The child has seen no other health-care provider but you
Both parents have been involved with each office visit
The child is afebrile while staying at the day-care center
The parents have resisted having painful or risky diagnostic tests performed on the child
The child responds well to usual medical therapies
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 (choice C);
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.
Munchausen Syndrome
Question #194
QID: 16668
Topic: Syncope
Subject: Pediatrics
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)
c)
d)
e)
24-hour Holter monitoring
A pulmonary/cardiac stress test
An echocardiogram
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 perfusion. Recovery is rapid, with
no focal neurologic sense of confusion or headache. The event can be duplicated with tilt
testing, demonstrating hypotension and bradycardia.
Question #195
QID: 16725
Topic: Meckel's Diverticulum
Subject: Pediatrics
What is the most common cause of bleeding in patients with Meckel’s diverticulum?
a) Helicobacter pylori infection causing ileal mucosal ulceration
b) Ulceration of the small bowel due to acid secretion by ectopic gastric mucosa
c) Arteriovenous malformation causing mucosal bleeding
d) Intussusception causing mucosal bleeding from inflammation
e) Twisting of the small bowel around the fibrous cord or band often associated with
Meckel’s diverticulum
The correct answer is b)
Explanation:
Gastrointestinal bleeding related to Meckel's diverticulum is caused by ulceration of the
small bowel (choice b) due to acid secretion by ectopic gastric mucosa within the
diverticulum. The site of mucosal ulceration and bleeding is adjacent to or just downstream
from the diverticulum, not from the mucosa or ectopic tissue within the diverticulum.
→ Heliobacter pylori (choice A) has not been shown to be an etiologic agent.
→ Arteriovenous malformation (choice C) is not a major complication of Meckel’s
diverticulum.
→ Intussusception (choice D) is fairly common in patients with Meckel’s diverticulum but
is not a frequent cause of bleeding.
→ Intestinal obstruction (not bleeding) related to Meckel’s diverticulum can result from
volvulus (choice E), in children. The intestines, usually the small bowel, can twist around
the fibrous cord or band often associated with Meckel’s diverticulum such as those from the
tip of the diverticulum to the peritoneal lining of the anterior abdominal wall, or other
adhesions
Question #196
QID: 17665
Topic: Meckel's Diverticulum
Subject: Pediatrics
A previously healthy 2-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 (choice A) have right lower quadrant pain, abdominal
tenderness, guarding, and vomiting, but not rectal bleeding.
→ With acute viral gastroenteritis (choice B), 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 (choice C) 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 (choice E) 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.
Meckel's Diverticulum
Question #197
QID: 16755
Topic: Otitis Externa
Subject: Pediatrics
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) Pseudomonas 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.
Question #198
QID: 16806
Topic: Nephrotic Syndrome
Subject: Pediatrics
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 show the following:
Hematocrit: 42%
WBCs: 6.2 x 10^9/L with normal differential
Creatinine: 71 µmol/L
BUN: 6.4 mmol/L
Albumin: 23 g/L
Calcium: 1.84 mmol/L
Sodium: 128 mmol/L
Potassium: 3.7 mmol/L
Total cholesterol: 8 mmol/L
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 8 mmol/L.
→ Congenital renal artery stenosis is an uncommon cause of problems in childhood and
typically presents with hypertension in adults.
Question #199
QID: 17407
Topic: Nephrotic Syndrome
Subject: Pediatrics
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) Hyperlipidemia
e) Red blood cell casts
The correct answer is e)
Explanation:
Nephrotic syndrome is a common cause of edema in pediatric patients. 85% 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.
Dependent edema is the most prominent sign. The retina has a wet appearance. Subungual
edema with horizontal lines (called Muehrcke lines) also may occur.
Heavy proteinuria over an extended period of time leads to a state of protein depletion with
muscle wasting, thinning of the skin, and growth failure.
Hypoalbuminemia is an important marker of nephrotic syndrome.
Hyperlipidemia also is a feature of a nephrotic state.
The presence of RBC casts is almost pathognomonic of glomerulonephritis (nephritic
syndrome).
Question #200
QID: 16871
Topic: Sleep Apnea
Subject: Pediatrics
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 75th 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
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. Clinical diagnosis of obstructive
sleep apnea is reliable; however, the gold standard evaluation is overnight
polysomnography.
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.
Question #201
QID: 16875
Topic: Malaria
Subject: Pediatrics
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.
Malaria
Question #202
QID: 16878
Topic: Vaginal Examination
Subject: Pediatrics
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.
Question #203
QID: 17033
Topic: Pneumothorax
Subject: Pediatrics
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.
Question #204
QID: 17034
Topic: Safety, seatbelt
Subject: Pediatrics
At a well care visit, the father questions you about which car restraint system is best for his
child, who is 48-inch (122cm) 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 c)
Explanation:
Seatbelts are designed for adults and older children. Once a child can sit all the way against
the vehicle seat back with legs bent comfortably over the edge of the seat, and with the
shoulder belt flat across the shoulder and chest, he or she is ready to move from the booster
seat to the vehicle seatbelt.
One should make sure the shoulder strap lies across the child's shoulder and the middle of
the chest (not the neck or face), and the lap belt crosses over the hips (not the stomach).
Children under 13 years of age are safest in the back seat. Never put two children in the
same seatbelt or place the shoulder strap behind the child's back.
Use a seatbelt for every trip.
-36 kg (80 lb.), or 145 cm (4', 9”) tall or 8 years old
-One person. One seatbelt
[for more info refer to Ministry on Transportation website, ON --> http://
www.mto.gov.on.ca/english/safety/carseat/choose.shtml]
Question #205
QID: 17036
Topic: Spondylolysis
Subject: Pediatrics
Which one of the following would be the most typical presentation of spondylolysis or
spondylolisthesis in a 15-year-old football player?
a)
b)
c)
d)
Low back pain radiating to one buttock
Radicular pain with paresthesia over the dorsal foot
Difficulty initiating urination
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.
Question #206
QID: 17205
Topic: Spondylolysis
Subject: Pediatrics
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 2 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.
Question #207
QID: 17045
Topic: Metatarsus Adductus
Subject: Pediatrics
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.
Question #208
QID: 17106
Topic: Tarsal Coalition
Subject: Pediatrics
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)
c)
d)
e)
stress fracture
plantar fasciitis
turf toe
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.
Question #209
QID: 17126
Topic: Retinitis Pigmentosa
Subject: Pediatrics
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.
Question #210
QID: 17148
Topic: Safety, sports
Subject: Pediatrics
Which one of the following is a contraindication to participation in contact sports?
a) Mononucleosis
b) Gastroesophageal reflux
c) Essential hypertension
d) Sickle cell trait
e) Atrial septal defect
The correct answer is a)
Explanation:
Mononucleosis (choice A) is the only contraindication for contact sport out of the choices
given in this question. It is a clinical syndrome consisting of fever, pharyngitis, and
adenopathy caused by Epstein-Barr virus. It is commonly seen in adolescents and young
adults.It is primarily diagnosed by observation of symptoms, but suspicion can be confirmed
by diagnostic tests such as heterophile antibody tests.Mortality and morbidity rates due to
uncomplicated primary EBV infectious mononucleosis are low. The rare cases of attributed
mortality are usually related to spontaneous splenic rupture. Contact sports increase risks of
splenic rupture in these patients, therefore, they should be avoided.
→ Gastroesophageal reflux (choice B) is not a contraindication for contact sports.
→ Essential hypertension (choice C ) can improve with watching diet and exercise. While
exercise doesn't necessarily have to be contact sport, this is also a form of physical activity
that would be beneficial in hypertension management.
→ Sickle cell trait (choice D) almost never causes clinical disease. Occasionally hematuria
may be noted in patients with sickle cell disease, but it is not a condition that requires to
avoid contact sports.
→ Atrial septal defect (choice E) is usually asymptomatic and is not a contraindication for
contact sports.
Question #211
QID: 17169
Topic: Nasolacrimal Duct Obstruction
Subject: Pediatrics
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.
Question #212
QID: 17401
Topic: Nasolacrimal Duct Obstruction
Subject: Pediatrics
At the 6-month well-child visit, you notice that the baby’s right eye is tearing excessively.
On exam, the baby is thriving and the eye exam is otherwise normal. Dye disappearance test
shows some dye in the eye that is visible as a bright green tear meniscus. 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. Congenital nasolacrimal duct obstruction occurs in approximately 5% of normal
newborn infants. The blockage occurs most commonly at the valve of Hasner at the distal
end of the duct. The blockage can be unilateral or bilateral. The rate of spontaneous
resolution is estimated to be 90% within the first year of life.
The dye disappearance test may be used to determine if tears are draining at the proper
rate. All of the fluorescein should drain into the nose within five minutes if the lacrimal
drainage system has no obstruction. One of two events occurs if the nasolacrimal system is
obstructed: the dye may remain in the eye and be visible as a bright green tear meniscus, or
the dye may escape over the eyelid and drain down the cheek. The test is normal if most of
the dye is gone within five minutes and abnormal if a large amount of the dye persists or has
drained over the lower eyelid and down the cheek.
→ Dacryocystitis (choice A) is a superimposed infection of the tear duct.
→ Open globe (choice B) implies rupture of the sclera and is uncommon.
→ Congenital glaucoma (choice D) and chronic irritation from allergies (choice E) are
uncommon causes of painless tearing in a baby.
Question #213
QID: 17429
Topic: Nasolacrimal Duct Obstruction
Subject: Pediatrics
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.
Question #214
QID: 17188
Topic: Infantile Colic
Subject: Pediatrics
A 3-month-old male is brought to your office by his exhausted parents. The child is bottle
fed with cow’s milk formula. For the past 3 weeks he has cried uncontrollably for several
hours most evenings. He refuses the bottle and cannot be distracted. There has been no
vomiting, although he frequently “spits up” when carried, rocked, or burped. His mother
describes 2-3 normal bowel movements a day. Your examination is unremarkable. The child
is gaining weight appropriately.
The most likely diagnosis is:
a) pyloric stenosis
b) annular pancreas
c) infantile colic
d) Hirschsprung’s disease
e) casein allergy
The correct answer is c)
Explanation:
The most widely accepted definition of infantile colic is the Wessel definition, which
describes colic as “unexplained paroxysmal bouts of fussing and crying that lasted > 3 hours
a day, for > 3 days a week, for > 3 weeks duration.” The absence of vomiting and the
normal stools make the other diagnoses unlikely.
Question #215
QID: 17193
Topic: Little League Elbow
Subject: Pediatrics
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.
Question #216
QID: 17219
Topic: Marfan's Syndrome
Subject: Pediatrics
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.
Question #217
QID: 17714
Topic: Marfan's Syndrome
Subject: Pediatrics
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.
Question #218
QID: 17230
Topic: Syndesmotic Sprain
Subject: Pediatrics
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.
Question #219
QID: 17412
Topic: Tuberous Sclerosis
Subject: Pediatrics
An 8 year old boy is brought to your office by his mother for evaluation. She is concerned
about his poor school performance as he is much “slower” to learn than the other children in
his class. 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)
b)
c)
d)
Sturge-Weber syndrome
Von Hippel-Lindau disease
Neurofibromatosis
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.
Tuberous Sclerosis
Tuberous Sclerosis
Question #220
QID: 17243
Topic: Speech Screening
Subject: Pediatrics
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 (choice D).
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.
Question #221
QID: 17255
Topic: Primary Amenorrhea
Subject: Pediatrics
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. She denies any sexual activity.
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) Pregnancy test
The correct answer is a)
Explanation:
Primary amenorrhea is absence of menstruation by age 14 in women without secondary
sexual characteristics or absence of menstruation by age 16 in women with secondary
sexual characteristics. 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 (choice A) is appropriate for this
problem.
→ Karyotype analysis (choice B) 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 (choice C) 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 (choice D) and pregnancy test (choice E) are used to
evaluate secondary amenorrhea.
Amenorrhea
Question #222
QID: 17283
Topic: Polythelia
Subject: Pediatrics
A 14-year-old Hispanic female presents with a dark spot on her right lateral chest (see
Image). Her mother says the lesion has 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.
Question #223
QID: 17373
Topic: Tetralogy of Fallot
Subject: Pediatrics
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) IV morphine
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 oxygen - pulmonary vasodilator
and a systemic vasoconstrictor). If these fail, they are followed by intravenous therapy of
morphine (0.1 mg/kg per dose). 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 rightto-left shunt.
Tetralogy of Fallot
Tetralogy of Fallot
Question #224
QID: 17377
Topic: Phenylketonuria
Subject: Pediatrics
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) Long-term treatment with sapropterin may improve metabolic control and tolerance to
phenylalanine in all affected patients
e) Untreated patients develop mental retardation, spasticity, and behavior problems
The correct answer is d)
Explanation:
Phenylketonuria (PKU) is an autosomal recessive metabolic genetic disorder characterized
by a mutation in the gene for the hepatic enzyme phenylalanine hydroxylase (PAH).This
impairs the body’s ability to metabolize the essential amino acid phenylalanine. This leads
to accumulation of phenylalanine in body fluids. Long-term treatment with sapropterin in
tetrahydrobiopterin (BH4) responsive patients with PKU improves metabolic control,
increases tolerance to dietary phenylalanine, and improves quality of life. Patients treated
with sapropterin have an approximately fourfold increase in median phenylalanine
tolerance, compared with patients treated only through diet. However, BH4-responsive PKU
patients are only 50% of all the affected patients, and stating that this treatment is effective
in all patients with PKU is an incorrect statement (choice D)
→ The parents’ recurrence risk is 25% in future pregnancies (choice A) is true, as PKU is an
autosomal recessive condition.
→ The child will need to be on a special formula restricting phenylalanine (choice B) is
true. Strict dietary management with monitoring of phenylalanine blood levels is essential in
early childhood as neurodevelopment takes place
→ The prognosis for intellectual development is good with strict dietary management
(choice C) is true.Patients who are treated from birth and closely monitored have a good
prognosis for normal intellectual development.
→ Untreated patients develop mental retardation, spasticity, and behavior problems (choice
E) is true.Patients whose treatment is delayed or not closely monitored will become
mentally retarded.
Question #225
QID: 17378
Topic: Varicella
Subject: Pediatrics
A 3-year-old is admitted to the hospital with a very pruritic rash. The infectious disease
consultant identifies it as chickenpox. Which of the following is not true:
a)
b)
c)
d)
e)
Varicella is highly contagious and this patient should be carefully isolated
Varicella may be lethal in immunocompromised hosts
Varicella is no longer contagious when all lesions are crusted over
Varicella is pruritic to the extent that antipruritic drugs may be appropriate
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.
Chicken Pox (Varicella)
Question #226
QID: 17381
Topic: Milk Allergy
Subject: Pediatrics
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.
Question #227
QID: 17393
Topic: Patau Syndrome
Subject: Pediatrics
Which of the following statements is true regarding this patient’s condition?
a)
b)
c)
d)
e)
This condition is autosomal dominant
This condition cannot be detected prenatally
This condition is usually caused by a missing chromosome
Affected individuals are usually females while males die in utero
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 equally affected; this condition does not cause lethality in
males.
Question #228
QID: 17399
Topic: Shoulder Dystocia
Subject: Pediatrics
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.
Question #229
QID: 17403
Topic: SIADH
Subject: Pediatrics
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 brain abscess (choice A) is a complication that may cause seizures, but usually is not
one of the presenting signs. This complication may need neurosurgical care.
→ Again, subdural empyema (choice B) is not a presenting sign, but seizures resulting from
irritation from an empyema usually respond well to therapy.
→ Increased ICP (choice D) is a possible complication from meningitis and may cause
seizures (but not as common as hyponatremia). Medical therapy is usually not sufficient.
→ This child is too old to make a diagnosis of a febrile seizure (choice E). Given the
presenting signs and symptoms one should always consider bacterial infection first.
Question #230
QID: 17404
Topic: Roseola Infantum
Subject: Pediatrics
A 2-year-old boy presents to the office with an intermittent fever of 40°C (104°F) for the
past three days. The physical examination reveals no source of infection. However, you
notice faint pink maculopapular rash on his trunk. The patient does not appear toxic, and the
parents feel that he appears well between fevers. They also add that the rash was not seen
earlier. The differential diagnosis includes:
a) Rubella
b) Erythema infectiosum (Fifth disease)
c) Erythema toxicum
d) Roseola
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. Roseola is typically characterized by a history of 3 days of high fever (often
up to 40°C) followed by rapid defervescence and a characteristic rash (fades within a few
hours to 2 d) which is:
-Maculopapular or erythematous
-Typically beginning on the trunk and may spread to involve the neck and extremities
-Nonpruritic
-Blanches on pressure
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.
Question #231
QID: 17406
Topic: Short Stature
Subject: Pediatrics
Which of the following is not a direct 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 (choice B) 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.
→ Malnutrition (choice A) is commonly associated with proportionate short stature.
→ Teratogen exposure (choice C), intrauterine growth retardation, and placental
dysfunction are prenatal causes of proportionate short stature.
→ Turner’s syndrome (choice D) and trisomy 21 are chromosomal causes of proportionate
short stature.
→ Constitutional delay (choice E) is one of the most common causes of proportionate short
stature.
Question #232
QID: 17420
Topic: Short Stature
Subject: Pediatrics
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.
Question #233
QID: 17896
Topic: Short Stature
Subject: Pediatrics
A 16-year-old male accompanied by his mother presents to your outpatient clinic with
concerns about his short stature and “boyish” looks. He is a sophomore in high school but is
frequently mistaken for someone much younger. Radiographs reveal a bone age of 14.7
years.
Which one of the following would suggest the need for further evaluation?
a) A family history of delayed growth
b) Height below the fifth percentile for age
c) Weight below the fifth percentile for age
d) Prepubescent testicular size
The correct answer is d)
Explanation:
Most cases of short stature are due to constitutional growth delay, a term which implies that
the child is normal but delayed in his development. A hallmark of this condition is being
below the fifth percentile for height for most of childhood. Usually these children are thin
and have a family history of delayed development. Bone age would be expected to be at
least 2.5 standard deviations below the mean for age- matched peers of the same
chronologic age. However, most experts agree that if no signs of puberty are seen by 14
years of age (no breast development in girls, no testicular enlargement in boys), then further
workup for a more serious condition should be sought. Other indications for evaluation
would be no menarche in a girl by 16 years of age and underdeveloped genitalia in a boy 5
years after his first pubertal changes.
Question #234
QID: 17409
Topic: Mastoiditis
Subject: Pediatrics
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 38.2°C (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.
Question #235
QID: 17417
Topic: Purpura Fulminans
Subject: Pediatrics
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.
Question #236
QID: 17425
Topic: RSV, Palivizumab
Subject: Pediatrics
Which of the following is false 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 weekly for six doses for infants/children that meet specific criteria
c) It should be given to a 6-month-old term infant with hemodynamically significant
cyanotic heart disease
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) (choice D). It should be considered for use in infants and
children younger than 2 years of age with chronic lung disease (choice A) 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
(choice E). It should be also used in children younger than 2 years of age with
hemodynamically significant cyanotic and acyanotic heart disease (choice C).
Canadian indications for administration of palivizumab:
http://www.cfp.ca/cgi/content/full/56/8/769/T10560769
Question #237
QID: 17427
Topic: Intraventricular Hemorrhage
Subject: Pediatrics
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.
Question #238
QID: 17428
Topic: Status Epilepticus
Subject: Pediatrics
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 (choice B) 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.
→ Administration of rectal diazepam (choice A) and IV administration of lorazepam (choice
C) are first line agents in treating status epilepticus. They act to potentiate action of gammaaminobutyric acid (GABA), an inhibitory neurotransmitter in the CNS, and rapidly abrogate
ongoing seizure activity.
→ IV loading dose of phenytoin (choice D) is an integral part of status epilepticus
management. Even if the patient was previously compliant with phenytoin treatment with
levels within therapeutic range, phenytoin should still be administered to bring the levels
to 20-30 µg/mL.
→ Correction of any abnormalities of the airway, breathing, and circulation (choice E) is of
major importance.Any indication of respiratory insufficiency should be addressed by
intubation.
Question #239
QID: 17430
Topic: Torus Fracture
Subject: Pediatrics
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 followup 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.
Question #240
QID: 17431
Topic: Pulmonary Hemosiderosis
Subject: Pediatrics
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.
Question #241
QID: 17433
Topic: Meningococcus Prophylaxis
Subject: Pediatrics
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 (not High-resolution chromosomal 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.
Question #242
QID: 17435
Topic: Sexual Development
Subject: Pediatrics
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
e) Testicular enlargement, height growth spurt, penile enlargement, pubic hair
The correct answer is d)
Explanation:
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 year 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 year) is affected by psychologic, cultural, and biologic factors. First
ejaculation takes place about 1 year after penis growth accelerates. Gynecomastia, usually in
the form of breast buds, is common in young adolescent boys and usually resolves within
several years.
Question #243
QID: 17511
Topic: Respiratory Syncytial Virus
Subject: Pediatrics
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
c) Oxygen
d) Palivizumab
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.
Question #244
QID: 17689
Topic: Respiratory Syncytial Virus
Subject: Pediatrics
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. 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 (SpO2) persistently falls below 90% and can be
discontinued when an adequate level returns.
Antiviral therapy for RSV bronchiolitis is controversial because of its marginal benefit,
cumbersome delivery, potential risk to caregivers, and high cost. 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. If used, it should be administered intramuscularly
in five monthly doses of 15 mg/kg, usually beginning in November or December.
Question #245
QID: 17575
Topic: Infectious Mononucleosis
Subject: Pediatrics
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 120/70 mm Hg, Temp is 39°C, 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 x 10^9/L
Hemoglobin: 145 g/L
Platelet: 200 x 10^9/L
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 (choice C) 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.
→ Although, acute HIV infection (choice A) could give similar symptoms and should be
ruled out; it is unlikely, as acute HIV infection would give leucopenia (not leucocytosis).
→ Acute leukemia (choice B) is unlikely in the presence of a normal blood count and absent
blasts.
→ Non specific viral pharyngitis (choice D) would present with flu like illness (coryza)
rather than sore throat and lymphadenopathy.
→ Streptococcal tonsillitis (choice E) 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.
Question #246
QID: 17705
Topic: Nutrition
Subject: Pediatrics
Cow’s milk should be withheld from a child’s diet until what age?
a) 4 months
b) 6 months
c) 12 months
d) 15 months
e) 24 months
The correct answer is c)
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 before 9 to 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.
→ 4 months (choice A) and 6 months (choice B) solid foods and juices are initiated.
→ 12 months-18 months (choice D), children can eat eggs, potatoes, drink whole milk, ironfortified cereal, and margarine.
→ 18 months-3 years (choice E) can eat meat, bread, fruits/dessert.
Question #247
QID: 17756
Topic: Nutrition
Subject: Pediatrics
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.
Question #248
QID: 17618
Topic: Medication Compliance
Subject: Pediatrics
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. 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%. 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.
Question #249
QID: 17637
Topic: Still's Murmur
Subject: Pediatrics
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.
Question #250
QID: 17733
Topic: Strabismus
Subject: Pediatrics
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.
Question #251
QID: 17741
Topic: Sleep
Subject: Pediatrics
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.
Question #252
QID: 17773
Topic: Physical Examination
Subject: Pediatrics
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 (choice B). This can help divert the child’s
attention if she is ticklish and give the child a sense of control.
→ Diversion attempts (choice A) are often unsuccessful with a ticklish child.
→ Applying increased pressure (choice C) may only make the exam more painful to the
patient and thus more difficult.
→ Restraining the child by anyone (choice D and choice E)) will make the exam much
more difficult and potentially more traumatic to the child.
Question #253
QID: 17827
Topic: Long-QT Syndrome
Subject: Pediatrics
A 17-year-old soccer player presents for a preparticipation examination. His family history
is significant for the autopsy-negative sudden death of his 12-year-old sister while playing
basketball, and for his mother and maternal grandmother having recurrent syncopal
episodes. His medical history and examination are completely normal. Prior to approving
his participation in sports, which one of the following is recommended?
a)
b)
c)
d)
e)
A resting EKG
A stress EKG
An echocardiogram
Pulmonary function testing
No further evaluation
The correct answer is a)
Explanation:
A family history of sudden death and recurrent syncope is highly suspicious for genetic
long-QT syndrome. It is best diagnosed with a resting EKG that shows a QTc >460 msec in
females and >440 msec in males. This syndrome especially places young people at risk for
sudden death. Management may include beta-blockers, an implantable cardioverterdefibrillator, and no participation in competitive sports.
Ref: Roden DM: Long-QT syndrome. N Engl J Med 2008;358(2):169-176.
Question #254
QID: 17867
Topic: Oppositional Defiant Disorder
Subject: Pediatrics
The parents of a 7-year-old male ask you to evaluate him because of increasing concerns
about his temper tantrums over the past 9 months. He often becomes angry and hostile,
argues with them constantly, and refuses to follow rules or directions. A major source of
difficulty is his refusal to quit playing with his toys when he is asked to come to the dinner
table. After the child ignored repeated attempts to get him to come to the table a few nights
ago, the father became frustrated and told him he had lost his television privileges. In
response, the child became aggressive and destructive, breaking his toys and sweeping his
dinner plate and glass of milk onto the floor. The parents describe many similar scenarios at
bedtime, bath time, and when he is getting dressed. They believe that their son is
deliberately behaving this way to annoy them.
This history is most consistent with:
a) Attention-deficit/hyperactivity disorder
b) Bipolar disorder
c) Conduct disorder
d) Oppositional defiant disorder
e) Normal childhood individualization
The correct answer is d)
Explanation:
This child meets the DSM-V criteria for oppositional defiant disorder, defined as a pattern of
negativistic, hostile, and defiant behavior lasting at least 6 months. The child will often lose
his or her temper, argue with adults, actively defy or refuse to comply with adults’ requests
or rules, deliberately annoy people, blame others for his or her mistakes or misbehavior, be
easily annoyed by others, appear angry and resentful, or be spiteful or vindictive. At least
four of these behaviors must be present to meet the criteria for diagnosis. The disturbance in
behavior must also cause clinically significant impairment in social, academic, or
occupational functioning, and the behaviors must not occur exclusively during the course of
a psychotic or mood disorder. Meeting the criteria for conduct disorder excludes the
diagnosis of oppositional defiant disorder. If the individual is 18 years of age or older and
meets the criteria for antisocial personality disorder, then oppositional defiant disorder is
excluded.
Oppositional Defiant Disorder
Question #255
QID: 17900
Topic: Prolactinoma
Subject: Pediatrics
A 15-year-old white female who has had regular periods since age 12 comes to your office
because of secondary amenorrhea and a milky discharge from her breasts. A pregnancy test
is negative.
The best test for initial evaluation of the pituitary in this patient is:
a) Plasma antidiuretic hormone
b) Plasma ACTH
c) Serum prolactin
d) Serum FSH and LH
e) Fasting growth hormone
The correct answer is c)
Explanation:
Anterior pituitary hormone overproduction is suspected on clinical grounds and confirmed
by appropriate laboratory evaluation. The most common secretory pituitary adenomas are
prolactinomas. They cause galactorrhea and hypogonadism, including amenorrhea,
infertility, and impotence. Growth hormone-secreting tumors, which are the next most
common secretory pituitary tumors, cause acromegaly or gigantism. Next in frequency are
corticotropic (ACTH-secreting) adenomas, which cause cortisol excess (Cushing’s disease).
Glycoprotein hormone-secreting pituitary adenomas (secreting TSH, LH, or FSH) are the
least common. TSH-secreting adenomas are a rare cause of hyperthyroidism. Paradoxically,
most patients with gonadotropin-secreting adenomas have hypogonadism.
Question #256
QID: 17913
Topic: Probiotics
Subject: Pediatrics
A 24-year-old female who works at a day-care facility presents to your office to discuss
ways to avoid getting “all the infections the kids get.” She plans to enroll her child in the
facility. She is specifically concerned about diarrheal illnesses, and a friend has suggested
the use of probiotics.
You tell her that probiotics:
a) Can lessen the severity and duration of infectious diarrhea
b) Are recommended only for patients who are immunocompromised
c) Have no known side effects
d) Often interact with common prescription medications
e) Are not appropriate for use in children
The correct answer is a)
Explanation:
Probiotics are microorganisms with likely health benefits, based on recent randomized,
controlled trials. Good evidence suggests that probiotics reduce the incidence, duration, and
severity of antibiotic-associated and infectious diarrhea. Common side effects include
flatulence and abdominal pain. Contraindications include short-gut syndromes and
immunocompromised states. There are no known drug interactions, and these agents appear
safe for all ages.
Question #257
QID: 18261
Topic: Secondary enuresis
Subject: Pediatrics
An 8-year-old male is brought to your department by his mother, because of bed wetting for
the last 3 weeks. The mother reports that this occurs at night only and it seems to have been
embarrassing for him. She states that it happens about five times a week and has continued
even when the boy was put on fluid restriction after 6 pm for the last 10 days. He has not
lost weight during this period and denies having excessive thirst. The boy had stopped
bedwetting at the age 4 and since then he had never had a similar problem. The mother
denies any changes in the family or stressful events and says that the boy’s nutrition is
regular and he was not on any special diet. Which of the following is the initial step in
management of this patient?
a) Urinalysis
b) Observation for 2 weeks
c) Desmopressin
d) Use of alarm devices
e) Kidneys, ureters, bladder X-ray (KUB)
The correct answer is a)
Explanation:
This child presents with nocturnal enuresis at the age of 8 after having achieved control over
micturition for 4 years. His condition is considered secondary enuresis, as this is defined as
enuresis occurring 6 months after a child had been continent for at least 6 months. Normally
98% of children achieve daytime continence by the age of 3 while 80% achieve nocturnal
continence by this age. By approximately age 4 years, all children with normal bladder
function should have acquired this ability.
When evaluating a child most likely to have secondary enuresis physicians should be alert
for symptoms associated with diabetes mellitus, diabetes insipidus, cystitis, overactive
bladder or dysfunctional voiding, sleep disordered breathing, constipation, urethral
obstruction, and major motor seizure. Psychological problems are also possible causes of
secondary enuresis. The best initial study for screening this patient is urinalysis (choice A).
Cystitis would present with white blood cells and bacteria on urinalysis, while urethral
obstruction may be associated with red blood cells. The presence of glucose would suggest
diabetes mellitus, while a specific gravity greater than 1.020 would rule out diabetes
insipidus.
→ Observation for 2 weeks (choice B) is incorrect. This child has been observed for the last
3 weeks and the best next step is to explore possible causes of enuresis.
→ Desmopressin (choice C) is considered in children with primary enuresis by the age of 7.
While it may help with enuresis symptoms, it is not appropriate to start this medication
before important investigations are completed.
→ Use of alarm devices (choice D) is also incorrect, as the child’s condition needs to be
properly investigated first.
→ Kidneys, ureters, bladder X-ray (choice E) is incorrect. Despite its name, it is not
typically used to investigate pathology of the kidney, ureter, and bladder. These structures
are better assessed with intravenous pyelogram or CT urography. KUB is typically used to
investigate gastrointestinal conditions such as a bowel obstruction and gallstones, and can
detect the presence of kidney stones.
Key point:
Secondary enuresis is urinary incontinence in children occurring 6 months after achieving
control over micturition. It may be caused by anatomical abnormalities, urinary tract
infections, hormonal disturbances, and psychological problems. The most important
screening test is urinalysis.
Question #258
QID: 18083
Topic: Sudden Infant Death Syndrome (SIDS)/Acute Life Threatening Event - (ALTE)
Subject: Pediatrics
Which one of the following is recommended to reduce the risk of sudden infant death
syndrome (SIDS)?
a)
b)
c)
d)
The use of home cardiorespiratory monitors
The use of soft bedding materials
Having the infant sleep in a prone position
Having the infant sleep in a separate bed
e) Maintaining a room temperature of 78°F-80°F (25.5°C-26.7°C) when the infant is
sleeping
The correct answer is d)
Explanation:
Bed sharing has been shown to increase the risk of SIDS. Having the infant sleep in a
separate bed would decrease his/her risk of sudden infant death syndrome (SIDS) (choice
D)
Home cardiorespiratory monitoring (choice A) has not been shown to be effective for
preventing SIDS.
The risk of SIDS increases with higher room temperatures (choice E) and soft bedding
(choice B).
Placing the infant in a supine position will significantly decrease the risk of SIDS, and is
probably the most important preventive measure that can be taken (choice C).
Question #259
QID: 18082
Topic: Newborn Rash
Subject: Pediatrics
During rounds, you notice a new rash on a full-term 2-day-old white female. It consists of 1
mm pustules surrounded by a flat area of erythema, and is located on the face, trunk, and
upper arms. An examination is otherwise normal, and she does not appear ill.
Which one of the following is the most likely diagnosis?
a) Erythema toxicum neonatorum
b) Transient neonatal pustular melanosis
c) Acne neonatorum
d) Systemic herpes simplex
e) Staphylococcus aureus sepsis
The correct answer is a)
Explanation:
This infant has the typical “flea-bitten” rash of erythema toxicum neonatorum (ETN). ETN
is a benign self-limited eruption occurring primarily in healthy newborns in the early
neonatal period. Erythema toxicum neonatorum is characterized by macular erythema,
papules, vesicles, and pustules, and it resolves without permanent sequelae.
→ Transient neonatal pustular melanosis (choice B) is most common in black newborns,
and the lesions lack the surrounding erythema typical of ETN.
→ Acne neonatorum (choice C) is associated with closed comedones, mostly on the face.
→ As the infant described is not ill, infectious etiologies (choice D and choice E) are
unlikely.
Question #260
QID: 18099
Topic: Norwalk Gastroenteritis
Subject: Pediatrics
Which one of the following is true concerning Norwalk virus?
a) Outbreaks occur mostly in settings with large numbers of children, such as schools and
day-care centers
b) Viral shedding continues long after the acute illness
c) The virus does not survive long on most environmental surfaces
d) An episode of Norwalk gastroenteritis leads to long-lasting immunity
e) It is a less common cause of diarrhea in adults than Shigella
The correct answer is b)
Explanation:
Outbreaks of Norwalk gastroenteritis occur in a wide variety of settings, involve all ages,
and are more likely to involve high-risk groups such as immunocompromised patients or the
elderly (choice A is incorrect).
Not only does viral shedding of the Norwalk virus often precede the onset of illness, but it
can continue long after the illness has clinically ended (choice B is correct).
The virus persists on environmental surfaces and can tolerate a broad range of temperatures
(choice C is incorrect).
There are multiple strains of the virus, so a single infection does not confer immunity, and
repeated infections occur throughout life (choice D is incorrect).
It is the most common cause of diarrhea in adults (choice E is incorrect).
Question #261
QID: 18332
Topic: Septic Arthritis Work Up
Subject: Pediatrics
A 4-year-old female patient is brought to you by her parents on account of having knee pain
over the past few days. The mother says she noticed the girl started limping 2 days ago,
referring pain in her left knee and also had fever, which was not controlled by paracetamol.
She refers that the girl has been irritable, has not been eating well, and she is not as happy as
she usually is. She reports no relevant medical history.
On examination, she has a temperature of 38.7°C, a heart rate of 123 bpm, and a respiratory
rate of 23 /minute. You notice a markedly swollen, red, tender, painful and warm left knee,
which has very limited and painful mobility and no other remarkable signs.
Which of the following diagnostic tests is the best for excluding septic arthritis as a
diagnosis?
a) Blood culture
b) ESR and CRP
c) Gram stain of synovial fluid
d) WBC count of the synovial fluid
e) X-ray
The correct answer is b)
Explanation:
ESR and CRP (choice B) together have a negative predictive value of almost 90 percent. Of
these, the one with the greatest negative predictive value by it self is CRP. This means that
negative results in CRP (usually less than 1mg/dL) and ESR (less than 20 mm/hr) mean that
the patient is very unlikely to have septic arthritis. Also, CRP is better for monitoring
response to treatment of septic arthritis than other methods.
→ The blood culture (choice A) of a patient with septic arthritis only turns out to be positive
in 40-50 percent of the cases, giving it a very poor negative predictive value.
→ Gram stain of synovial fluid (choice C) is not reliable for the diagnosis or exclusion of
septic arthritis. 50 percent of synovial fluid aspirations are sterile in cases of septic arthritis
confirmed with clinical and laboratory findings, including positive blood culture.
→ Generally speaking, synovial fluid WBC counts (choice D) of more than 50 000 cells/
microL with a predominance of polymorphonuclear leukocytes indicates a greater likelihood
of the patient having septic arthritis. However, the synovial fluid WBC count is neither
sensitive nor specific for the diagnosis of septic arthritis. It may happen to be much lower in
unusual causes of bacterial arthritis (eg. Brucella), and it may exceed 50 000 cells/microL in
patients with juvenile idiopathic arthritis, serum sickness, or reactive arthritis.
→ Normal X-ray (choice E) does not exclude the diagnosis of Septic Arthritis, therefore it
has a poor negative predictive value. It does not add much to the diagnostic evaluation of
Septic Arthritis. However, it may be a valuable adjunct to the examination of the hip, mainly
to compare the contralateral joint.
Key point:
ESR and CRP together have a negative predictive value of almost 90 percent. This means
that negative results in CRP and ESR mean that the patient is very unlikely to have septic
arthritis
Question #262
QID: 18161
Topic: Inflammatory Bowel Disease
Subject: Pediatrics
Over the last 6 months a developmentally normal 12-year-old white female has experienced
intermittent abdominal pain, which has made her quite irritable. She also complains of joint
pain and general malaise. She has lost 5 kg (11 lb) and has developed an anal fissure.
Which one of the following is the most likely cause of these symptoms?
a) Celiac disease (gluten enteropathy)
b) Irritable bowel syndrome
c) Hepatitis A
d) Crohn's disease
e) Giardiasis
The correct answer is d)
Explanation:
The most common age of onset for inflammatory bowel disease is during adolescence and
young adulthood, with a second peak at 50-80 years of age. The manifestations of Crohn’s
disease are somewhat dependent on the site of involvement, but systemic signs and
symptoms are more common than with ulcerative colitis. Perianal disease is also common in
Crohn’s disease. Irritable colon and other functional bowel disorders may mimic symptoms
of Crohn’s disease, but objective findings of weight loss and anal lesions are extremely
uncommon. This is also true for viral hepatitis and giardiasis. In addition, the historical and
epidemiologic findings in this case are not consistent with either of these infections. Celiac
disease and giardiasis can produce Crohn’s-like symptoms of diarrhea and weight loss, but
are not associated with anal fissures.
Question #263
QID: 18183
Topic: Infant Vitamin D Intake Recommendations
Subject: Pediatrics
For a healthy 1-month-old, daily vitamin D intake should be:
a) 50 IU
b) 100 IU
c) 200 IU
d) 400 IU
e) 800 IU
The correct answer is d)
Explanation:
It is now recommended that all infants and children, including adolescents, have a minimum
daily intake of 400 IU of vitamin D, beginning soon after birth. The current
recommendation replaces the previous recommendation of a minimum daily intake of 200
IU/day of vitamin D supplementation beginning in the first 2 months after birth and
continuing through adolescence. These revised guidelines for vitamin D intake for healthy
infants, children, and adolescents are based on evidence from new clinical trials and the
historical precedent of safely giving 400 IU of vitamin D per day in the pediatric and
adolescent population. New evidence supports a potential role for vitamin D in maintaining
innate immunity and preventing diseases such as diabetes mellitus and cancer.
Question #264
QID: 18212
Topic: Turners syndrome
Subject: Pediatrics
A 15-year-old female is brought to the hospital by her mother because she has never had
menstrual periods and the mother is concerned. On physical examination the girl appears
short, has a webbed neck. Four-limb blood pressures were also evaluated: higher blood
pressures were noted in the arms while the ones of the lower extremities were normal.
Which of the following is the best way to confirm this girl’s diagnosis?
a) Echocardiography
b) FSH, LH, and Estrogen levels
c) Karyotype
d) Brain MRI
e) Bone age assessment
The correct answer is c)
Explanation:
This girl has primary amenorrhea, a webbed neck, and a significant difference between the
blood pressure in the upper and lower extremities (suggesting possible coarctation of the
aorta). These findings suggest Turner syndrome as the most likely diagnosis. The best way
to confirm this diagnosis is a standard 30 cell Karyotype, which in Turner syndrome would
reveal 45, XO cell line or a cell line with deletion of the short arm of the X chromosome.
→ An echocardiography (choice A) is useful in evaluating cardiovascular abnormalities of
Turner syndrome such as the coarctation of the aorta; while this is an important
characteristic of Turner syndrome, it is not the best way to confirm it.
→ FSH, LH, and Estrogen (choice B) are likely to be abnormal in this patient. With
estrogen being low while FSH and LH are elevated; this, however, is not the best way to
confirm Turner syndrome.
→ Brain MRI (choice D) would be useful in cases of amenorrhea caused by pituitary
pathology such as craniopharyngioma, it is not the best way to confirm Turner syndrome.
→ Bone age assessment (choice E) will be useful in the management of this patient as
hormone therapy is being considered; however, this is not the best way to confirm Turner
syndrome.
Key point:
When Turner syndrome is suspected, Karyotype is the best way to confirm it.
Question #265
QID: 18218
Topic: Primary enuresis
Subject: Pediatrics
A 6-year-old girl was brought to your department for follow-up regarding her bed-wetting.
She has never been dry during her night time sleeping. She bed-wets about 3 times a week,
and her bed-wetting history does not include daytime bedwetting. Parents deny any
significant changes in the family or stressful events in their household. Urinalysis, imaging
studies of the urinary system, and the spinal cord evaluation did not reveal any
abnormalities. Which of the following is the best recommendation as next step in
management?
a) Emotional support, diary, and reward system
b) Behavioral conditioning with alarm devices
c) Treatment with Desmopressin acetate
d) Give Imipramine therapy at bedtime
e) Reasonable punitive measures for wet nights
The correct answer is a)
Explanation:
This child’s most likely has primary enuresis (PE), which is defined as bed-wetting or
urinary incontinence at night after the age of 5 in the absence of a secondary etiology. The
child does not seem to have psychosocial stressors and anatomical and pathological causes
have been ruled out with appropriate studies. Enuresis can be divided into primary enuresis
(PE) and secondary enuresis (SE). A child who has been continent for at least 6 months
before the onset of the bedwetting is considered to have SE. The pathogenesis of PE may be
similar to that of SE. In PE, psychological problems are almost always the result of the
condition as it is stressful for the child and only rarely the cause. In SE, however,
psychological problems are a possible cause.
The initial step recommended in the treatment of primary enuresis is non-pharmacologic
treatment with motivational therapy in children younger than 7 years. This includes
emotional support for the child, reassurances, diary and chart, and a reward system when the
child demonstrates commitment in participation such as drinking fluids only on agreed
hours (choice A). If motivational therapy is unsuccessful after 3 months, active therapy with
either alarm devices or desmopressin should be considered.
→ Behavioral conditioning with alarm devices (choice B) could be the next approach if
motivational therapy is not successful after 3 months.
→ Treatment with desmopressin acetate (choice C) is not recommended as the initial step of
treatment; however, it may be considered if motivational therapy fails and parents strongly
object against alarm devices or rapid-onset is the priority.
→ Imipramine (choice D) is a tricyclic antidepressant that has been used extensively for
decades in the management of primary enuresis; however, its use has gradually declined
because of the potential major side effects including sleep disorders, dry mouth, nausea, and
nervousness.
→ Punishment in any form (choice E) has no role in the management of primary enuresis, in
fact it is likely to be counterproductive.
Key point:
When primary enuresis is diagnosed, non-pharmacologic treatment options should be
attempted first. Motivational therapy is recommended as the initial mode of treatment. For
pharmacologic therapy desmopressin is an effective treatment.
Question #266
QID: 18280
Topic: Post-meningitis follow up
Subject: Pediatrics
A 5-year-old is brought to your department because of fever and headaches. He has had
these symptoms for the last 48 hours and initially parents gave him Tylenol but he seems to
be getting worse. The child’s immunization scheduled was not properly followed. His vital
signs are: temperature 39.9°C, blood pressure 105/65 mmHg, pulse 100 bpm, and
respirations 19/min.
On physical examination he has no petechial rashes, his skin is warm, and nuchal rigidity is
noted. CSF studies reveal elevated neutrophil count, elevated protein, and decreased
glucose. Which of the following is the most common complication to be evaluated on his 6week-treatment follow-up appointment?
a) Subdural effusions
b) Rheumatic heart disease
c) Hearing loss
d) Cortical blindness
e) Postinfection glomerulonephritis
The correct answer is c)
Explanation:
This child’s symptoms of fever, headache, and the findings on physical examination of
nuchal rigidity are suggestive of meningitis. The CSF studies with elevated neutrophil,
increased protein, and decreased glucose point to bacterial meningitis. Children who are not
properly immunized are particularly at risk. Bacterial meningitis can have serious sequelae
even after appropriate treatment. Sensorineural hearing loss (choice C) is noted in 20% to
30% of Hemophilus influenza meningitis survivors. Audiologic assessments are
recommended in these patients in 4 to 6 weeks after antibiotic treatment clears the infection.
There are other possible complications such as hydrocephalus, cortical blindness, epilepsy,
behavioral changes, motor coordination, and intellectual disability; however, the most
common complication that should be assessed 6 weeks after treatment is hearing loss.
→ Subdural effusions (choice A) are asymptomatic complications that generally resolve
without neurological sequelae.
→ Rheumatic heart disease (choice B) occurs as a complication of group A Streptococcus
pharyngitis. It is unlikely to be the cause of meningitis in children of this age. The most
common causes are Pneumococcus pneumonia, Meningococcal meningitis, and Hemophilus
influenza.
→ Cortical blindness (choice D) is a rare complication of meningitis. It is far less common
than hearing loss.
→ Post-infection glomerulonephritis (choice E) is not known to be a complication of the
major bacteria associated with meningitis in children of this age. It can occur in children
with group A streptococcus.
Key point:
Bacterial meningitis is characterized by elevated neutrophil count, elevated protein, and
decreased glucose in the CSF. Neurologic complications are common and the most common
neurologic sequelae is sensorineural hearing loss and children should have audiologic
assessment 4 to 6 weeks after treatment.
Question #267
QID: 18283
Topic: Osteomyelitis treatment
Subject: Pediatrics
An 8-year-old boy is brought to your department with complaints of hip pain for the last 5
days. The pain is described as constant in nature and has been gradually increasing as it
started out mild but it is getting more severe.
Vital signs are 39°C, BP 110/70 mmHg, pulse 95 bpm, respirations 18/min. Physical
examination reveals focal point tenderness of the proximal femur region. Technetium
radionuclide scan reveals increased osteoblastic activity of proximal femur. Needle
aspiration is performed and the specimen is sent for culture. Which of the following should
be offered as initial treatment at this point?
a) IV nafcillin
b) IV vancomycin
c) IV ciprofloxacin
d) IV doxycycline
e) IV ceftriaxone
The correct answer is b)
Explanation:
This patient’s clinical picture is suggestive of osteomyelitis. It is suggested by symptoms of
hip pain, fever, tenderness of proximal femur on physical examination, and technetium
radionuclide scan that demonstrates increased osteoblastic activity. It is an inflammation of
the bone primarily caused by Staphylococcus aureus though cases of Kingella kingae in
children younger than 3 years of age have been increasing. Bone infections in children are
primarily hematogenous in origin, although cases secondary to penetrating trauma, surgery,
or infection in a contiguous site are also reported.
Initial treatment in this patient would be empirical as the results of bacterial culture have not
yet been obtained. IV vancomycin (choice B) is considered the best initial therapy as it has
adequate coverage against methicillin-resistant staphylococcus.
→ IV nafcillin (choice A) is inappropriate for empiric treatment because of high resistance
rate, estimated to be 30%.
→ IV ciprofloxacin (choice B) would be effective against Kingella kingae, but not against
Staphylococcus aureus. For younger children, fluoroquinolones are also known to cause
cartilaginous tissue damage.
→ IV doxycycline (choice D) is inappropriate in children who are 8 years old and younger
due to its adverse effects on teeth. Currently, there’s no sufficient data to support its
effectiveness against methicillin resistant staphylococcus.
→ IV ceftriaxone (choice E) might be helpful in a child with sickle cell anemia who might
have Salmonella or Haemophilus influenza, but is not the best choice in this patient who is
more likely to be infected with Staphylococcus aureus.
Key point:
Staphylococcus aureus is the most common cause of osteomyelitis in children and the best
empiric treatment is IV vancomycin.
Osteomyelitis
Question #268
QID: 18382
Topic: Iron-deficiency anemia
Subject: Pediatrics
As part of a strategy to prevent development of iron deficiency anemia in children, a
regional hospital is planning to do some lab investigations for iron status on blood collected
from children with normal hemoglobin levels for other purposes.
Which of the following lab results marks the most advanced stage of iron deficiency?
a)
b)
c)
d)
e)
High free erythrocyte protoporphyrin level
High serum total iron binding capacity
Low serum iron level
Low transferrin saturation
Low serum ferritin
The correct answer is a)
Explanation:
High free erythrocyte protoporphyrin (choice A) marks the most advanced stage of iron
deficiency and indicates that iron deficiency anemia is imminent. Heme synthesis requires
presence of protoporphyrin and iron and when there is no enough of available iron, free
erythrocyte protoporphyrin (FEP) levels rise and hemoglobin synthesis is impaired. If
proper measures to provide iron are not taken, then iron deficiency anemia will develop.
The correct sequence of events towards development of iron deficiency anemia is as
follows:
→ Stage 1: Low iron stores: reflected by low serum ferritin (choice E). Despite the low iron
stores, enough iron is transported to the bone marrow to form enough red cells and
hemoglobin stays within the normal range.
→ Stage 2: When iron stores fall further, low serum iron results (choice C). Despite the low
serum iron, however, the rate of hemoglobin synthesis may remain normal. One possible
reason for this is an increased iron extraction capability of developing red cells possibly due
to increased expression of transferrin receptor.
→ Stage 3: The falling serum iron level (choice C) stimulates transferrin synthesis and a rise
of serum transferrin. The low serum iron together with high serum transferrin increase total
iron binding capacity (choice B) and decrease transferrin saturation (choice D).
→ Stage 4: When iron stores are totally depleted, serum iron drops to very low levels,
availability of iron for hemoglobin synthesis will then be compromised. Free erythrocyte
protoporphyrin levels will thus, rise (choice A).
Key point:
Normal levels of free erythrocyte protoporphyrin (FEP) indicate that the amount of iron
available is enough to support normal hemoglobin synthesis. However, once serum levels of
FEP start to rise, the amount of available iron available is insufficient and iron deficiency
anemia is imminent.
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Question Count: 1141
Question #1
QID: 15402
Topic: Acanthosis Nigricans
Subject: Medicine
A 56-year-old female with past medical history of diabetes mellitus type 2 presents with a rash on the region of her axilla.
See picture:
This rash is known as what?
a)
b)
c)
d)
Malignant Melanoma
Hodgkin disease
Keratosis
Acanthosis Nigricans
The correct answer is d)
Explanation:
Acanthosis nigricans is most commonly caused by insulin resistance, usually from type 2 diabetes mellitus.
Other causes are familial, obesity, drug-induced, malignant (gastric cancer), idiopathic, and Polycystic ovary syndrome. In
the context of a malignant disease, Acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as
Acanthosis nigricans maligna. Acanthosis nigricans should make you suspicious for a malignancy.
People with acanthosis nigricans should be screened for diabetes and, although rare, cancer. Controlling blood glucose
levels through exercise and diet often improves symptoms.
Acanthosis Nigricans
Acanthosis Nigricans
Question #2
QID: 15404
Topic: Cushing's Syndrome
Subject: Medicine
In Cushing syndrome you find all, except:
a) Hypotension
b) Obesity
c) Striation of skin
d) Trunk obesity
The correct answer is a)
Explanation:
Cushings syndrome is one of the secondary causes of hypertension. Therefore the blood pressure would be high. Along
with Cushings, the other causes include Hyperaldosteronism, Aortic coarctation, Pheochromocytoma and Stenosis of renal
artery. Remember the mnemonic C.H.A.P.S. for these 5 causes of secondary hypertension.
Question #3
QID: 15763
Topic: Cushing's Syndrome
Subject: Medicine
What
a)
b)
c)
d)
is
the
diagnostic
test
of
choice
to
confirm
Cushing
syndrome?
CT of abdomen
DST (dexamethasone supression test)
Random serum cortisol
MRI of brain
The correct answer is b)
Explanation:
Cushing's syndrome is a constellation of clinical abnormalities caused by chronic high blood levels of cortisol or related
corticosteroids. Cushing's disease is Cushing's syndrome that results from excess pituitary production of ACTH, usually
secondary to a pituitary adenoma. Typical symptoms include moon facies and truncal obesity with thin arms and legs.
Diagnosis
is
by
history
of
receiving
corticosteroids
or
by
elevated
serum
cortisol.
Diagnosis is confirmed with the dexamethasone test, in which 1, 1.5, or 2 mg of dexamethasone is administered po at 11
to 12 pm and plasma cortisol is measured at 8 to 9 am the next morning. In most normal patients, this drug suppresses
morning plasma cortisol to ≤ 1.8 μg/mL (≤ 50 nmol/L), whereas patients with Cushing's syndrome virtually always have a
higher level. A more specific but equally sensitive test is to give dexamethasone 0.5 mg po q 6 h for 2 days (low dose). In
general, a clear failure to suppress levels in response to low-dose dexamethasone establishes the diagnosis.
Cushing Syndrome
Question #4
QID: 16005
Topic: Cushing's Syndrome
Subject: Medicine
A 52-year-old woman, recently diagnosed with hypertension, presents to her family physician complaining of hirsutism
and acne. Laboratory examination reveals: cortisol 1500 nmol/L (N: 200 - 660 nmol/L) aldosterone 200 pmol/L (N: 140 415
pmol/L)
ACTH
4
pmol/L
(N:
4
22
pmol/L)
Which
a)
b)
c)
d)
e)
one
of
the
following
is
the
most
likely
diagnosis?
Addison's disease
Cushing's syndrome
Bartter's syndrome
Renal artery stenosis
Conn's syndrome
The correct answer is b)
Explanation:
In Cushing's syndrome, the level of corticosteroids is excessive, usually from overproduction by the adrenal glands.
Corticosteroids alter the amount and distribution of body fat. Excessive fat develops throughout the torso and may be
particularly noticeable at the top of the back. A person with Cushing's syndrome usually has a large, round face (moon
face). The arms and legs are usually slender in proportion to the thickened trunk. Muscles lose their bulk, leading to
weakness.
High corticosteroid levels over time raise the blood pressure, weaken bones (osteoporosis), and diminish resistance to
infections. The risk of developing kidney stones and diabetes is increased, and mental disturbances, including depression
and hallucinations, may occur. Women usually have an irregular menstrual cycle. Children with Cushing's syndrome grow
slowly and remain short. In some people, the adrenal glands also produce large amounts of androgens (testosterone and
similar
hormones),
leading
to
increased
facial
and
body
hair
in
women
and
balding.
When Cushing's syndrome is suspected one should measure the level of cortisol, the main corticosteroid hormone, in the
blood. Normally, cortisol levels are high in the morning and lower late in the day. In people who have Cushing's
syndrome, cortisol levels are very high throughout the day.
Cushing Syndrome
Question #5
QID: 15408
Topic: Sexual Dysfunction
Subject: Medicine
All the following can be given to improve sexual function in males, except:
a) Sildenafil
b) Estrogen
c) Testosterone
d) Gonadotrophin-releasing hormone analogues
e) Tadalafil
The correct answer is b)
Explanation:
Sexual dysfunction in males can be treated with various drugs. Viagra (sildenafil) (choice A) is a popular choice for
erectile dysfunction (ED). Testosterone (choice C) is used as it promotes and maintains secondary sex characteristics in
androgen-deficient males. Gonadotropin-releasing hormones (choice D) have been used in patients with GonadotropinReleasing Hormone Deficiency because these patients can develop hypogonadism leading to infertility and sexual
dysfunction.
Estrogen (choice B) has no role in the treatment of male sexual dysfunction, but in females estrogen creams are used for
atrophic vaginitis in the elderly.
Question #6
QID: 15929
Topic: Optic Neuritis
Subject: Medicine
If present, which one of the following features is of most specific value in differentiating optic neuritis from papilledema?
a)
b)
c)
d)
e)
It may cause pain upon eye movement
Blurring of the disc margins
Enlargement of the blind spot
Swelling of the disc
The condition is bilateral.
The correct answer is a)
Explanation:
Papilledema is swelling of the optic disc (papilla), usually in association with increased intracranial pressure,
characterized by hyperemia, blurring of the disk margins, microhemorrhages, blind spot enlargement, and engorgement of
retinal veins. The condition usually is bilateral, the nerve head is very elevated and swollen, and pupil response typically
is
normal.
Vision is not affected initially (although there is an enlargement of the blind spot), and there is no pain upon eye
movement. Secondary optic atrophy and permanent vision loss can occur if the primary cause of the papilledema is left
untreated.
Optic neuritis is an inflammation of the optic nerve. It may affect the part of the nerve and disc within the eyeball
(papillitis) or the portion behind the eyeball (retrobulbar optic neuritis, causing pain with eye movement). It also includes
degeneration or demyelinization of the optic nerve. There will be no visible changes in the optic nerve head (disc) unless
some
optic
atrophy
has
occurred.
The condition is unilateral rather than bilateral. If the nerve head is involved, it is slightly elevated, and pupillary response
in that eye is sluggish. There usually is a marked but temporary decrease in vision for several days or weeks, and there is
pain in the eye when it is moved. Single episodes generally do not result in optic atrophy nor in permanent vision loss;
however, multiple episodes can result in both.
Question #7
QID: 17187
Topic: Gout
Subject: Medicine
A 72-year-old patient has an acute onset of joint pain and swelling. Aspiration reveals monosodium urate crystals.
Compared with younger patients, geriatric patients presenting for the first time with this condition are more likely to:
a)
b)
c)
d)
e)
be male
have a monoarticular presentation
have involvement of joints of the upper extremity
have podagra (first metatarsophalangeal joint involvement)
be free of tophi
The correct answer is c)
Explanation:
The presentation of gout in the elderly is often different from the classic presentation. It occurs more often in women, has
a polyarticular onset, and often involves small joints of the hands. Older patients also tend to develop tophi early. Gout
may appear in joints with Heberden’s nodes from osteoarthritis. Podagra is the classic presentation of gout in the younger
population.
Gout
Question #8
QID: 15681
Topic: Vitamin B12 Deficiency
Subject: Medicine
A strict vegan, develops symptoms of fatigue, dizziness and dyspnea. She comes in for evaluation and her CBC shows
anemia with a MCV of 104 fL. What is the most appropriate next step in diagnosis?
a)
b)
c)
d)
Iron level
Hemoglobin electrophoresis
Vitamin B12 level
RBC scan
The correct answer is c)
Explanation:
In vitamin B12 deficiency anemia develops, causing paleness, weakness, fatigue, and, if severe, shortness of breath and
dizziness. A severe deficiency may cause tingling or loss of sensation in the hands and feet, muscle weakness, loss of
reflexes,
difficulty
walking,
confusion,
and
dementia.
The diagnosis is based on blood tests. A CBC will show macrocytic anemia. When high doses of vitamin B12
supplements are taken, most symptoms resolve. Symptoms due to nerve damage, such as neuropathy or dementia in older
people,
may
persist.
Vitamin B12 deficiency develops in people who do not consume any animal products (vegans) unless they take
supplements. If a vegan mother breastfeeds her infant, the infant is at risk of vitamin B12 deficiency.
An iron level and Hb electrophoresis would be useful of the anemia was microcytic (MCV < 80 fL). An RBC scan would
be useful if bleeding is suspected.
Vitamin B12 Deficiency
Question #9
QID: 15846
Topic: Vitamin B12 Deficiency
Subject: Medicine
A 48-year-old man complains of fatigue and shortness of breath. Peripheral blood smear reveals macrocytosis. Labs are as
follows:
Hematocrit:
Hemoglobin:
Serum
vitamin
Serum
folate
Which
one
32%
103
B12
level:
of
the
g/L
level:
66
16
following
(Normal
(Normal
pmol/L
(Normal
nmol/L
(Normal
causes
listed
below
140-174
150-750
4-22
is
42%-52%)
g/L)
pmol/L)
nmol/L)
most unlikely?
a)
b)
c)
d)
e)
Vegetarianism
Colonic diverticulitis
Regional enteritis
Pancreatitis
Fish tapeworm infection
The correct answer is b)
Explanation:
This patient has vitamin B12 deficiency related macrocytic anemia. Pernicious anemia is a chronic illness caused by
impaired absorption of vitamin B12 because of a lack of intrinsic factor (IF) in gastric secretions.
Causes include inadequate dietary intake (ie, vegetarian diet), chronic pancreatitis, tapeworm infestation with
Diphyllobothrium latum occurs from eating poorly cooked lake fish, surgical loss of the ileum or diseases such as tropical
sprue, regional enteritis and ulcerative colitis.
Vitamin B12 Deficiency
Question #10
QID: 16918
Topic: Vitamin B12 Deficiency
Subject: Medicine
Which one of the following is true regarding the use of oral vitamin B12 to treat vitamin B12 deficiencies?
a)
b)
c)
d)
e)
A daily maintenance dose of 1000 μg is effective
It is not effective for pernicious anemia
It is not effective after total gastrectomy
It is not effective after terminal ileum resection
It should be used only if the stage I Schilling test is normal
The correct answer is a)
Explanation:
There is strong evidence for the existence of an alternative pathway to the usual intrinsic factor/terminal ileum pathway
for vitamin B12 absorption. Studies have shown that oral vitamin B12 at daily doses of 1000 μg is effective for the
treatment of vitamin B12 deficiency even in the absence of intrinsic factor (pernicious anemia), an acidic environment
(gastrectomy), or terminal ileum resection (resection or damage from Crohn's disease). This high oral dose is required
because doses of 500 μg or less are only variably absorbed via the alternative pathway. The Schilling test is no longer
needed for determining the route of therapy for vitamin B12 deficiency, as high-dose oral therapy is effective even if the
stage I Schilling test is abnormal.
Vitamin B12 Deficiency
Question #11
QID: 17764
Topic: Vitamin B12 Deficiency
Subject: Medicine
A patient with end-stage renal failure is found to be anemic. You suspect a vitamin B12 deficiency, but testing reveals that
her vitamin B12 level is “low normal.” Which one of the following laboratory test results would confirm a diagnosis of
vitamin B12 deficiency?
a) Low epogen
b) Low folic acid
c) High methylmalonic acid (MMA)
d) Low homocysteine
e) A normal peripheral smear
The correct answer is c)
Explanation:
Patients with renal failure often have normal vitamin B12 levels despite an actual deficiency. In this situation, the
clinician can order a methylmalonic acid (MMA) level to confirm the diagnosis. Vitamin B12 is the necessary coenzyme
in the metabolism of MMA to succinyl-CoA. Thus, in the absence of vitamin B12, MMA levels increase. Additionally,
homocysteine levels would be elevated in the presence of vitamin B12 deficiency.
Vitamin B12 Deficiency
Question #12
QID: 18438
Topic: Vitamin B12 Deficiency
Subject: Medicine
A 65-year-old woman was brought to the hospital with confusion. Her daughter believed that she became forgetful over
the
last
few
months.
Physical examination: she was pale, but not jaundiced or cyanosed, heart rate 102 beat per minute, respiratory rate 20 per
minute, blood pressure 138/86 mmHg and body temperature 36.7°C; both upper and lower limbs appeared spastic and all
reflexes
were
exaggerated.
The
rest
of
physical
examination
was
normal.
Complete
blood
count
showed
the
following:
Hemoglobin
Hematocrit
Red
Reticulocyte
Platelet
Red
cell
count
count
cell
2.4
count
120
distribution
x
x
width
80g/L
0.27
10^12/L
1%
10^9/L
12%
White
Erythrocyte
Red
Mean
Mean
cell
count
sedementation
cell
indices
corpuscular
corpuscular
4
x
rate
were
volume
hemoglobin
as
112
32
10^9/L
6mm/hour
follows:
fl
pg
Which of the following investigations should be done next?
a) Gastric biopsy
b) Bone marrow biopsy
c) Serum B12 level
d) Schilling test
e) Serum parietal cell antibody
The correct answer is c)
Explanation:
Serum B12 level (choice C) is the investigation to be done next. Age of the patient, neurologic symptoms and macrocytic
anemia are suggestive of vitamin B12 deficiency. An investigation, to rule out vitamin B12 deficiency, is required. Serum
B12
level
is
considered
a
robust
investigation
in
ruling
out
vitamin
B12
deficiency.
Patients with vitamin B12 deficiency usually present with signs and symptoms of anemia as well as neurological and
psychiatric manifestations. However, in some patients the hematological and neurological manifestations are sometimes
dissociated. Also, often, asymptomatic patients are identified when a megaloblastic blood picture is encountered in a
routine blood count. The neurologic manifestations are both sensory and motor and include light headedness, impaired
smell and taste, numbness, progressive deterioration of visual acuity, spastic gait disturbances, forgetfulness and inability
to focus. Thus, if any patient presents with any of these symptoms or signs and a clear explanation cannot be found, serum
B12
should
be
measured.
→ Gastric biopsy (choice A) is not the correct choice. Even if gastric biopsy shows the typical histological features
suggestive of pernicious anemia like atrophy of gastric mucosa of the body and fundus with inflammatory cell infiltrate,
vitamin B12 deficiency cannot be proved. B12 deficiency does necessarily develop in all patients with these histologic
features. Gastric biopsy would, however, help in investigating the possible causes of vitamin B12 deficiency.
→ Bone marrow biopsy (choice B) is not the correct choice. Bone marrow examination to demonstrate megaloblastic
erythropoiesis is usually unnecessary. Even if performed, this examination will not distinguish B12 deficiency from folate
deficiency.
→ Schilling test (choice D) is used to differentiate pernicious anemia from other causes of vitamin B12 deficiency. This
test
should
be
done
only
after
vitamin
B12
deficiency
is
established.
→ Like the Schilling test, serum parietal cell antibody (choice E) can be used to differentiate between pernicious anemia
and other causes of vitamin B12 deficiency. This test, however, has a high degree of false positive results and can be
positive in 16% of normal females over the age of 60. Thus, demonstration of parietal cell antibody does establish the
diagnosis
of
vitamin
B12
deficiency.
Key
point:
When vitamin B12 deficiency is suspected in an anemic patient or one with neurologic or psychiatric manifestations, the
best investigation to rule it in or out is measurement of serum B12 level.
Vitamin B12 Deficiency
Question #13
QID: 15414
Topic: Epididymitis
Subject: Medicine
A 35-year-old man presents with swelling in the right scrotum. You notice a tender mass above the testis. The skin of his
scrotum is red and inflamed. Elevation of the right hemiscrotum relieves the pain. He has pyuria.
What is the diagnosis?
a) Epididymitis
b) Varicocele
c) Gonococcal urethritis
d) Nephrolithiasis
e) Prostatitis
The correct answer is a)
Explanation:
Epididymitis presents with scrotal pain and swelling. Prehn's sign is positive (Prehn's sign, the physical lifting of the
testicles relieves the pain of epididymitis but not pain caused by testicular torsion). Epididymitis is most common in
young men ages 19 - 35. It is usually caused by the spread of a bacterial infection from the urethra or the bladder. The
most common infections that cause this condition in young heterosexual men are gonorrhea and chlamydia. In children
and older men, E. coli and similar infections are much more common. This is also true in homosexual men.
Tests
include
U/A
and
Urine
culture.
Treatment
is
with
antibiotics.
> Varicocele (choice B) is often asymptomatic , though patients may report scrotal pain or heaviness. A bag of worms is
described
on
examination.
> Gonococcal urethritis (choice C) would present with dysuria and itching. The described Prehn's sign in this patient
suggests
epididymitis.
> Nephrolithiasis (choice D) causes lower abdominal pain that radiates to the groin. Tenderness in flank region can also
be elicited on physical examination. The prehn's sign noted in this patient suggests epididymitis.
> Prostatitis (choice E) if symptomatic, it may cause urinary frequency, dysuria, and incomplete voiding. Digital rectal
examination may reveal tender, nodular, hot, boggy, or normal-feeling gland. It may also reveal suprapubic abdominal
tenderness. Prehn's sign noted in this patient suggests epididymitis.
Question #14
QID: 16368
Topic: Epididymitis
Subject: Medicine
A 45-year-old white male comes to your office with a 2-day history of pain and swelling in the right testicle. He has no
dysuria or urinary frequency, and denies any sexual contact except with his wife. On examination you note tenderness in
the right posterior aspect of the right testicle, along with some swelling and erythema of the overlying scrotal skin.
Cremasteric
reflex
is
normal.
Which
a)
b)
c)
d)
e)
one
of
the
following
is
true
regarding
this
situation?
The most likely etiologic agent is Chlamydia trachomatis
Immediate surgical referral is indicated
Anaerobic bacteria are the infecting agents in most cases
The patient should be treated symptomatically until results from a urethral culture are available
Antibiotic therapy should include coverage for coliform bacteria
The correct answer is e)
Explanation:
Epididymitis is an inflammation of the epididymis due to various infectious agents or to local trauma. Pain may develop
over a day or two, or even more gradually. In men under the age of 35 who are sexually active, the most common
etiologic organisms are Chlamydia trachomatis and Neisseia gonorrhoeae. In men over 35, infectious epididymitis is
usually nonspecific and is caused by coliform bacteria or Pseudomonas species. The preferred treatment is ofloxacin, 400
mg orally twice a day for 10 days. Alternative therapy is a single dose of ceftriaxone, 250 mg, plus doxycycline, 100 mg
twice a day for 10 days.
Question #15
QID: 18388
Topic: Epididymitis
Subject: Medicine
A 20-year-old male presents with a complaint of pain in his right testis. The onset of pain has been gradual and has been
associated with dysuria and urinary frequency. The patient has no medical problems and is sexually active.
On examination he has some swelling and mild tenderness of the testis. The area posterior to the testis is swollen and very
tender. He has a normal cremasteric reflex, and the pain improves with elevation of the testicle.
Which one of the following would be the most appropriate management of this patient?
a)
b)
c)
d)
e)
Surgical evaluation
Doppler ultrasonography
Ceftriaxone and doxycycline
Levofloxacin
Ciprofloxacin
The correct answer is c)
Explanation:
This patient has epididymitis. In males 14-35 years of age, the most common causes are Neisseria gonorrhoeae and
Chlamydia trachomatis. The recommended treatment in this age group is ceftriaxone, 250 mg intramuscularly, and
doxycycline, 100 mg twice daily for 10 days. A single 1-g dose of azithromycin may be substituted for doxycycline. In
those under age 14 or over age 35, the infection is usually caused by one of the common urinary tract pathogens, and
levofloxacin, 500 mg once daily for 10 days, would be the appropriate treatment.
If there is concern about testicular torsion, urgent surgical evaluation and ultrasonography are appropriate.
Testicular torsion is most common between 12 and 18 years of age but can occur at any age. It usually presents with an
acute onset of severe pain and typically does not have associated urinary symptoms. On examination there may be a highriding transversely oriented testis with an abnormal cremasteric reflex and pain with testicular evaluation. Color Doppler
ultrasonography will show a normal-appearing testis with decreased blood flow.
Question #16
QID: 15543
Topic: Peptic ulcer
Subject: Medicine
A patient who has chronic peptic ulcer asks for the best method for curing this disease. Your answer is:
a)
b)
c)
d)
Helicobacter pylori eradication
Proton pump inhibitors
H2 blockers
Nissen fundoplication
The correct answer is a)
Explanation:
H. pylori and NSAIDs disrupt normal mucosal defense and repair, making the mucosa more susceptible to acid. H. pylori
infection is present in 50 to 70% of patients with duodenal ulcers and 30 to 50% of patients with gastric ulcers. If H.
pylori is eradicated, only 10% of patients have recurrence of peptic ulcer disease, compared with 70% recurrence in
patients
treated
with
acid
suppression
alone.
Symptoms include pain often localized to the epigastrium and relieved by food or antacids. The pain is described as
burning or gnawing, or sometimes as a sensation of hunger. The course is usually chronic and recurrent.
Diagnosis of peptic ulcer is suggested by patient history and confirmed by endoscopy (EGD). Treatment of gastric and
duodenal
ulcers
requires
eradication
of
H.
pylori
when
present.
Methods of decreasing acidity include a number of drugs including proton pump inhibitos and H2 blockers.
Nissen fundoplication is a surgical treatment for chronic GERD.
Question #17
QID: 17947
Topic: Peptic ulcer
Subject: Medicine
A 35-year-old woman who was born in Vietnam has had her dyspepsia diagnosed by endoscopy as a duodenal ulcer. Her
pathology is positive for Helicobacter pylori. She has not previously been diagnosed with peptic ulcer disease. What
would be the preferred treatment option?
a) Combination antibiotics plus omeprazole
b) Omeprazole alone
c) Surgical vagotomy and pyloroplasty
d) Octreotide
e) Ranitidiine
The correct answer is a)
Explanation:
A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid
and digestive juices. Because infection with H. pylori bacteria is a major cause of ulcers, antibiotics are often used.
Neutralizing or reducing stomach acid by taking drugs that directly inhibit the stomach's production of acid promotes
healing of peptic ulcers regardless of the cause. In most people, treatment is continued for 4 to 8 weeks.
Proton pump inhibitors (eg omeprazole) are the most potent of the drugs that reduce acid production. Proton pump
inhibitors promote healing of ulcers in a greater percentage of people in a shorter period of time than do histamine (H2)
blockers.
Question #18
QID: 15416
Topic: Pheochromocytoma
Subject: Medicine
A 65-year-old man presents with a history of paroxysms of sweating, palpitations, headaches and anxiety. This happens
off and on. His blood pressure on exam is 156/95 mmHg. On further history he tells you that one of his relatives had
thyroid
cancer.
At
a)
b)
c)
d)
e)
this
time
what
tests
should
be
done
first?
24 hour urinary catecholamines and metanephrines
Serum VMA
CT of adrenal
CT of head
CMP
The correct answer is a)
Explanation:
This patient needs to be screened for pheocromocytoma. Pheochromocytoma is a tumor of the adrenal gland which causes
very high levels of the catecholamines (epinephrine and norepinephrine) to be secreted into the bloodstream. This can lead
to many sympathetic nervous system symptoms like elevated blood pressure, palpitations, anxiety, diaphoresis,
headaches,
weight
loss.
These
symptoms
happen
is
spurts
or
paroxysms.
Diagnoses is made by measuring the level of the catecholamines and their breakdown products or metabolites which are
called metanephrines in a 24 hour urine collection. Treatment involves medicines to control the blood pressure and
surgery to remove the tumor. (Metanephrine levels are considered the most sensitive and specific test for a
pheochromocytoma, while vanillylmandelic acid is the least specific test and has a false-positive rate greater than 15%.)
Recall
MEN
the
I
MEN
(Wermer
syndromes.
syndrome)
MEN
-
(Multiple
tumors
of
endocrine
the
neoplasia)
pancreas,
pituitary
has
three
and
types:
parathyroid.
MEN IIa (Sipple syndrome) - medullary thyroid carcinoma, pheochromcytoma and tumor of the parathyroid.
MEN
IIb
Medullary
thyroid
carcinoma,
pheochromocytoma
and
neuromas.
This patient could have MEN II if you consider his family history.
Pheochromocytoma
Question #19
QID: 15961
Topic: Pheochromocytoma
Subject: Medicine
A 40-year-old woman has episodic headaches that last 30 minutes and are associated with sweating, palpitations, and
feelings of apprehension. She has lost 6.8 kg over the past three months. Physical examination reveals a thin woman with
a pulse of 112 beats/minute and a blood pressure of 150/100 mmHg lying and 130/80 mmHg standing.
Which
a)
b)
c)
d)
e)
one
of
the
following
is
the
most
likely
diagnosis?
Pheochromocytoma
Hyperaldosteronism
Posterior fossa tumor
Renal artery stenosis
Carcinoid syndrome
The correct answer is a)
Explanation:
A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes
persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine products in blood or urine. Imaging
tests, especially CT or MRI, help localize tumors. Treatment involves removal of the tumor when possible. Drug therapy
for control of BP includes alpha-blockade, possibly combined with beta-blockade. Initiate a beta blocker only after
adequate alpha blockade (usually, 2 days).
Pheochromocytoma
Question #20
QID: 15975
Topic: Pheochromocytoma
Subject: Medicine
A 38-year-old woman has episodic headaches that are associated with sweating, palpitations, and feelings of
apprehension. She has lost 7 kg over the past three months. Physical examination reveals a thin woman with a pulse of
114
beats/minute
Which
a)
b)
c)
d)
e)
one
and
of
a
blood
the
pressure
following
of
is
150/100
mmHg
the
most
lying
and
helpful
130/80
mmHg
diagnostic
standing.
test?
CT scan of the brain
Captopril renal nuclear medicine scan
24 hour urinary 5-hydroxyindoleacetic acid (5-HIAA) levels
24 hour urinary aldosterone levels
24 hour urinary vanillylmandelic acid (VMA) and catecholamine levels
The correct answer is e)
Explanation:
A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes
persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine products in blood or urine. Imaging
tests, especially CT or MRI, help localize tumors. Treatment involves removal of the tumor when possible. Drug therapy
for control of BP includes alpha-blockade, possibly combined with beta-blockade.
Question #21
QID: 15419
Topic: STD - Chlamydia
Subject: Medicine
A 24-year-old man is diagnosed with gonorrhea. He is treated with ceftriaxone. He returns a few days later and states that
he still has symptoms of dysuria and discharge. His urine microscopy shows no organisms.
What
a)
b)
c)
d)
is
the
likely
cause
of
his
symptoms?
Chlamydia
Herpes
Latent gonorrhea
Syphylis
The correct answer is a)
Explanation:
It is a standard guideline to always treat a patient with Gonorrhea for both Gonorrhea and Chlamydia. Chlamydia is the
most prevalent STD. It is most common among people in their late teens and early twenties and can coexist with
gonorrhea.
Treatment options include for Gonorrhea: Ceftriaxone 125 mg IM single dose, for Chlamydia: Doxycycline 100 mg Bid
for 7 days or Azithromycin 1 gram orally as a single dose. In patient’s that are pregnant, avoid doxycycline. The patient
should also be advised to have his sexual partner treated.
Question #22
QID: 15422
Topic: Corneal abrasion
Subject: Medicine
A passenger on a bus sustains an injury to his eye with the newspaper of a neighboring person. His vision becomes blurry
and
he
develops
redness
and
pain
in
his
eye.
What
a)
b)
c)
d)
is
the
likely
diagnosis?
Corneal abrasion
Conjunctivitis
Iritis
Keratitis
The correct answer is a)
Explanation:
Corneal abrasion is the most common type of injury involving the cornea. Contact with dust, dirt, sand, wood shavings,
metal particles or even an edge of a piece of paper can scratch or cut the cornea. Because the cornea is extremely
sensitive, abrasions can be painful. In case of such an injury, prompt medical care should be obtained.
Question #23
QID: 15423
Topic: Hearing loss
Subject: Medicine
The
a)
b)
c)
d)
most
common
cause
of
sensorineural
hearing
loss
in
the
elderly
is:
Meniere's disease
Physical trauma
Ototoxic drugs
Presbycusis
The correct answer is d)
Explanation:
The most common cause of hearing impairment in the elderly is presbycusis which is hearing loss that occurs in the high
frequency
range
(4000Hz
to
8000Hz).
Meneiere’s disease is a combination of vertigo, tinnitus and hearing loss. Ototoxic drugs such as aminoglycosides and
loop diuretics can cause hearing loss in elderly also.
Question #24
QID: 15628
Topic: Hearing loss
Subject: Medicine
A 22-year-old male, working as a waiter in a nightclub, noticed a gradual hearing loss. He admitted that the noise level in
his
job
is
very
high
and
that
he
was
not
advised
to
wear
ear
protection.
Which
a)
b)
c)
d)
e)
one
of
the
following
does
he
most
likely
suffer
from?
Sensory hearing loss and vertigo
Both sensory and conductive hearing loss
Conductive hearing loss and ataxia
Sensory hearing loss and tinnitus
Conductive hearing loss and nystagmus
The correct answer is d)
Explanation:
When we are exposed to harmful noise, sounds that are too loud or loud sounds that last a long time, sensitive structures
in
our
inner
ear
can
be
damaged,
causing
noise-induced
hearing
loss
(NIHL).
Continuous exposure to loud noise also can damage the structure of hair cells, resulting in hearing loss and tinnitus,
although
the
process
occurs
more
gradually
than
for
impulse
noise.
NIHL is 100 percent preventable. All individuals should understand the hazards of noise and how to practice good hearing
health in everyday life. To protect your hearing: Know which noises can cause damage (those at or above 85 decibels).
Wear earplugs or other hearing protective devices when involved in a loud activity.
Question #25
QID: 15713
Topic: Hearing loss
Subject: Medicine
A 74-year-old man presents with bilateral symmetrical sensorineural hearing loss. Physical exam is otherwise normal.
What
is
the
most
likely
diagnosis?
a)
b)
c)
d)
Otosclerosis
Acoustic neuroma
Presbycusis
Circulatory deficit
The correct answer is c)
Explanation:
Presbycusis, or age-related hearing loss, is the cumulative effect of aging on hearing. Also known as presbyacusis, it is
defined as a progressive bilateral symmetrical age-related sensorineural hearing loss. The hearing loss is confined to
higher frequencies. Presbycusis is the most common cause of hearing losing in elderly.
Question #26
QID: 16340
Topic: Hearing loss
Subject: Medicine
Which
a)
b)
c)
d)
e)
of
the
following
is not a
cause
of
sensorineural
hearing
loss?
Ossicular discontinuity
Ototoxicity
Méniére disease
Noise
Presbycusis
The correct answer is a)
Explanation:
Hearing loss also may be caused by damage to the sensory structures (hair cells) of the inner ear, auditory nerve, or
auditory nerve pathways in the brain (sensorineural hearing loss). These sensory structures may be damaged by drugs,
infections,
tumors,
and
skull
injuries.
Causes of sensorineural hearing loss include aging, brain tumors, certain drugs (ototoxicity), presbycusis, loud noise,
Meniere's disease and sudden pressure changes from flying, diving, and strenuous exercise.
Question #27
QID: 16603
Topic: Hearing loss
Subject: Medicine
You see a 90-year-old male with a five-year history of progressive hearing loss. The most common type of hearing loss at
this age affects:
a) Predominately high frequencies
b) Predominately mid-frequencies
c) Predominately low frequencies
d) All frequencies roughly the same
The correct answer is a)
Explanation:
In the geriatric population, presbycusis is the most common cause of hearing loss. Patients typically have the most
difficulty hearing higher frequencies such as consonants. Lower-frequency sounds such as vowels are preserved.
Question #28
QID: 17883
Topic: Hearing loss
Subject: Medicine
A 47-year-old female presents with progressive difficulty hearing. She is employed as an office worker, has no significant
past medical history, and takes no medications. Physical examination shows no gross abnormalities of her outer ears. The
external ear canals are free of cerumen, and the tympanic membranes move well to insufflation. Weber’s test and the
Rinne
test
have
results
that
are
compatible
with
a
conductive
hearing
loss.
Which one of the following is the most likely cause of this patient’s hearing loss?
a) Noise-induced hearing loss
b) Meniere’s disease
c) Otosclerosis
d) Acoustic neuroma
e) Perilymphatic fistula
The correct answer is c)
Explanation:
Otosclerosis typically presents between the third and fifth decades, and is more common in women. The chief feature of
otosclerosis is a progressive conductive hearing loss. Occasionally, when lesions impinge on the stapes footplate, a
sensorineural loss may occur. All of the other choices are exclusively sensorineural in character. Meniere’s disease also
causes fluctuating hearing loss. Noise-induced hearing loss frequently and characteristically is accompanied by tinnitus.
Perilymphatic fistula is associated with sudden unilateral hearing loss with tinnitus and vertigo. Acoustic neuroma is
associated with tinnitus and gradual hearing impairment.
Question #29
QID: 17918
Topic: Hearing loss
Subject: Medicine
Which one of the following historical or audiographic findings in an elderly person would indicate that hearing loss is due
to something other than presbycusis?
a) Conductive hearing loss
b) Bilateral hearing loss
c) Symmetric hearing loss
d) Gradual hearing loss
e) High-frequency hearing loss
The correct answer is a)
Explanation:
Presbycusis, the hearing loss associated with aging, is gradual in onset, bilateral, symmetric, and sensorineural.
Question #30
QID: 17995
Topic: Hearing loss
Subject: Medicine
Conductive hearing loss is a symptom of:
a) Presbycusis
b) Meniere disease
c) Cholesteatoma
d) Bell's palsy
e) Acoustic neuroma
The correct answer is c)
Explanation:
Conductive hearing loss is reduced conduction (transmission) of the vibrations of sound waves to the inner ear. It
generally results from a problem with the outer or middle ear. Typical causes of conductive hearing loss among adults are
blockage of the ear canal by earwax, stiffening of the ossicles by scar tissue that results from middle ear infection or
surgery, and fluid accumulation in the middle ear due to a blocked eustachian tube.
Causes of conductive hearing loss include cholesteatoma (noncancerous tumor in the middle ear caused by an ear
infection), chronic middle ear fluid (otitis media with effusion), middle ear infection (otitis media), obstruction of external
ear canal (for example, with wax, a tumor, or pus from an infection), otosclerosis (bony overgrowth of the ossicles) and
perforated eardrum.
Question #31
QID: 15428
Topic: EKG - Atrial flutter
Subject: Medicine
A 63-year-old woman presents to the ED with palpitations, with a pounding feeling in her chest and shortness of breath.
An
EKG
done
shows
the
following:
This
a) Atrial fibrillation
b) Atrial flutter
c) Ventricular fibrillation
patient
has:
d) Ventricular flutter
The correct answer is b)
Explanation:
An
EKG
of
Atrial
flutter
will
show
the
following:
Atrial
rate:
Usually
300
beats/min,
ranging
between
220
and
350
beats/min
Rhythm:
The
atrial
rhythm
is
regular
P waves: Flutter waves resemble a sawtooth or picket fence and are best seen in leads II, III or aVF
PR
interval:
Usually
the
PR
interval
is
regular,
but
it
may
vary
QRS
interval:
This
pattern
is
usually
normal
Treatment involves rate control with calcium channel blockers or beta blockers. Conversion of rate with a type I
antiarrhythmic agent, such as quinidine or procainamide follows.
Question #32
QID: 15430
Topic: DM
Subject: Medicine
Which
a)
b)
c)
d)
of
the
following
diabetes
drugs
is
contraindicated
in
liver
and
kidney
failure?
Insulin
Metformin
Glyburide
Acarbose
The correct answer is b)
Explanation:
Insulin works by directly pushing glucose from the bloodstream into the cells. Metformin works by inhibiting hepatic
gluconeogenesis. Glyburide is an oral sulfonylurea hypoglycemic drug that increases pancreatic insulin secretion.
Acarbose inhibits enzymes needed to digest carbohydrates. Because the carbohydrates are not broken down into glucose
molecules,
less
glucose
is
absorbed
into
the
bloodstream.
Metformin is contraindicated in people with any condition that could increase the risk of lactic acidosis, including liver
and kidney disorders (creatinine levels over 132 μmol/l).
Question #33
QID: 15504
Topic: DM
Subject: Medicine
The
a)
b)
c)
d)
drug
of
choice
for
an
obese
diabetic
type
2
patient
is:
Acarbose
Metformin
Rosiglitazone
Glyburide
The correct answer is b)
Explanation:
Metformin has been clearly established as the drug of choice in obese patients with diabetes mellitus. Metformin is as
effective as sulphonylureas at reducing HbA1c, and most importantly has a beneficial effect on overall mortality in obese
patients.
Metformin monotherapy is unlikely to be effective in patients who fail to respond to sulphonylureas, but in patients who
are secondary failures to sulphonylureas, the addition of metformin causes substantial blood glucose lowering. Metformin
should be avoided in patients with renal dysfunction. Otherwise its effects on bodyweight, serum lipids and its lack of
hypoglycemia effect make it an excellent first line agent.
Question #34
QID: 15564
Topic: DM
Subject: Medicine
Which
a)
b)
c)
d)
e)
of
the
following
is
the
best
test
in
the
long
term
follow
up
of
a
diabetic
patient?
HbA1c
C-Peptide
Fasting blood glucose
Random blood glucose
Diary of postprandial blood glucose values
The correct answer is a)
Explanation:
There
are
two
common
ways
to
assess
how
well
diabetes
is
controlled:
frequent
measurements
of
blood
glucose,
and
measurement
of
glycohemoglobin
(A1c).
Each method has its good and bad points, but combined they give a fairly accurate picture of the state of glucose control
in
a
diabetic.
Most
physicians
will
use
both
methods.
Hemoglobin is an iron containing molecule present in red blood cells that is responsible for transporting oxygen around
the body. Glucose can bind irreversibly to hemoglobin via a process known as glycation. Hemoglobin that has glucose
attached is known as glycated hemoglobin, often abbreviated to HbA1c or simply A1c.
Because red blood cells have life span of 120 days (3 months) measuring the level of glycated hemoglobin in blood
effectively shows the average blood glucose level for the previous 6-8 weeks. In conjunction with regular blood glucose
monitoring diaries, A1c tests can help in determining if a patient's treatment plan needs altering in any way to better
control blood glucose levels. Studies have shown that glycohemoglobin values in the "better ranges" correlate with less
incidence
of
diabetic
complications
later
in
life.
> A C-peptide test measures the level of this peptide in the blood. It is generally found in amounts equal to insulin. A Cpeptide test can be done when diabetes has just been found and it is not clear whether type 1 diabetes or type 2 diabetes is
present.
> Self-blood glucose monitoring is a valuable diabetes management tool, which includes both random (pre- or postprandial) and fasting blood sugar levels, as recommended (not postprandial glucose levels only).
Question #35
QID: 15883
Topic: DM
Subject: Medicine
Which one of the following is the best indicator of adequate control in a patient with diabetes mellitus?
a)
b)
c)
d)
e)
Fasting blood glucose
24-hour glycosuria
Blood glucose 2 hours after meals
Glycosylated hemoglobin (hemoglobin A1C)
Urine free of glucose
The correct answer is d)
Explanation:
In the normal 120-day life span of the red blood cell, glucose molecules join hemoglobin, forming glycated hemoglobin.
In individuals with poorly controlled diabetes, increases in the quantities of these glycated hemoglobins are noted.
Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated hemoglobin within the red cell
reflects the average level of glucose to which the cell has been exposed during its life cycle. Measuring glycated
hemoglobin assesses the effectiveness of therapy by monitoring long-term serum glucose regulation.
The International Diabetes Federation recommend HbA1c values below 6.5%, while the American Diabetes Association
recommends that the HbA1c be below 7.0% for most patients. A high HbA1c represents poor glucose control.
Persistent elevations in blood sugar (and therefore HbA1c) increase the risk for the long-term vascular complications of
diabetes such as coronary disease, heart attack, stroke, heart failure, kidney failure, blindness, erectile dysfunction,
neuropathy (loss of sensation, especially in the feet), gangrene, and gastroparesis (slowed emptying of the stomach).
Question #36
QID: 16076
Topic: DM
Subject: Medicine
A 34-year-old laborer comes to the office because of a 2 kg (5 lb) weight loss and an increased appetite. He has diabetes
mellitus and has been taking insulin in divided doses. He says that home monitoring of his serum glucose concentration
has
shown
values
from
15
mmol/L
to
17.8
mmol/L.
Which
of
the
following
is
the
most
appropriate
management?
a)
b)
c)
d)
e)
Add metformin
Change to another type of insulin
Increase his caloric intake
Increase his insulin dose
Redistribute his caloric intake
The correct answer is d)
Explanation:
This patient has inadequately treated insulin-dependent diabetes. The goal serum glucose for therapy is < 6.6 mmol/L.
Since there is no indication that the insulin type is incorrect (hypoglycemia), the patient simply requires an increased
dosage
of
his
current
insulin
type.
Metformin is an oral antihyperglycemic agent that acts by increasing peripheral utilization of glucose. The primary
purpose of medications such as this is to delay or avoid the requirement for exogenous insulin. Once a patient is on
insulin, these drugs are of little benefit. Secondarily, most patients with non-insulin dependent diabetes have relative
“insulin resistance” and it is for this reason that glucose utilization drugs are employed as first line management.
This patient’s symptoms of increased weight loss and appetite are a function of his poor glucose control, not of inadequate
caloric intake. Poorly controlled insulin dependent diabetics are often thin as they waste muscle to liberate glucose in an
attempt to provide glucose for the body. The defect is with the inability to utilize the glucose already present so the end
result is hyperglycemia and muscle wasting. For similar reasons, there is no need to alter his caloric distribution.
Question #37
QID: 16353
Topic: DM
Subject: Medicine
A 75-year-old white male with well-controlled type 2 diabetes mellitus is scheduled for an abdominal CT scan with oral
and
intravenous
iodinated
contrast.
Which one of the following medications should be withheld 48 hours before and after the procedure?
a)
b)
c)
d)
e)
Glyburide (Micronase, DiaBeta)
Glipizide (Glucotrol)
Acarbose (Precose)
Metformin (Glucophage)
Rosiglitazone (Avandia)
The correct answer is d)
Explanation:
Metformin should be withheld before and after radiographic procedures with contrast, due to its interaction with iodinated
contrast materials. This interaction may cause impaired renal function or lactic acidosis. The other drugs listed do not
carry this risk.
Question #38
QID: 16805
Topic: DM
Subject: Medicine
Metformin (Glucophage), which is normally used in the management of diabetes mellitus, has also been shown to have a
beneficial
effect
in:
a)
b)
c)
d)
e)
Osteoporosis
Hyperthyroidism
Polycycstic ovary syndrome
Right ventricular hypertrophy
Morbid truncal obesity
The correct answer is c)
Explanation:
Recent data suggests that insulin resistance and hyperinsulinemia are important in the pathogenesis of polycystic ovary
syndrome (PCOS). Treatment with drugs that reduce glucose levels, such as metformin, has been shown to correct many
of the metabolic abnormalities associated with PCOS. Such correction results in resumption of ovulation, decreased
insulin resistance, and improved beta-cell function; it also produces improvement in cardiovascular risk factors such as
dyslipidemia and impaired fibrinolysis.
Question #39
QID: 16919
Topic: DM
Subject: Medicine
Thiazolidinedione antidiabetic agents include rosiglitazone (Avandia) and pioglitazone (Actos). Their mechanism of
action
is:
a)
b)
c)
d)
e)
Decreased insulin resistance
Decreased carbohydrate absorption in the intestinal tract
Increased insulin release by the pancreas
Increased insulin production by the pancreas
Increased gluconeogenesis
The correct answer is a)
Explanation:
Thiazolidinediones decrease insulin resistance by binding to nuclear peroxisome proliferators-activated receptors. They
decrease gluconeogenesis and have no effect on insulin release or production by the pancreas, or on intestinal
carbohydrate absorption.
Question #40
QID: 16981
Topic: DM
Subject: Medicine
A 45-year-old male was recently diagnosed with type 2 diabetes mellitus. He presents to your office today to begin oral
antihyperglycemic therapy. Results of a fasting serum metabolic panel include the following:
Laboratory Findings:
Sodium:136 mmol/L (N 136-145)
Potassium: 3.7 mmol/L (N 3.5-5.1)
Chloride: 102 mmol/L (N 98-107)
BUN: 15 mg/dL (N 7-18)
Creatinine: 1.7 mg/dL (N 0.6-1.3)
Glucose: 183 mg/dL
Which one of the following medications would be contraindicated in this patient?
a) Glipizide (Glucotrol)
b) Acarbose (Precose)
c) Metformin (Glucophage)
d) Pioglitazone (Actos)
The correct answer is c)
Explanation:
Maintaining good blood glucose control is important for preventing the microvascular complications of diabetes mellitus.
A number of oral antihyperglycemic agents are available, but each drug class has unique adverse effects that affect their
appropriateness for individual patients. In this case, the patient has evidence of renal impairment (serum creatinine ≥1.5
mg/dL for men and ≥1.4 mg/dL for women). This leads to an increased risk of lactic acidosis when a biguanide such as
metformin is used. Other contraindications to biguanide use include hepatic dysfunction, congestive heart failure,
metabolic acidosis, dehydration, and alcoholism. The sulfonylureas include chlorpropamide (1st generation) and glipizide
(2nd generation). They are associated with weight gain and hypoglycemia. α-Glucosidase inhibitors (e.g., acarbose) are
less effective than other drug classes as monotherapy and can be associated with gastrointestinal side effects.
Thiazolidinediones (e.g., pioglitazone) are associated with weight gain, edema, and potential liver injury.
Question #41
QID: 16997
Topic: DM
Subject: Medicine
A 48-year-old female presents with a new onset of polyuria and polydypsia. A random finger-stick blood glucose level is
17.6
mmol/L.
Which one of her medications listed below is most likely to be linked to her new onset of diabetes?
a)
b)
c)
d)
e)
Amlodipine
Paroxetine
Risperidone
Trazodone
Lisinopril
The correct answer is c)
Explanation:
Recent data suggests a link between atypical antipsychotics and diabetes. In particular, studies have suggested an
increased risk of diabetes for patients on risperidone (choice C), quetiapine, clozapine, and olanzapine. This association
has been noted even in patients who do not gain weight on the antipsychotic. The other medications listed have not been
implicated
in
diabetes.
Some experts recommend checking a fasting glucose level before and soon after initiating an atypical antipsychotic. In
addition, monitoring blood glucose every 3-6 months should be considered, especially in patients with other risk factors
for developing diabetes. Patients with preexisting diabetes may suffer worsened glycemic control when started on an
atypical antipsychotic.
Question #42
QID: 17136
Topic: DM
Subject: Medicine
A contraindication to the use of metformin (Glucophage) in a patient with type 2 diabetes mellitus is:
a) Obesity
b) Insulin resistance
c) Renal insufficiency
d) Concurrent use of glyburide (DiaBeta, Micronase)
The correct answer is c)
Explanation:
Metformin decreases glucose production in the liver and increases glucose uptake. It has no effect on pancreatic insulin
secretion. It is useful to help overcome insulin resistance, and can be used concurrently with a sulfonylurea. Studies have
proven its safety and usefulness in the obese diabetic. It is contraindicated in renal insufficiency, as increased
concentrations of the drug can cause lactic acidosis. Other contraindications include hepatic disease, a previous history of
lactic acidosis, heart failure treated with drugs, and chronic lung disease.
Question #43
QID: 17231
Topic: DM
Subject: Medicine
A 45-year-old male comes to your office for follow-up of his diabetes mellitus, which was diagnosed 3 months ago. He
wanted to try lifestyle modification, including diet, exercise, and weight loss, before trying medications. He has lost 3 kg
(7 lb), but still is 14 kg (31 lb) overweight. His examination is unremarkable, as is his chemistry profile. His hemoglobin
A1c level
is
8.3%.
Which one of the following would be most appropriate at this point?
a) Exenatide (Byetta)
b) Glyburide (Micronase, DiaBeta)
c) Insulin
d) Metformin (Glucophage)
e) Rosiglitazone (Avandia)
The correct answer is d)
Explanation:
The Diabetes Association recommends lifestyle intervention along with metformin as initial therapy for type 2 diabetes. If
the follow-up hemoglobin A1c is more than 7.0%, then insulin (most effective), a sulfonylurea (least expensive), or a
glitazone (no risk of hypoglycemia) can be added. The hemoglobin A1c should be checked every 3 months until it is less
than 7.0%, and every 6 months thereafter.
Question #44
QID: 17246
Topic: DM
Subject: Medicine
Which one of the following statements regarding blood glucose monitoring in patients with type 1 diabetes is most
correct?
a)
b)
c)
d)
Blood glucose testing from a fingertip site is preferred
Monitoring blood glucose 5 times per day is too often
A random blood glucose level of 5.6 mmol/L (100 mg/dL) is too high
Continuous blood glucose monitoring can result in higher hemoglobin A1c levels
The correct answer is a)
Explanation:
According to the Diabetes Control and Complications Trial, patients should assess fingertip blood glucose levels at least 3
times per day, including at bedtime, as well as before and after exercising and before driving. Although testing from other
sites is usually reliable, it can be inaccurate if performed within 60 minutes of meals or after exercise. If a patient’s
random blood glucose level is less than 5.6 mmol/L (100 mg/dL), a small snack should be eaten. Preprandial results
should be 5.0-7.3 mmol/L (90-130 mg/dL), and postprandial levels should be less than 10.0 mmol/L (180 mg/dL).
Continuous blood glucose monitoring has been shown to generally lead to tighter control and lower hemoglobin
A1c levels.
Question #45
QID: 17697
Topic: DM
Subject: Medicine
A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a nursing home. His blood glucose
level, which he rarely checks, is typically over 11.1 mmol/L. His serum creatinine level is 167 µmol/L. He also has had
several episodes of heart failure. His current medications include glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and
furosemide (Lasix). Which one of the following would be most appropriate to add to this patient’s regimen to treat his
diabetes mellitus?
a) The diabetic 1800-calorie/day diet
b) Metformin (Glucophage)
c) Pioglitazone (Actos)
d) Exenatide (Byetta)
e) Insulin glargine (Lantus)
The correct answer is e)
Explanation:
For geriatric patients in long-term care facilities, the predictable glucose control of insulin glargine is the best approach to
consider
initially.
→ The current guidelines do not recommend a strict diet for frail diabetic patients in nursing homes.
→ Exenatide is not recommended for the frail elderly because of concerns about weight loss and nausea.
→ Heart failure precludes the use of pioglitazone, and renal failure precludes the use of metformin.
Question #46
QID: 17719
Topic: DM
Subject: Medicine
Which one of the following most increases insulin sensitivity in an overweight patient with diabetes mellitus?
a) Metformin (Glucophage)
b) Acarbose (Precose)
c) Glyburide (DiaBeta, Micronase)
d) NPH insulin
The correct answer is a)
Explanation:
Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This means lower insulin levels achieve
the same level of glycemic control, and may be one reason that weight changes are less likely to be seen in diabetic
patients on metformin. Acarbose is an alpha-glucosidase inhibitor that delays glucose absorption.
Question #47
QID: 17738
Topic: DM
Subject: Medicine
A 40-year-old female comes to your office for a routine examination. She has been in good health and has no complaints
other than obesity. Her mother is diabetic and the patient has had a child that weighed 4kg (9 lb) at birth. Her examination
is negative except for her obesity. A fasting glucose level is 7.1 mmol/L, and when repeated 2 days later it is 7.5 mmol/L.
Which one of the following would be most appropriate at this point?
a) Diagnose type 2 diabetes mellitus and begin diet and exercise therapy
b) Begin an oral hypoglycemic agent
c) Order a glucose tolerance test
d) Tell the patient that she has impaired glucose homeostasis but is not diabetic
The correct answer is a)
Explanation:
The criteria for diagnosing diabetes mellitus include any one of the following: symptoms of diabetes (polyuria, polydipsia,
weight loss) plus a casual glucose level 11.1 mmol/L; a fasting plasma glucose level 7 mmol/L; or a 2-hour postprandial
glucose level 11.1 mmol/L after a 75-gram glucose load or a glycated hemoglobin (A1C) value of ≥ 6.5%. In the absence
of
unequivocal
hyperglycemia
the
test
must
be
repeated
on
a
different
day.
The criteria for impaired glucose homeostasis include either a fasting glucose level of 6.1-6.9 mmmol/L (impaired fasting
glucose) or a 2-hour glucose level of 7.8-11 mmol/L on an oral glucose tolerance test or or an A1C of 6.0% to 6.4%.
Normal values are now considered 6.1 mmol/L for fasting glucose and 7.8 mmol/L for the 2-hour glucose level on an oral
glucose tolerance test.
Question #48
QID: 17762
Topic: DM
Subject: Medicine
An 18-year-old male seen in your office is found to be overweight and to have acanthosis nigricans. Both of his parents
have a history of diabetes mellitus. His fasting plasma glucose level is 6.2 mmol/L. Which one of the following is the
correct diagnosis?
a) Prediabetes
b) Type 1 diabetes mellitus
c) Type 2 diabetes mellitus
d) Maturity-onset diabetes of the young
The correct answer is a)
Explanation:
This patient has prediabetes, which is defined as having a fasting plasma glucose level of 5.6 to 6.9 mmol/L.
These patients are at high risk for developing diabetes mellitus later in life. Prediabetes is associated with metabolic
syndrome, and weight loss, exercise, and certain pharmacologic agents have been shown to prevent or delay the
subsequent
development
of
diabetes
mellitus.
Diabetes mellitus is diagnosed in three ways: symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) plus a
random plasma glucose level 11.1 mmol/L; a fasting plasma glucose level 7 mmol/L; or a glucose level 11.1 mmol/L on a
2-hour 75-g oral glucose tolerance test. It is important to note that in the absence of unequivocal hyperglycemia the
diagnosis must be confirmed by repeat testing on a subsequent day. Once the diagnosis of diabetes is confirmed, further
testing is needed to differentiate between type 1, type 2, and maturity-onset diabetes of youth.
Question #49
QID: 17868
Topic: DM
Subject: Medicine
In patients with type 2 diabetes mellitus, intensive glycemic control has not been shown to be beneficial for which one of
the following diabetic complications?
a) Peripheral neuropathy
b) Foot infections
c) Cardiovascular disease
d) Proliferative retinopathy
e) Nephropathy
The correct answer is c)
Explanation:
Intensive management of hyperglycemia, with a goal of achieving nondiabetic glucose levels, helps reduce microvascular
complications such as retinopathy, nephropathy, and neuropathy. Foot infections are less common in patients without
neuropathy and in patients with good glycemic control. Intensive management of hyperglycemia also has a beneficial
effect on cardiovascular disease in patients with type 1 diabetes mellitus but, unfortunately, not in patients with type 2
diabetes mellitus. In fact, there is data to suggest that intensive glycemic control (hemoglobin A1c < 6.5) may be
detrimental in certain populations, such as the elderly and those with cardiovascular disease.
Question #50
QID: 17897
Topic: DM
Subject: Medicine
A 60-year-old black male is found to have type 2 diabetes mellitus. Which one of the following should be ordered before
initiating treatment with metformin?
a) Serum electrolytes
b) A serum creatinine level
c) A CBC
d) A lipid panel
e) A thyroid panel
The correct answer is b)
Explanation:
Metformin is contraindicated in patients with renal dysfunction, because it is associated with an increased incidence of
lactic acidosis.
Question #51
QID: 15432
Topic: Lung Abscess
Subject: Medicine
A 45-year-old man develops fever, cough with sputum production, night sweats, anorexia and weight loss. The
expectorated sputum characteristically is foul smelling and bad tasting. Imaging shows he has developed an abscess in his
lung.
He
is
HIV
negative.
All of the following organisms may cause lung abscess in this patient, except:
a) Pneumocystis carinii
b) Staphylococcus aureus
c) Klebsiella pneumonia
d) Pseudomonas species
The correct answer is a)
Explanation:
Lung abscess can be caused by a bacterial infection that reaches the lungs in several ways. The most common is aspiration
of
oropharyngeal
contents.
Patients at the highest risk for developing lung abscess have the following risk factors: poor dentition, seizure disorder and
alcohol
abuse.
In addition the following infectious etiologies of pneumonia may progress to parenchymal necrosis and lung abscess
formation: Pseudomonas
aeruginosa, Klebsiella
pneumoniae,Staphylococcus
aureus, Streptococcal
pneumonia and Nocardia species.
Pneumocystis jiroveci (formerly Pneumocystis carinii) is an opportunistic bug that can cause lung abscess in HIV/AIDS
patients by taking advantage of the patients weakened immune system.
Question #52
QID: 15436
Topic: Stroke
Subject: Medicine
A 51-year-old white woman with a history of hypertension and non-insulin-dependent diabetes mellitus presents to the
emergency department with with short-term memory impairment and a blindness. Patient exhibits Anton's syndrome
secondary
to
occlusion
of:
a) Left anterior cerebral artery
b) Right anterior cerebral artery
c) Left middle cerebral artery
d) Right middle cerebral artery
e) Posterior cerebral artery
The correct answer is e)
Explanation:
This patient has developed a stroke due to bilateral occlusion of the posterior cerebral artery (PCA).
The PCA supplies parts of the midbrain, subthalamic nucleus, basal nucleus, thalamus, mesial inferior temporal lobe, and
occipital
and
occipitoparietal
cortices.
Bilateral infarction in the distal PCAs produces cortical blindness (blindness with preserved pupillary light reaction). The
patient is often unaware of the blindness or may even deny it (Anton's syndrome - a state in which they fervently believe
they can see when they cannot). Tiny islands of vision may persist, and the patient may report that vision fluctuates as
images are captured in the preserved portions. Rarely, only peripheral vision is lost and central vision is spared, resulting
in "gun-barrel" vision.
Question #53
QID: 17810
Topic: Stroke
Subject: Medicine
A 55-year-old male who had an episode of atrial fibrillation that converted in the emergency department after 24 hours is
asymptomatic and currently in sinus rhythm. He is in good health otherwise and has no history of hypertension, diabetes
mellitus,
heart
failure,
transient
ischemic
attack,
or
stroke.
What is the most appropriate management for this patient at this point?
a) Observation
b)
c)
d)
e)
Aspirin
Warfarin (Coumadin), with a goal INR of 1.5-2.5
Warfarin, with a goal INR of 2.0-3.0
Warfarin, with a goal INR of 2.5-3.5
The correct answer is a)
Explanation:
The absolute rate of stroke depends on age and comorbid conditions. The stroke risk index CHADS , used to quantify risk
of stroke for patients who have atrial fibrillation and to aid in the selection of antithrombotic therapy, is a mnemonic for
individual stroke risk factors: C (congestive heart failure), H (hypertension), A (age 75), D (diabetes mellitus), and S
(secondary prevention for prior ischemic stroke or transient attack - most experts include patients with a systemic embolic
event). Each of these clinical parameters is assigned one point, except for secondary prevention, which is assigned 2
points. Patients are considered to be at low risk with a score of 0, at intermediate risk with a score of 1 or 2, and at high
risk with a score 3. The patient in this question has a CHADS2 score of 0, which is low risk. Patient's of this age with lone
AF lasting < 48 hours without clinical or imaging abnormalities, with no hypertension or other cardiovascular disease, or
related pulmonary disease can be simply observed (choice A) and treatment with aspirin or warfarin is not indicated at this
point.
→ Aspirin (choice A) is not indicated for a lone atrial fibrillation that occurred only once for less than < 48 hours in a
patient < 60 years old, who is otherwise healthy. At presentation to ED a patient with AF should be given heparin as it is
still possible for thrombus to occur before 48 hours, but once a patient returns to sinus rhythm < 48 hours of AF, and is
otherwise
younger
and
healthy,
anticoagulation
treatment
is
not
necessary.
→ Warfarin (Coumadin), with a goal INR of 1.5-2.5 (choice C), Warfarin, with a goal INR of 2.0-3.0 (choice
D), Warfarin, with a goal INR of 2.5-3.5 (choice E) are all incorrect. Warfarin is indicated in patients who meet the
CHADS2 score of 2 or higher.
Question #54
QID: 18404
Topic: Stroke
Subject: Medicine
A 50-year-old known hypertensive man was brought to the emergency department after a sudden feeling of numbness and
weakness of his left arm and left half of the face. No other symptoms could be elicited and the patient could engage in
dialogue,
normally.
Vital signs including blood pressure were stable. Left shoulder, upper arm, forearm and hand muscles have power of 2.
Pain and temperature sensations are impaired on the left arm and left side of the face. No motor or sensory impairment
could be detected on the right side or left lower side of the body. Visual fields were normal. The rest of physical
examination
was
normal.
Ischemic
stroke
was
suspected.
Which of the following arteries is the most likely site of blockage?
a) Right middle cerebral artery
b) Superior division of right middle cerebral artery
c) Inferior division of right middle cerebral artery
d) Lenticulostriate branches of the right middle cerebral artery
e) Right anterior cerebral artery
The correct answer is b)
Explanation:
The superior division of the right middle cerebral artery (MCA) (choice B) is the most likely site of blockage in this
patient. Patients with blockage of this division of MCA usually present with contralateral weakness and sensory loss on
the arm and face. This division of the right MCA supplies the lateral surface of the right cerebral hemisphere above the
lateral fissure but short of the superolateral portions, which are supplied by the anterior cerebral artery (ACA). Thus,
motor, sensory and sensory association areas for the left upper part of the body (arm and face) are supplied by this
division of MCA and weakness and sensory impairment are expected to affect these parts of the body. The lower limb is
spared because its motor and sensory representation is located in the superolateral of frontal and parietal lobes which are
supplied by the ACA. Because the right or non-dominant hemisphere is affected, our patient does not have any form of
aphasia.
→ Patients with MCA blockage (choice A) usually present with symptoms and signs of blockage of its superior division
(choice B), inferior division (choice C) and lenticulostriate division (choice D). Thus, these patients are expected to
present with left sided weakness and hemianesthesia affecting the face, arm, and leg. Because the non-dominant right
hemisphere is affect, hemi-neglect, astereognosis and anosognosia, hemianopsia rather than aphasia are also present.
→ Patients with inferior division of right middle cerebral artery (MCA) blockage (choice C) usually present with left
sided homonymous hemianopsia because this artery supplies the parts of optic pathway that pass through the temporal
lobe. Because the non-dominant hemisphere is affected, hemi-neglect, astereognosis, and anosognosia rather than aphasia
accompanies
the
hemianopsia.
→ Patients with blockage of lenticulostriate branches of the right MCA (choice D) usually present with left sided
hemianesthesia and hemiparesis of the leg, arm, and face. The lenticulostriate branches of the right MCA together with
anterior choroidal artery supply the posterior limb of the internal capsule on the right where the motor and sensory fibers
pass between the cortex and brain stem. Because motor and sensory fibers for both upper and lower parts of the body
come
close
to
each
other,
both
of
these
parts
of
the
body
are
affected.
→ Patients with right anterior cerebral artery (ACA) blockage (choice E) usually present with left sided hemianesthesia
and hemiparesis of the leg. The right ACA supplies the superolateral portions of the right frontal and parietal lobes, which
due homunculus topography, contains the motor and sensory areas of the lower part of the body (leg). The arms and the
face are usually not affected by blockage of the ACA because cortical areas representing these parts of the body are
located along the lateral surface of the cerebral hemisphere and are supplied by superior division of MCA.
Key
point:
Weakness and anesthesia of the left arm and left half of the face and sparing of the lower leg is most likely caused by
blockage in the territory of the middle cerebral artery (MCA) other than the lenticulostriate division. Absence of hemineglect and hemianopsia exclude blockage of the inferior division and favours blockage of the superior division of the
right MCA.
Question #55
QID: 15496
Topic: Prostate Cancer
Subject: Medicine
A 56-year-old man, whose father died of prostate cancer, is found to have on digital rectal exam (DRE) a small nodule on
the
right
lobe
of
his
prostate.
His
PSA
level
is
2.2.
The
appropriate
management
is:
a)
b)
c)
d)
Follow up in 3 months with DRE and PSA
Follow up in 6 months with DRE and PSA
Follow up in 12 months with DRE and PSA
Ultrasound guided biopsy now
The correct answer is d)
Explanation:
An annual digital rectal examination (DRE) beginning at age 50 year for the early detection of both rectal and prostate
cancer is, recommended. PSA testing screening guidelines are still not established - insufficient evidence (in quality or
quantity) to make a recommendation; however, other factors may influence decision making (done if required by patient).
A PSA level of less than 4 ng/ml is normal. A level between 4 and 10 is the ‘grey’ zone and above 10 is suspicious for
malignancy.
During a DRE, a nodule must be taken seriously since 50% of prostate nodules are cancerous. Especially in this patient
who has positive family history. The presence or absence of cancer in a prostate nodule is ordinarily determined by the
results of a transrectal needle aspiration biopsy.
Prostate Cancer
Question #56
QID: 15585
Topic: Prostate Cancer
Subject: Medicine
A 78-year-old man develops prostate cancer and is also found to have metastases. He would like to have definitive
treatment.
Which
of
the
following
is not an
appropriate
treatment?
a)
b)
c)
d)
e)
Androgen deprivation
Castration
Leuprolide
Watchful waiting
Flutamide
The correct answer is d)
Explanation:
Patients with a locally advanced tumor or metastases may benefit from androgen deprivation by castration, either
surgically with bilateral orchiectomy or medically with luteinizing hormone-releasing hormone (LHRH) agonists, such as
leuprolide.
Radical prostatectomy (removal of prostate with adnexal structures and regional lymph nodes) is probably best for
patients
<
70
with
a
tumor
confined
to
the
prostate.
Most patients, regardless of age, prefer definitive therapy. Watchful waiting (choice D) may be appropriate for
asymptomatic patients > 70 with localized prostate cancer, but it would be inappropriate in this symptomatic patient who
definitely
wants
to
try
everything
that
can
be
done
to
treat
his
condition.
>
Androgen
deprivation
(choice
A)
is
an
appropriate
treatment
in
this
patient
>
Castration
(choice
B)
is
appropriate
treatment
in
prostate
cancer
> Leuprolide (choice C) is a gonadotropin releasing hormone that would be beneficial in the management of this patient.
> Flutamide ( choice E) is a non-steroidal anti-androgen that is also useful in the treatment of prostate cancer
Question #57
QID: 16128
Topic: Prostate Cancer
Subject: Medicine
A 70-year-old man complains of increasing urinary frequency and dribbling. On physical examination, a digital rectal
exam reveals a normal-sized prostate. The prostate specific antigen level is elevated at 14 ng/mL. Ultrasonography reveals
a
small
hypoechoic
area
on
the
prostate
measuring
5
x
9
mm.
Which
a)
b)
c)
d)
of
the
following
is
the
most
appropriate
next
step?
Finasteride
Biopsy of prostate
Repeat PSA in 3 months
Alfuzosin
The correct answer is b)
Explanation:
Measurement of serum levels of prostate-specific antigen (PSA) can be used to screen for prostate cancer. However, this
substance can also be elevated in prostate hypertrophy. A transrectal ultrasound can identify lesions not palpable on rectal
examination, and the area can be biopsied under ultrasound guidance.
Prostate Cancer
Question #58
QID: 15438
Topic: BPH
Subject: Medicine
In
the
treatment
of
benign
prostate
hyperplasia
a) 5-alpha-reductase inhibitors reduce smooth muscle tone
b) Beta-reductase agonists reduce smooth muscle tone
c) 5-beta-reductase inhibitors are used for BPH treatment
(BPH),
which
of
the
following
is
true?
d) Alpha-adrenergic antagonists reduce smooth muscle tone
The correct answer is d)
Explanation:
In BPH, the prostate gland cells increase in number and eventually narrow the urethra that they surround.
This can lead to urinary problems such as frequency, hesitancy and retention. A digital rectal exam will show an enlarged
prostate. A PSA level, urinalysis and prostate ultrasound are commonly obtained. Two main types of drugs are used to
treat
this.
Alpha adrenergic receptor antagonists (alfuzosin, terazosin) block receptors in the bladder neck and prostate to relax the
smooth muscle, resulting in improvement in urine flow rate and reduction in symptoms of BPH.
The androgen DHT causes prostatic enlargement. 5 alpha reductase inhibitors (finasteride and dutasteride) inhibit
conversion of testosterone to DHT, causing serum DHT levels to decrease. This reduces prostatic size and improves
urinary symptoms.
BPH
Question #59
QID: 16325
Topic: BPH
Subject: Medicine
A 75-year-old man with a history of nocturia has not micturated for the last 10 hours, and is complaining of severe lower
abdominal
pain.
The
most
likely
cause
is:
a) Benign prostatic hyperplasia
b) Prostate cancer
c) Renal failure
d) Prostatitis
e) Urinary tract infection
The correct answer is a)
Explanation:
Benign prostatic hyperplasia is nonmalignant adenomatous overgrowth of the periurethral prostate gland. Symptoms are
those of bladder outlet obstruction, urinary frequency, urgency, nocturia, hesitancy, incomplete emptying, terminal
dribbling, overflow incontinence, or complete urinary retention. Diagnosis is based on digital rectal examination,
cystoscopy or transrectal ultrasonography.
BPH
Question #60
QID: 17882
Topic: BPH
Subject: Medicine
During a comprehensive health evaluation a 65-year-old black male reports mild, very tolerable symptoms of benign
prostatic hyperplasia. He has never smoked, and his medical history is otherwise unremarkable. Objective findings
include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific
antigen
level
is
1.8
ng/mL.
Based on current evidence, which one of the following treatment options is most appropriate at this time?
a) Observation, with repeat evaluation in 1 year
b) Saw palmetto
c) An alpha-receptor antagonist
d) A 5-alpha-reductase inhibitor
e) Urologic referral for transurethral resection of the prostate
The correct answer is a)
Explanation:
Watchful waiting with annual follow-up (choice A) is appropriate for men with mild benign prostatic hyperplasia (BPH).
Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the treatment of choice, if
indicated. PSA levels > 2.0 ng/mL for men in their 60s correlate with a prostatic volume > 40 mL. This patient’s PSA
falls
below
this
level.
→ A recent high-quality, randomized, controlled trial found no benefit from saw palmetto (choice B) with regard to
symptom relief or urinary flow after 1 year of therapy. The current guidelines do not recommend the use of phytotherapy
for
BPH.
→ Alpha-blockers (choice C) provide symptomatic relief in men whose disease has progressed to the point that they have
moderate
to
severe
BPH
symptoms.
→ In men with a prostatic volume > 40 mL, 5 alpha-reductase inhibitors (choice D) should be considered for treatment.
→ Surgical consultation (choice E) is appropriate when medical therapy fails or the patient develops refractory urinary
retention, persistent hematuria, or bladder stones.
BPH
Question #61
QID: 15439
Topic: Diagnostic Investigations
Subject: Medicine
A 70-year-old man presents with recurrent bilateral lower lobe pneumonia with mild dysphagia. On exam he is otherwise
normal.
What
is
the
procedure
of
choice
to
arrive
at
the
diagnosis?
a)
b)
c)
d)
Barium swallow
Serum protein electrophoresis
CBC
ESR
The correct answer is a)
Explanation:
Swallowing disorders are common, especially in the elderly, and may cause dehydration, weight loss, aspiration and
airway
obstruction.
Aspiration is the passage of food or liquid through the vocal folds. Persons who aspirate are at increased risk for the
occurrence of serious respiratory sequelae, including airway obstruction and aspiration pneumonia.
The most valuable investigations in patients with suspected esophageal dysphagia include a barium swallow study,
endoscopy and esophageal manometry. Diagnostic study of choice would be a barium swallow. The barium will show any
structural defects such as strictures, narrowing or tumors.
Question #62
QID: 17266
Topic: Diagnostic Investigations
Subject: Medicine
A 60-year-old white male comes to your office for evaluation of a chronic cough productive of large amounts of sputum,
accompanied by dyspnea on exertion. He has smoked 2 packs of cigarettes a day for the past 40 years.
The best diagnostic test for evaluating this problem is:
a) arterial blood gases
b) alpha-1-antitrypsin
c) brain natriuretic peptide (BNP)
d) CT of the chest
e) spirometry
The correct answer is e)
Explanation:
Considering the patient's history, the most likely diagnosis is COPD. It is important to note that in questions that ask the
single best answer, when two choices seem to be a possibility, then the most common is the right answer.
In patients with suspected COPD, the best diagnostic test is office spirometry (choice E). If the FEV 1/FVC ratio is < 70%
and the FEV1 is < 80% of predicted, the patient has COPD. This generally occurs in mid- to late life. While cigarette
smoking is the largest single risk factor, only 20% of smokers develop clinically significant COPD. The second most
common risk factor is alpha1-antitrypsin deficiency, which causes 1% of cases. These patients present with cough, sputum
production, and dyspnea on exertion. They often experience orthopnea soon after reclining, whereas patients with heart
failure typically experience orthopnea several hours after reclining, when fluid mobilizes from the lower extremities.
→ Arterial blood gases (choice A) would be the best test to evaluate the severity of an acute attack or exacerbation.
→ Alpha-1-antitrypsin(choice B) would be useful in patients with alpha1-antitrypsin deficiency. These patients develop
COPD
early
even
without
exposure
to
tobacco
products.
→ Brain natriuretic peptide (choice C) is useful in the assessment of patients with congestive heart failure. The most
likely
diagnosis
in
this
patient
is
COPD.
→ CT of the chest (choice D) may be useful in the diagnosis of emphysema. However, it would only be used as an
adjunctive study in a patient suspected of COPD.
Question #63
QID: 17712
Topic: Diagnostic Investigations
Subject: Medicine
A 42-year-old female presents with a 2-day history of chest pain. She describes the pain as sharp, located in the right
upper chest, and worsened by deep breathing or coughing. She also complains of shortness of breath. She was previously
healthy and has no recent history of travel. Her vital signs are normal. A pleural friction rub is noted on auscultation of the
lungs. The remainder of the examination is normal. An EKG, cardiac enzymes, oxygen saturation, and a D-dimer level are
all
normal.
Which one of the following would be most appropriate at this point?
a) No further testing
b) A chest radiograph
c) An antinuclear antibody test
d) Echocardiography
e) Pulmonary angiography
The correct answer is b)
Explanation:
This patient has pleurisy. Patients presenting with pleuritic chest pain may have life-threatening disorders, and pulmonary
embolism, acute myocardial infarction, and pneumothorax should be excluded. While 5%-20% of patients with
pulmonary embolism present with pleuritic chest pain, this patient has no risks for pulmonary embolism and the normal
D-dimer level obviates the need for further evaluation. Moderate- to high-risk patients may need a helical CT scan or
other
diagnostic
testing.
An EKG and chest radiograph are recommended in the evaluation of acute/subacute pleuritic chest pain. The chest
radiograph will exclude pneumothorax, pleural effusion, or pneumonia. An echocardiogram would not be indicated if the
cardiac examination and EKG are normal. An antinuclear antibody level could be considered in recurrent pleurisy or if
other symptoms or signs of lupus were present, but it would not be indicated in this patient.
Most cases of acute pleurisy are viral and should be treated with NSAIDs unless the workup indicates another problem.
Question #64
QID: 15440
Topic: Lung Cancer Etiology
Subject: Medicine
A 63-year-old man develops hemoptysis, weight loss and chest pain. His initial chest x-ray shows a mass which is further
confirmed
by
CT
of
the
chest.
Biopsy
is
positive
for
malignancy.
Which
a)
b)
c)
d)
e)
of
the
following
is least likely
to be
a
cause
of
his
lung
cancer?
Asbestos
Radiation
Nickel mining
Marijuana
Tobacco
The correct answer is d)
Explanation:
Lung cancer is now the number one cause of cancer deaths in both men and women. Initial symptoms include hemoptysis,
chest pain and weight loss. Imaging studies such as chest x-ray and chest CT are done. A bronchoscopy guided biopsy is
needed
to
obtain
a
tissue
sample
to
determine
if
the
mass
is
malignant.
Smoking causes 87% of all lung cancers. Other causes include exposure to the following: asbestos, radon, arsenic,
chromium,
exposure
to
radiation,
uranium,
nickel,
aromatic
hydrocarbons
and
ethers.
Marijuana, unlike tobacco and alcohol, does not appear to cause head, neck, or lung cancer. The risk of lung cancer due to
smoking marijuana or cocaine is less clear than with tobacco. An association between lung cancer and smoking these
agents has been difficult to prove because studies were limited by selection bias, small sample size, and failure to adjust
for tobacco smoking. In addition, the duration from the onset of drug use to outcome (ie, lung cancer) may have been too
short for lung cancer to develop because young participants were enrolled in most studies.
Question #65
QID: 15803
Topic: Hyponatremia
Subject: Medicine
A 72-year-old man with a history of recently diagnosed small cell cancer of the lung, presents to the emergency room
following
a
witnessed,
single,
tonic-clonic
seizure.
His
serum
sodium
is
106
mmol/L.
Which one of the following is the best immediate approach to the management of his electrolyte disturbance?
a)
b)
c)
d)
e)
Fluid restriction
Intravenous normal saline at 25 mL/hr
Intravenous normal saline at 100 mL/hr
Intravenous 3% saline at 25 mL/hr
Intravenous 3% saline at 100 mL/hr
The correct answer is e)
Explanation:
This patient most likely has severe syndrome of inappropriate antidiuretic hormone. Given the presentation, this patient
should be treated with Intravenous 3% saline at 100 mL/hr with frequent (q 2 to 4 h) electrolyte determinations (choice
E).
Severe hyponatremia (plasma Na < 109 mmol/L; effective osmolality < 238 mOsm/kg) in asymptomatic patients can be
treated safely with stringent restriction of water intake. However, treatment is more aggressive when neurologic
symptoms (eg, confusion, lethargy, seizures, coma) are present. The debate primarily concerns the pace and degree of
hyponatremia
correction.
Many experts recommend that plasma Na be raised no faster than 1 mmol/L/h, but replacement rates of up to 2 mmol/L/h
for the first 2 to 3 h have been suggested for patients with seizures. Regardless, the rise should be ≤ 10 mmol/L over the
first 24 h. More vigorous correction risks precipitation of osmotic demyelination syndrome.
Hypertonic (3%) saline (containing 513 mmol Na/L) may be used, but only with frequent (q 2 to 4 h) electrolyte
determinations. For patients with seizures or coma, ≤ 100 mL/h may be administered over 4 to 6 h in amounts sufficient to
raise
the
serum
Na
4
to
6
mmol/L.
> Fluid restriction (choice A) is incorrect. This patient's history doesn't reveal that she was drinking large amount of
fluids; while fluid restriction is normally the initial treatment for syndrome of inappropriate antidiuretic hormone patients,
this is normally done in asymptomatic patients; once seizures develop, the most preferred treatment is hypertonic saline.
> Intravenous normal saline (choice B) and (choice C) are incorrect. Treatment for patients who present with seizure due
to
hyponatremia
is
done
with
hypertonic
saline.
> Intravenous 3% saline 25ml/hr (choice D) would be insufficienct to correct the patient's condition in a timely manner.
Question #66
QID: 17847
Topic: Hyponatremia
Subject: Medicine
A 55-year-old male is brought to the emergency department because of confusion and seizures. He has a history of
hypertension and obstructive sleep apnea due to obesity. He is not conscious and no other history is available. An
examination shows no focal neurologic findings, but a general examination is limited because of his size. Breath sounds
are diminished, and heart sounds are difficult to hear. He has venous insufficiency changes on his lower extremities, with
brawny-type edema. Laboratory testing reveals a sodium level of 116 mmol/L (N 135-145), but normal renal and liver
functions. A chest radiograph shows mild cardiomegaly. A BNP level is pending, but immediate treatment is felt to be
indicated.
Which one of the following is the treatment of choice for this patient?
a) Valsartan
b) Furosemide
c) Vasopressin
d) Hypertonic saline
e) Conivaptan
The correct answer is d)
Explanation:
This patient has severe hyponatremia manifested by confusion and seizures, a life-threatening situation warranting urgent
treatment with hypertonic (3%) saline. The serum sodium level should be raised by only 1-2 mmol/L per hour, to prevent
serious neurologic complications. Saline should be used only until the seizures stop. Some authorities recommend
concomitant use of furosemide, especially in patients who are likely to be volume overloaded, as this patient is, but it
should not be used alone. The arginine vasopressin antagonist conivaptan is approved for the treatment of euvolemic or
hypervolemic hyponatremia, but not in patients who are obtunded or in a coma, or who are having seizures.
Question #67
QID: 15443
Topic: Squamous Cell Carcinoma
Subject: Medicine
A 62-year-old man who is a cigar and pipe smoker develops a circular lesion on the lower lip. See picture:
What
a)
b)
c)
d)
is
Basal cell carcinoma
Squamous cell carcinoma
Actinic keratoses
Malignant melanoma
The correct answer is b)
Explanation:
the
most
likely
diagnosis?
Squamous cell carcinoma of the oral cavity occurs mostly in smokers. About 38% of all oral squamous cell carcinomas
occur on the lower lip. Fortunately for lower lip lesions, 5 year survival is 90%, and metastases are rare. Surgery and
radiation
therapy
are
the
treatments
of
choice.
Basal cell carcinoma most often appears on sun-exposed areas such as the face, scalp, ears, chest, back, and legs. The
most common appearance of basal cell cancer is that of a small dome-shaped bump that has a pearly white color. Basal
cell cancer can also appear as a pimple-like growth that heals, only to come back again.
Squamous Cell Carcinoma
Question #68
QID: 15800
Topic: Squamous Cell Carcinoma
Subject: Medicine
A 60-year-old man has an ulcerating carcinoma of the lateral side of the tongue. Which one of the following features has
the
most
important
effect
upon
his
management?
a)
b)
c)
d)
e)
He smokes 30 cigarettes daily
He has a hard cervical lymph node 1.5 cm in diameter
The tumor measures 2 cm in diameter
The tumor is a squamous cell carcinoma
He has severe dental caries
The correct answer is b)
Explanation:
Oral squamous cell carcinoma affects about 30,000 Americans each year. Ninety percent are smokers. Alcohol is also a
risk factor. Early, curable lesions are rarely symptomatic; thus, preventing fatal disease requires early detection by
screening. Treatment is with surgery, radiation, or both. The overall 5-yr survival rate is 52%.
If carcinoma of the tongue is localized (no lymph node involvement), 5-yr survival is about 50%. For localized carcinoma
of the floor of the mouth, 5-yr survival is 65%. With lymph node metastasis, the 5-yr survival is 20%.
For tongue lesions, radiation therapy is often the treatment of choice because surgery is extensive, disfiguring, and
associated with poor quality of life. In addition, patients with cancer of the floor of the mouth are often medically
compromised and are not good candidates for surgery.
Question #69
QID: 17270
Topic: Squamous Cell Carcinoma
Subject: Medicine
A 75-year-old white male presents with a nonhealing 2.5-cm ulcer on his neck. A 4-mm punch biopsy reveals a squamous
cell
carcinoma.
Which one of the following would be most appropriate at this time?
a) Cryosurgery
b) Electrodesiccation and curettage
c) Mohs’ surgery
d) Surgical excision with 6-mm margins
e) Radiotherapy
The correct answer is d)
Explanation:
For treatment of squamous cell carcinoma (SCC) greater than or equal to 20 mm, surgical excision with 6-mm margins is
the preferred treatment. This will clear 95% or more of these tumors, and provides good cosmetic results.
→ Cryosurgery (choice A) or electrodessication (choice B) can be used for tumors < 1 cm.
→ Mohs’ surgery (choice C) would be appropriate if the tumor were high-risk (e.g., if it were in a location associated with
a
high
risk
of
metastasis.)
→ Radiation therapy (choice E) as primary treatment for cutaneous SCC is typically reserved for patients who are unable
to undergo surgical excision.
Squamous Cell Carcinoma
Question #70
QID: 15410
Topic: Erectile dysfunction
Subject: Medicine
A man comes to see you. His past medical history includes hypertension. He tells you that he has experienced impotence
for the past 6 months with his wife. But he is able to develop an erection in the morning and while reading an adult
magazine
in
the
washroom.
What should you do?
a) Change his blood pressure medicine
b) Prescribe and ED medicine like Cialis or Levitra
c) Reassurance
d) Check a testosterone level
e) Discuss couples counseling
The correct answer is e)
Explanation:
Erectile dysfunction (ED) is a common problem among males. It can be caused by medicine side effects. Beta blockers
used to treat hypertension are common causes of male ED. However this patients history suggests he has non-organic
impotence. Since he is able to achieve an erection. At this time is appropriate to discuss counseling for him and his wife to
help treat this partner-specific ED.
Question #71
QID: 15599
Topic: Erectile dysfunction
Subject: Medicine
A 40-year-old man complains to his doctor of impotence. Which one of the following medication could be implicated?
a)
b)
c)
d)
e)
Tadalafil
Sertraline
Clarithromycin
Enalapril
Clozapine
The correct answer is b)
Explanation:
Sertraline is an SSRI used in the treatment of depression. Some of the various side effects of selective serotonin re-uptake
inhibitors include: nausea, loss of appetite, diarrhea, anxiety or irritability, problems sleeping or drowsiness, loss of sexual
desire or ability (impotence), headaches or dizziness, weight gain.
Question #72
QID: 15844
Topic: Parkinson's Disease
Subject: Medicine
A 72-year-old man has suffered a fall. His daughter reports that, for several months, she has noticed that he walks with
smaller, shuffling footsteps and that his spine and arms seem always to be flexed when walking.
All
a)
b)
c)
d)
e)
of
the
following
may
be
found
in
this
patient, except:
Intention tremor of the hand
No expression in the face
Pill rolling tremor in both hands
Micrography
Mild dementia
The correct answer is a)
Explanation:
Parkinson's disease is an idiopathic, slowly progressive, degenerative CNS disorder characterized by resting tremor,
muscular rigidity, slow and decreased movement, mask-like face expression, and postural instability. Diagnosis is clinical.
Treatment is with levodopa plus carbidopa, other drugs, and, for refractory symptoms, surgery.
A resting tremor of one hand is often the first symptom. The tremor is characterized as follows: Often involving the wrist
and fingers in movements similar to those used to manipulate small objects or pills (pill-rolling tremor) Usually, the
hands,
arms,
and
legs
are
most
affected,
in
that
order.
Dementia can occur. Hypokinesia and impaired control of distal musculature cause micrographia (writing in very small
letters)
and
make
activities
of
daily
living
increasingly
difficult.
Intention tremor is a dyskinetic disorder consisting of wide tremor during voluntary movements. A tremor that gets worse
when a person is moving or reaching for an object is called an intention tremor. It is the result of dysfunction of the
cerebellum.
Question #73
QID: 16467
Topic: Parkinson's Disease
Subject: Medicine
In differentiating early Parkinson’s disease from variants such as drug-induced parkinsonism, progressive supranuclear
palsy, and multiple system atrophy, which one of the following is the most important clue?
a)
b)
c)
d)
e)
A resting tremor
Bradykinesia
Rigidity
Gait difficulty
Loss of postural reflexes
The correct answer is a)
Explanation:
Resting
tremor
is
the
most
common
presentation
of
Parkinson’s
disease.
It is rare in progressive supranuclear palsy and multiple system atrophy, and less common in drug-induced parkinsonism.
Question #74
QID: 16683
Topic: Parkinson's Disease
Subject: Medicine
A 75-year-old male has not seen a physician in 25 years and presents with advanced Parkinson’s disease. The mainstray
of
treatment would
be:
a)
b)
c)
d)
e)
Referral to a neurosurgeon for thalamotomy
Amantadine (Symmetrel)
Benztropine (Cogentin)
Pramipexole (Mirapex)
Carbidopa/levodopa (Sinemet)
The correct answer is e)
Explanation:
Carbidopa/levodopa (choice E) is better for initial therapy in older patients, and those who present with more severe
symptoms.
Slow-release
versions
of
this
combination
may
decrease
motor
fluctuations.
> Stereotactic thalamotomy (choice A) is used to ameliorate tremors that have become disabling. This procedure has been
replaced by other surgical options such as pallidotomy and high-frequency, deep-brain stimulation of specific nuclei.
> While anticholinergics such as benztropine (choice C) and amantadine (choice B) may provide some improvement of
symptoms, these effects wane within a few months. Such medications are not a good option in this patient with advanced
disease.
> Dopamine agonists (choice D) provide some improvements in motor complications, but are mainly used to delay the
introduction of levodopa in younger patients, to avoid levodopa-related adverse reactions.
Question #75
QID: 17229
Topic: Parkinson's Disease
Subject: Medicine
Which one of the following is more consistent with Parkinson’s disease than with other variant parkinsonian syndromes?
a) Tremor at the onset of illness
b) Frequent falls at the onset of illness
c) Urinary urge incontinence at the onset of illness
d) Symmetric, bilateral motor manifestations at the onset of illness
The correct answer is a)
Explanation:
Tremor is characteristically an early manifestation of Parkinson’s disease. It is less pronounced in other variant
parkinsonian syndromes. Examples of these syndromes include multiple system atrophy and progressive supranuclear
palsy. Initial motor findings, including tremor, are often unilateral in Parkinson’s disease.
Early falls, autonomic dysfunction, and symmetric motor findings are more typical of variant parkinsonian syndromes.
Compared to Parkinson’s disease, these syndromes respond poorly to levodopa.
Question #76
QID: 17539
Topic: Parkinson's Disease
Subject: Medicine
During the morning rounds, a second year resident presents a patient as "a 58-year-old female who suffers from rigidity
and tremors. She has been diagnosed with a neurodegenerative disease involving the depigmentation of substantia nigra
and loss of dopaminergic input to basal ganglia." What is the disease in question?
a) Epilepsy
b) Parkinson’s disease
c) Mood disorder
d) Schizophrenia
e) Huntington disease
The correct answer is b)
Explanation:
Parkinson’s disease involves rigidity and tremors followed by akinesia. It is a neurodegenerative disease involving the the
depigmentation of substantia nigra and loss of dopaminergic input to basal ganglia. Lack of dopamine levels results in
over
excitation
of
muscles,
manifested
in
the
form
of
rigidity
and
tremors.
→ Epilepsy
(choice
A)
involves
loss
of
consciousness
with
muscular
movements.
→ Mood disorder (choice C) occurs due to the decreased production of not only dopamine but also nor-epinephrine and
serotonin.
→ Schizophrenia (choice D) is due to the excess production of dopamine, nor-epinephrine and serotonin.
→ The most striking neuropathology in Huntington disease (choice E) occurs within the neostriatum, in which gross
atrophy of the caudate nucleus and putamen is accompanied by selective neuronal loss and astrogliosis.
Question #77
QID: 17541
Topic: Parkinson's Disease
Subject: Medicine
During the morning rounds, a second year resident presents a patient as "a 58-year-old female who suffers from rigidity
and tremors. She has been diagnosed with a neurodegenerative disease involving the depigmentation of substantia nigra
and
loss
of
dopaminergic
input
to
basal
ganglia."
Regarding treatment of this patient, which of the following statements is true?
a) Studies demonstrate that a patient's quality of life deteriorates independently of at what stage of the disease the
treatment is instituted.
b) Levodopa is the most efficacious symptomatic medication with few short-term side effects.
c) Dopamine agonists and levodopa are started at a high dose, in order to reach therapeutic levels as soon as possible
d) Levadopa has more side effects than dopamine agonists
e) Anticholinergic medications provide good bradykinesia or rigidity relief but have no effect on tremor
The correct answer is b)
Explanation:
This patient suffers from Parkinson’s disease. Levodopa is the most efficacious symptomatic medication with few shortterm side effects (choice B - true), but its chronic use is associated with the development of fluctuations and dyskinesias.
Once
fluctuations
and
dyskinesias
become
problematic,
they
are
difficult
to
resolve.
→ Studies demonstrate that a patient's quality of life deteriorates quickly if treatment is not instituted at or shortly after
diagnosis
(choice
A
false)
→ Dopamine agonists provide moderate symptomatic benefit and rarely cause fluctuations and dyskinesias by
themselves, but they have more side effects than levodopa (choice D - false), including sleepiness and impulse control
disorders. However, these side effects resolve upon lowering the dose or discontinuing the medication.
→ Dopamine agonists and levodopa are started at a low dose, escalated slowly, and titrated to control symptoms (choice
C
false).
→ For patients who have disability due to tremor that is not adequately controlled with dopaminergic medication, an
anticholinergic agent can be used. Anticholinergic medications provide good tremor relief in approximately 50% of
patients but do not meaningfully improve bradykinesia or rigidity (choice E - false).
Question #78
QID: 17936
Topic: Parkinson's Disease
Subject: Medicine
A 73-year-old male sees you for evaluation of a tremor. Based on the history and examination, you suspect Parkinson’s
disease.
Which one of the following would be most helpful for confirming the diagnosis?
a) CT of the brain
b) MRI of the brain
c) A positive response to levodopa
d) Confirming that the tremor occurs with movement
e) Confirming that the tremor had a symmetric onset
The correct answer is c)
Explanation:
Patients with Parkinson's disease should respond to an adequate therapeutic challenge of levodopa or a dopamine agonist.
The diagnosis of idiopathic Parkinson's disease is clinical, not radiographic. Cardinal signs of Parkinson's disease include
an asymmetric tremor onset and a distal resting tremor of 3-6 Hz.
Question #79
QID: 15444
Topic: STD - Gonorrhea
Subject: Medicine
A teenage girl was raped and she was given a prophylactic drug to prevent gonorrhea. What is the most appropriate
treatment
of
choice?
a)
b)
c)
d)
Ceftriaxone
Doxycycline
Metronidazole
Azithromycin
The correct answer is a)
Explanation:
Treatment for
>
>
suspected
gonorrhea
Chlamydia
is
usually
Metronidazole
is
a
is
with
treated
treatment
Ceftriaxone,
with
for
which
either
bacterial
can
be
doxycycline
vaginosis
given
250mg
IM.
or
and
azithromycin.
trichomonis.
> Syphilis is treated with penicillin usually.
Gonorrhea
Question #80
QID: 17949
Topic: STD - Gonorrhea
Subject: Medicine
Which one of the following is appropriate and effective treatment for genitourinary gonorrhea in a 20-year-old male with
a purulent urethral discharge?
a) Amoxicillin 3.5 g orally once
b) Ciprofloxacin 500 mg orally once
c) Ceftriaxone 250 mg intramuscularly once
d) Doxycycline 100 mg 2 times daily for 3 days
e) Erythromycin 500 mg 4 times daily for 7 days
The correct answer is c)
Explanation:
Not only has the incidence of gonorrhea increased since 2002, but the rate of quinolone-resistant infection has also
increased. Ceftriaxone is therefore the currently recommended treatment, and amoxicillin, ciprofloxacin, and
erythromycin are no longer recommended because of resistance to these drugs. Doxycycline can be used but should be
continued
for
7
days.
Note: In 2011, the CDC changed the recommendation to dose ceftriaxone at 250 mg, which is an increase from the
previously recommended dose of 125 mg.
Question #81
QID: 15445
Topic: Onychomycosis
Subject: Medicine
A 53-year-old female presents with a fingernail infection. See picture:
This
a)
b)
c)
d)
should
be
treated
with:
Griseofulvin for 2 weeks
Terbinafine for 6 weeks
Itraconazole for 2 weeks
Nizoral for 1 year
The correct answer is b)
Explanation:
Onychomycosis (tinea unguium) is a fungal infection of the nail. In such infections you can see nail plate separation from
nail bed and thickened, discolored (white, yellow, brown, black), broken, and dystrophic nails.
Terbinafine (Lamisil) is the first-line therapy for these infections 250 mg per day for 6 weeks to treat fingernails and for
12 weeks to treat toenails. Complete blood count and ALT and AST levels are obtained at baseline, then every 4 to 6
weeks
during
therapy.
Itraconazole (Sporanox) is alternative first-line therapy for nail infections. Given 200 mg per day for 6 weeks to treat
fingernails and for 12 weeks to treat toenails. You need to monitor ALT and AST levels at baseline, then every 4 to 6
weeks during therapy.
Question #82
QID: 17871
Topic: Onychomycosis
Subject: Medicine
A 69-year-old female sees you for an annual examination. She asks you to look at her toes, and you note a fungal
infection in five toenails. She says the condition is painful and limits her ability to complete her morning walks. She asks
for treatment that will allow her to resume her daily walks as soon as possible. Her only other medical problem is allergic
rhinitis
which
is
well
controlled.
Which one of the following would be the most appropriate treatment for this patient?
a) Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeks
b) Oral terbinafine (Lamisil) daily for 12 weeks
c) Topical terbinafine (Lamisil AT) daily for 12 weeks
d) Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeks
e) Toenail removal
The correct answer is b)
Explanation:
Continuous therapy with oral terbinafine for 12 weeks has the highest cure rate and best long-term resolution rate of the
therapies listed. Other agents and pulsed dosing regimens have lower cure rates. Topical creams are not appropriate for
onychomycosis because the infection resides in the cell of the toenail. Antifungal nail lacquers have a lower cure rate than
systemic therapy and should be used only when oral agents would not be safe. Toenail removal is reserved for patients
with an isolated infected nail or in cases involving a dermatophytoma.
Question #83
QID: 15451
Topic: SVT
Subject: Medicine
A 68-year-old patient comes to ED complaining of dyspnea. On exam his vitals show HR 160 bpm, BP 110/60 mmHg.
His
EKG
shows
supraventricular
tachycardia
(SVT).
What
a)
b)
c)
d)
e)
is
the
treatment
of
choice?
Digoxin PO
Digoxin IV
Digoxin and Furosemide
Digoxin and Warfarin
Adenosine
The correct answer is e)
Explanation:
In the treatment of SVT, adenosine, a short-acting medication is used to decrease the heart rate. This medication is given
by IV to act quickly. Adenosine has some temporary side effects, including facial flushing, chest pain, shortness of breath,
nausea and dizziness. If a single dose does not stop supraventricular tachycardia, then you can give higher doses.
Adenosine successfully stops paroxysmal supraventricular tachycardia (PSVT) in more than 90% of cases.
If adenosine is unsuccessful, other medications can be used, such as calcium channel blockers, digoxin (Lanoxin), or betablockers.
Question #84
QID: 15673
Topic: SVT
Subject: Medicine
A young female presents with supraventricular tachycardia. The patient does not experience symptoms of haemodynamic
decompensation. The best initial management is:
a) IV Verapamil
b) Cardioversion
c) Increased vagal tone
d) Beta-blocker
e) IV Adenosine
The correct answer is c)
Explanation:
Vagal maneuvers are the first-line treatment in hemodynamically stable patients. Vagal maneuvers, such as breath-holding
and the Valsalva maneuver (ie, having the patient bear down as though having a bowel movement), all slow conduction in
the
AV
node
and
can
potentially
interrupt
the
reentrant
circuit.
Carotid massage is another vagal maneuver that can slow AV nodal conduction. Massage the carotid sinus for several
seconds on the nondominant cerebral hemisphere side. This maneuver is usually reserved for young patients. Due to the
risk of stroke from emboli, auscultate for bruits before attempting this maneuver. Do not perform carotid massage on both
sides. A Valsalva maneuver, if performed properly by the patient, can frequently avert an attack.
Synchronized cardioversion starting at 50 J can be used immediately in patients who are hypotensive, have pulmonary
edema,
have
chest
pain
with
ischemia,
or
are
otherwise
unstable.
When SVT is not terminated by vagal maneuvers, short-term management involves intravenous adenosine.
Other alternatives for the acute treatment of SVT include calcium channel blockers like verapamil, diltiazem or betablockers like metoprolol or esmolol.
Question #85
QID: 17279
Topic: SVT
Subject: Medicine
Which one of the following is true regarding supraventricular tachycardia (SVT)?
a) Verapamil is useful for decreasing recurrences of SVT
b) Hyperparathyroidism is a common cause of SVT
c) Hyponatremia is a common cause of SVT
d) Carotid sinus massage and adenosine are contraindicated in SVT
e) Excessive alcohol intake can suppress SVT
The correct answer is a)
Explanation:
The use of verapamil, propranolol, or digoxin reduces SVT episodes by 30%-50%. There is no evidence that one is
superior
to
the
others.
Hypokalemia and hyperthyroidism can cause SVT, but there is no association with hyperparathyroid disease or
hyponatremia.
Carotid sinus massage and adenosine have been used for diagnosing atrial tachycardia. (Adenosine is an ultra-short-acting
drug that is useful in SVTs of unknown origin both in making the diagnosis and in terminating those that are dependent on
the
AV
junction
and
some
focal
atrial
tachycardia.)
Excessive alcohol use can precipitate SVT.
Question #86
QID: 17666
Topic: SVT
Subject: Medicine
A 36-year-old white female presents to the emergency department with palpitations. Her pulse rate is 180 beats/min. An
EKG reveals a regular tachycardia with a narrow complex QRS and no apparent P waves. The patient fails to respond to
carotid massage or to two doses of intravenous adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step
would be to administer intravenous:
a) Amiodarone
b) Digoxin
c) Flecainide
d) Propafenone
e) Verapamil
The correct answer is e)
Explanation:
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by
the administration of intravenous verapamil or a beta-blocker. Verapamil has a longer half-life than adenosine and may
help maintain sinus rhythm following the termination of SVT. It is also advantageous for controlling the ventricular rate in
patients with atrial tachyarrhythmia. If that fails, intravenous propafenone or flecainide may be necessary. It is also
important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances.
Electrical cardioversion may be necessary if these measures fail to terminate the tachyarrhythmia. Consider
radiofrequency ablation for any patient with symptomatic paroxysmal supraventricular tachycardia in whom long-term
medical treatment is not effectively tolerated or desired.
Question #87
QID: 15452
Topic: Dementia
Subject: Medicine
All of the following dementias can benefit from specific treatments, except:
a) Normal pressure hydrocephalus
b) Alzheimer’s disease
c) Oligodendroglial tumor
d) Creutzfeldt Jakob disease
e) B12 deficiency
The correct answer is d)
Explanation:
The dementias associated with NPH (normal pressure hydrocephalus), Alzheimer's, sarcoidosis, and vitamin B12
deficiency can be either cured or benefit from the following treatments: shunting of the ventricles in NPH;
acetylcholinesterase inhibitors such as donepezil, rivastigmine and tacrine for Alzhiemer's; vitamin B12 replacement for
B12 deficiency. Maximal surgical resection is the intial step in treament of patients with suspected anaplastic
oligodendroglial
tumors.
Currently, Creutzfeldt–Jakob disease (CJD) cannot be cured, and its progress cannot be slowed. The disease is fatal,
usually within months or a few years.
Question #88
QID: 16999
Topic: Dementia
Subject: Medicine
A 60-year-old white female presents for her annual physical examination. She tells you that since her last visit she has
begun
taking ginkgo
biloba
to improve
her
memory.
She
takes
no
other
medications.
The evidence supporting a benefit from ginkgo biloba is best for which one of the following?
a) Tinnitus
b) Benign prostatic hyperplasia
c) Dementia
d) Intermittent claudication
The correct answer is c)
Explanation:
Studies support the use of ginkgo biloba for tinnitus, dementia, and intermittent claudication. Those examining its use in
patients with dementia are of the highest quality, and consistently demonstrate that ginkgo is more effective than placebo
in delaying cognitive decline. The studies examining its use in tinnitus, claudication, and cognitive improvement in people
with normal mentation are limited by bias and small numbers of studies with inconsistent results. Ginkgo is not
appropriate for the treatment of benign prostatic hyperplasia.
Question #89
QID: 15463
Topic: Hypothyroidism
Subject: Medicine
A patient on lithium therapy develops weakness, lethargy and increased sensitivity to cold. What investigation must be
done?
a)
b)
c)
d)
e)
Lithium level
TSH level
Reassurance
CBC
CMP
The correct answer is b)
Explanation:
It is well established that lithium therapy can cause hypothyroidism in about 2-3 % of patients. Once hypothyroidism is
diagnosed,
treatment
of
the
condition
should
be
investigated
rapidly
with
thyroxine.
Discontinuation of lithium therapy is an option but in most cases the psychiatric indication for continuing it is strong, as in
this patient. Once treatment is begun, regular monitoring of TSH and FT4 will be required.
Question #90
QID: 15602
Topic: Hypothyroidism
Subject: Medicine
A 38-year-old woman presents to you convinced that she has chronic fatigue syndrome. The history reveals no evidence
of fever or swollen glands, and no other symptoms other than fatigue and weight gain. Her physical examination is
completely
normal.
She
has
a
high
thyroid-stimulating
hormone
level.
You
a)
b)
c)
d)
e)
would
then
suspect
and
subsequently
confirm:
Hyperthyroidism secondary to pituitary adenoma
Hypothyroidism
Grave's disease
Thyroiditis
Chronic fatigue syndrome
The correct answer is b)
Explanation:
Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormone and a
slowing
of
vital
body
functions.
Insufficient thyroid hormone causes body functions to slow. Symptoms are subtle and develop gradually. They may be
mistaken for depression, especially among older people. Facial expressions become dull, the voice is hoarse and speech is
slow, eyelids droop, and the eyes and face become puffy. Many people with hypothyroidism gain weight, become
constipated,
and
are
unable
to
tolerate
cold.
Hypothyroidism is common, especially among older people, particularly women; it affects about 10% of older women. It
can,
however,
occur
at
any
age.
Very
severe
hypothyroidism
is
called
myxedema.
Diagnosis is made by obtaining TSH and FreeT4 levels. Treatment is with thyroid replacement with synthroid.
Question #91
QID: 15727
Topic: Hypothyroidism
Subject: Medicine
A young woman presents a feature of cold intolerance, fatigue, anorexia, weight gain and dry skin. Her TSH is increased
and
freeT4
is
low.
What
is
the
most
appropriate
treatment?
a)
b)
c)
d)
Beta-blocker
Levothyroxine
Methimazole
Propylthiouracil
The correct answer is b)
Explanation:
Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facies, hoarse slow
speech, and dry skin, and by low levels of thyroid hormones. Management includes treatment of the underlying cause and
administration of thyroxine.
Question #92
QID: 15859
Topic: Hypothyroidism
Subject: Medicine
An elderly woman notes the gradual onset of fatigue and feeling tired. She has gained a significant amount of weight over
the last year. She complains frequently that the house is too cold and is turning up the thermostat. Constipation has
become
a
problem.
Which
a)
b)
c)
d)
e)
of
the
following
is
true
of
this
primary
condition?
TSH is depressed
Anti-thyroglobulin antibody are elevated
Anti-thyroid microsomal antibodies are decreased
TRH is elevated
TSH is increased
The correct answer is e)
Explanation:
Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facies, hoarse slow
speech, and dry skin, and by low levels of thyroid hormones. Symptoms may include cold intolerance, constipation,
forgetfulness,
fatigue,
personality
changes
and
weight
gain.
Serum TSH is the most sensitive test. In primary hypothyroidism, there is no feedback inhibition of the intact pituitary,
and serum TSH is always elevated, whereas serum free T4 is low. In secondary hypothyroidism, free T4 and serum TSH
are low.
Question #93
QID: 15950
Topic: Hypothyroidism
Subject: Medicine
A 42-year-old woman has recently experienced fatigue, sleepiness, dry skin, constipation, and a 4.5 kg weight gain. Her
thyroid
is
firm
and
twice
the
normal
size.
Which one of the following is the most sensitive laboratory test that will be used to diagnose this patient's condition?
a)
b)
c)
d)
e)
Serum thyroxine (T4)
Serum triiodothyronine (T3)
T3 resin uptake
Serum thyroid-stimulating hormone (TSH) measurement
Antithyroid antibodies
The correct answer is d)
Explanation:
Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facies, hoarse slow
speech,
and
dry
skin,
and
by
low
levels
of
thyroid
hormones.
Serum TSH is the most sensitive test. In primary hypothyroidism, there is no feedback inhibition of the intact pituitary,
and serum TSH is always elevated, whereas serum free T4 is low. In secondary hypothyroidism, free T4 and serum TSH
are low (sometimes TSH is normal but with decreased bioactivity). Management includes treatment of the underlying
cause and administration of thyroxine.
Question #94
QID: 16004
Topic: Hypothyroidism
Subject: Medicine
A 28-year-old woman presents with a three month history of fatigue, weight gain, menstrual irregularity and declining
memory. Which of the following laboratory results is likely in the diagnosis of the underlying problem?
a)
b)
c)
d)
TSH increased, free T4 increased
TSH decreased, free T4 increased
TSH increased, free T4 decreased
TSH decreased, free T4 decreased
e) TSH within normal range, free T4 within normal range
The correct answer is c)
Explanation:
Hypothyroidism is common, especially among older people, particularly women; it affects about 10% of older women. It
can,
however,
occur
at
any
age.
Insufficient thyroid hormone causes body functions to slow. Symptoms are subtle and develop gradually. They may be
mistaken for depression, especially among older people. Facial expressions become dull, the voice is hoarse and speech is
slow, eyelids droop, and the eyes and face become puffy. Many people with hypothyroidism gain weight, become
constipated, and are unable to tolerate cold. The hair becomes sparse, coarse, and dry, and the skin becomes coarse, dry,
scaly,
and
thick.
Usually hypothyroidism can be diagnosed with one simple blood test: the measurement of thyroid-stimulating hormone,
which will be high due to a lack of negative feedback. A second blood test is needed to measure the level of the thyroid
hormone T4 that is not bound by protein (free). A low level confirms the diagnosis of hypothyroidism.
Question #95
QID: 16127
Topic: Hypothyroidism
Subject: Medicine
A 35-year-old woman comes to the physician because of palpitations, restlessness, sweating, weight loss, and a tremor for
the past 6 weeks. Examination shows a fine tremor, lid lag and stare, and pretibial myxedema. The thyroid gland is
diffusely enlarged, asymmetric, and lobular. A bruit is present over the gland. Laboratory studies show an undetectable
level of thyroid-stimulating hormone, an increased level of thyroid hormones, and an increased radioactive iodine uptake.
The diagnosis of Graves' disease is made and the treatment options are discussed. The patient selects radioactive iodine
therapy.
This
a)
b)
c)
d)
patient
is
at
greatest
risk
for
which
of
the
following
conditions?
Granulocytopenia
Hypothyroidism
Recurrent laryngeal nerve damage
Thyroid carcinoma
The correct answer is b)
Explanation:
Hypothyroidism is the main complication of radioactive iodine therapy, affecting up to 70% of patients in 10 years.
Radioactive iodine therapy is a safe and effective treatment for Graves' disease because it can provide the same ablative
effects of surgery without the surgical complications. There is no evidence that this treatment increases the risk for
carcinoma.
Question #96
QID: 16171
Topic: Hypothyroidism
Subject: Medicine
A 58-year-old woman is scheduled for an abdominal operation. She has hypothyroidism that is controlled with thyroid
replacement medication and will be unable to eat or drink for 4 days following the procedure. She is concerned about
receiving
her
thyroid
medication.
She
a)
b)
c)
d)
e)
should
be
advised
of
which
of
the
following?
Although she will have symptoms of hypothyroidism, she will not be given the medication
Although she will not receive the medication, she will have no adverse effects
The medication will be administered daily while the nasogastric tube is clamped
The medication will be discontinued temporarily before the operation
She will receive the medication intravenously
The correct answer is b)
Explanation:
Thyroxine is the hormone of choice for replacement therapy. It has a half-life of seven days, and any alteration in dose is
not reflected for four to six weeks. Therefore, it is very unlikely that she will develop signs and symptoms of
hypothyroidism. She will not be given the medication either through the nasogastric tube or intravenously, nor does she
require a preoperative loading dose.
Question #97
QID: 17603
Topic: Hypothyroidism
Subject: Medicine
A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central hypothyroidism secondary to a pituitary
adenoma. The nurse practitioner in your office orders a TSH level, which is found to be 0.1 mIU/mL (N 0.5-5.0). Which
one of the following would you recommend?
a) Decrease the dosage of levothyroxine
b) Increase the dosage of levothyroxine
c) Order a free T4 level
d) Order a TRH stimulation test
e) Repeat the TSH level in 3 months
The correct answer is c)
Explanation:
Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory findings are a
low serum free T4 and a low TSH. A free T4 level is needed to evaluate the proper dosage of replacement therapy in
secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in this case,
and the low level would prevent the physician from determining whether the dosage of levothyroxine is appropriate. In the
initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to
stimulation. It is not necessary in this case, since the diagnosis has already been made.
Question #98
QID: 17704
Topic: Hypothyroidism
Subject: Medicine
A 67-year-old female presents with progressive weakness, dry skin, lethargy, slow speech, and eyelid edema. Of the
following medications currently taken by this patient, which one is most likely to be causing her symptoms?
a) Donepezil (Aricept)
b) Lithium
c) Lisinopril (Prinivil, Zestril)
d) Alendronate (Fosamax)
e) Glyburide (DiaBeta, Micronase)
The correct answer is b)
Explanation:
This patient has classic signs of hypothyroidism. Of the drugs listed, only lithium is associated with the development of
hypothyroidism. In patients taking lithium, it is recommended that in addition to regular serum lithium levels, thyroid
function tests including total free T , and TSH be obtained yearly.
Question #99
QID: 18053
Topic: Hypothyroidism
Subject: Medicine
An asymptomatic 55-year-old male visits a health fair, where he has a panel of blood tests done. He brings the results to
you because he is concerned about the TSH level of 12.0 mU/L. His free T4 level is normal.
Which one of the following is most likely to be associated with this finding?
a) Atrial fibrillation
b) Reduced bone density
c) Systolic heart failure
d) Elevated LDL cholesterol
e) Type 2 diabetes mellitus
The correct answer is d)
Explanation:
With subclinical thyroid dysfunction, TSH is either below or above the normal range, free T4 or T3 levels are normal, and
the patient has no symptoms of thyroid disease. Subclinical hypothyroidism (TSH > 10 mU/L) is likely to progress to
overt hypothyroidism. Patients with a serum thyroid-stimulating hormone level greater than 10 mU/L have a higher
incidence
of
elevated
serum
low-density
lipoprotein
cholesterol
concentrations.
Subclinical hyperthyroidism (TSH < 0.1 mU/L) is associated with the development of atrial fibrillation, decreased bone
density, and cardiac dysfunction. Neither type of subclinical thyroid dysfunction is associated with diabetes mellitus.
There is insufficient evidence of benefit to warrant early treatment of either condition.
Question #100
QID: 15773
Topic: Amnesia
Subject: Medicine
Which
a)
b)
c)
d)
of
the
following
medications
may
cause
amnesia
as
a
side
effect?
Hydroxyzine
Fluoxetine
Triazolam
Clonidine
The correct answer is c)
Explanation:
Triazolam is a benzodiazepine medications used for sleep disorders. It can be addictive if used improperly. This
medication can cause sedation and, because of this, use of triazolam by seniors can contribute to falls and accidents and
cause confusion and amnesia.
Question #101
QID: 15471
Topic: Seizure
Subject: Medicine
A patient is on carbamazepine for his new onset seizures. He has now had 3 attacks in last 2 weeks. His serum level of
carbamazepine
is
within
the
therapeutic
range.
What
a)
b)
c)
d)
e)
is
the
next
step
in
management?
Repeat CT scan and EEG
Add another agent (eg. Phenytoin)
Re-check carbamazepine level in 2 weeks
Check CBC, CMP and TSH/FT4
Observe. No action is necessary at this point.
The correct answer is b)
Explanation:
This patient has already been diagnosed with a seizure disorder. He has been placed on carbamazepine and is currently at
a therapeutic level. But his seizures are not controlled. At this time another medication should be added. Choices include
phenytoin
and
valproic
acid.
>
A
repeat
CT
and
EEG
is
not
needed
at
this
time.
> His carbamazepine level is therapeutic yet he still has seizures so obtaining a repeat level is not correct.
> Although lab tests may be necessary, it is not the best choice at this time.
Question #102
QID: 16891
Topic: Seizure
Subject: Medicine
Of
a)
b)
c)
d)
e)
the
following,
which
is
the
most
frequent
cause
of
seizures
in
the
elderly?
Alcohol withdrawal
Stroke
Head trauma
Hypoglycemia
Dementia
The correct answer is b)
Explanation:
The conditions listed are all causes of seizures. Of course, there are many other causes of seizures in the elderly, including
primary and metastatic neoplasias (e.g., electrolyte disorders). However, in the geriatric population, cerebrovascular
disease is the most common cause of seizures, with about 10% of stroke victims developing epileptic seizures. Seizures
are more common following hemorrhagic strokes compared to nonhemorrhagic strokes.
Question #103
QID: 17200
Topic: Seizure
Subject: Medicine
A 36-year-old male with a history of a seizure disorder is brought to the emergency department with generalized tonicclonic activity. Emergency medical personnel report this has been ongoing for 20 minutes.
After initial resuscitative measures, the preferred medication in this situation is:
a) Phenytoin (Dilantin)
b) Fosphenytoin (Cerebyx)
c) Naloxone
d) Lorazepam (Ativan)
e) Valproate sodium (Depacon)
The correct answer is d)
Explanation:
This patient presents in status epilepticus (SE). Although diazepam has long been an effective treatment, lorazepam has
emerged as the preferred agent because of pharmacologic properties that should give it a longer duration of action than
diazepam.
→ Phenytoin and fosphenytoin are limited by potentially serious adverse effects, such as hypotension.
→ Intravenous valproic acid has been shown in a pilot study to be equal to or better than phenytoin in aborting
generalized
SE,
and
it
has
been
used
in
some
cases
of
focal
status
epilepticus
→ In some settings where drug intoxication might be likely, consider also adding naloxone.
Note: Suspect subtle status epilepticus or transformed status epilepticus in any patient who does not have improving level
of consciousness within 20-30 minutes of cessation of generalized seizure activity.
Question #104
QID: 17534
Topic: Seizure
Subject: Medicine
A 52-year-old male with a history of seizure attacks suffered from loss of consciousness and tonic-clonic muscular
contractions.
His
tongue
fell
back
into
his
throat
and
he
choked.
What is the medication of choice for the treatment of this patient's condition?
a) Phenytoin
b) Valproic acid
c) Tiagabine
d) Phenobarbital
e) Carbamazepine
The correct answer is b)
Explanation:
Valproic acid is considered the agent of first choice for the treatment of grandmal (tonic-clonic) seizures. It increases the
levels of GABA by affecting the potassium channels and also creates direct membrane stabilizing effect. Since it acts
through GABA it is the best medication for grandmal seizures with fewer side effects. It is administered orally with a dose
of 1000-3000 mg in divided doses. Medication should be taken with food to reduce the GI upset.
→ Phenytoin (choice A), followed by topiramate, carbamazepine (choice E), and zonisamide are suitable alternatives.
→ Tiagabine (choice C) is a weak medication for the treatment of grandmal seizure and it is effective for the treatment of
petitmal
seizures.
→ Phenobarbital (choice D) is also not the choice of medication for grandmal seizure but it is a good choice for status
epilepticus.
Question #105
QID: 17537
Topic: Seizure
Subject: Medicine
A 68-year-old man with a history of urolithiasis, suffered from a seizure attack which involved loss of consciousness with
tonic and clonic muscular contractions. His tongue fell back into his throat and he choked.
Which of the following medications is contraindicated in this patient's treatment?
a) Levetiracetam
b) Phenytoin
c) Topiramate
d) Carbamazepine
e) Valproic acid
The correct answer is c)
Explanation:
This patient suffers from tonic-clonic seizures (formerly known as grand mal seizures), which is characterized by sudden
loss
of
the
consciousness
followed
by
tonic
and
clonic
muscular
contractions.
Patients with a history of kidney stones or those taking high-dose vitamin C or calcium supplementation should not
take Topiramate because
of
the
increased
risk
of
kidney
stones.
→ Valproic acid is considered the agent of first choice for the treatment of grandmal (tonic-clonic) seizures.
→ Phenytoin and carbamazepine are reasonable second options among the older group of medications, but the newer
medications tend to work equally well if not better and have better side effect profiles, especially long-term side effect.
→ Levetiracetam is indicated for primary generalized tonic-clonic seizures in adults and children aged 6 years or older, as
well as for use in juvenile myoclonic epilepsy and for partial seizures.
Question #106
QID: 17878
Topic: Seizure
Subject: Medicine
A 32-year-old female experiences an episode of unresponsiveness associated with jerking movements of her arms and
legs. Which one of the following presentations would make a diagnosis of true seizure more likely?
a) Post-event confusion
b) Eye closure during the event
c) A history of fibromyalgia
d) A history of chronic back pain
e) A normal serum prolactin level after the event
The correct answer is a)
Explanation:
Up to 20% of patients diagnosed with epilepsy actually have pseudoseizures. Eye closure throughout the event is
uncommon in true seizures, and a history of fibromyalgia or chronic pain syndrome is predictive of pseudoseizures. If
obtained within 20 minutes of the event, a serum prolactin level may be useful in differentiating a true seizure from a
pseudoseizure. An elevated level has a sensitivity of 60% for generalized tonic-clonic seizures and 46% for complex
partial seizures. Other features suggestive of seizure activity include tongue biting, the presence of an aura, postictal
confusion, and focal neurologic signs.
Question #107
QID: 15476
Topic: Tapeworms
Subject: Medicine
Which
a)
b)
c)
d)
of
the
following
that
infect
humans
have
an
intermediate
host?
B. fragilis
S. epidermidis
Spirochetes
Tapeworm
The correct answer is d)
Explanation:
All tapeworms (cestodes) cycle through 3 stage: eggs, larvae, and adults. Adults inhabit the intestines of
definitive hosts, mammalian carnivores. Several of the adult tapeworms that infect humans are named after
their intermediate host: the fish tapeworm (Diphyllobothrium latum), the beef tapeworm (Taenia saginata), and
the
pork
tapeworm
(Taenia
solium).
The other answer choices are found in humans. Bacteroides fragilis in the large intestine. Staphylococcus
epidermidis on the skin and Spirochetes in the mouth.
Question #108
QID: 15477
Topic: Tuberculosis
Subject: Medicine
A patient with history of occupational exposure (worked in a silica mine) 20 years back, now presents with 6 month
history of cough and weight loss. CXR shows infiltrates and fibrosis in the upper lobes.
What
a)
b)
c)
d)
is
the
most
likely
diagnosis?
Pneumonia
Tuberculosis
Mesothelioma
Rapidly progressive silicosis
The correct answer is b)
Explanation:
Pulmonary tuberculosis is associated with silica dust exposure as an occupational disease. It is caused by Mycobacterium
tuberculosis in employees who have been exposed to crystalline silica dust in the workplace.
Symptoms include cough, hemoptysis, fever, chills and weight loss. Diagnosis is made by sputum cultures and CXR.
Treatment is usually with a combination of medicines such as Isoniazid, Rifampin, Ethambutol and Pyrazinamide.
> Pneumonia would not be this long of a duration and would
>
Mesothelioma
usually
affects
the lower
lobes
> Rapidly progressive silicosis develops within 6 months of acute exposure.
not present with
with
pleural
weight loss.
thickening.
Question #109
QID: 16938
Topic: Tuberculosis
Subject: Medicine
A 55-year-old patient with a known history of chronic alcohol abuse presents to your office because he has been losing
weight, he always feels tired and he has been coughing. A physical examination reveals a temperature of 38.8˚C
(101.8˚F). Hepatomegaly is noted on abdominal palpation. A chest radiograph shows diffuse, well-defined nodules that
are less than 5 mm in diameter. Alfa-fetoprotein is within normal limit.
Which one of the following is the most likely diagnosis?
a) Bronchiectasis
b) Reactivation pulmonary tuberculosis
c) Primary pulmonary tuberculosis
d) Miliary tuberculosis
e) Hepatic carcinoma
The correct answer is d)
Explanation:
Diffuse small pulmonary nodules are characteristic of miliary tuberculosis (TB). This disease is seen commonly in those
who are immunosuppressed due to alcohol abuse. This patient's symptoms of weight loss, fatigue, and cough are very
common in these patients. The findings of nodules on chest X-ray and hepatomegaly suggest the patient's TB may have
multiple organs involvement. This is why miliary TB (choice D) is the best choice.
→ Bronchiectasis (choice A) may be a complication of endobronchial TB, but occurs late in the course
→ Reactivation pulmonary TB (choice B) may also be a complication and the radiograph typically shows localized
lesions.
→ Primary TB (choice C) usually consists of hilar adenopathy and a focal infiltrate (Ghon complex). Primary TB is
usually a mild process, but if it becomes severe it usually presents with extensive lobar consolidation rather than diffuse
nodules.
→ Hepatic carcinoma (choice E) could be a complication of chronic viral hepatitis or chronic alcohol abuse, however, in
the majority of patients it is preceded by cirrhosis and the fact alfa-fetoprotein is negative in this patient should steer us
away from this choice.
Question #110
QID: 15641
Topic: Ureterolithiasis
Subject: Medicine
A 55-year-old man presents to the hospital with the complaint of severe intermittent pain in his right lower back that
radiates
around
Which
one
a)
b)
c)
d)
e)
his
of
trunk
into
his
the
following
lower
is
quadrant
the
most
and
upper
likely
right
thigh.
diagnosis?
Hepatitis
Appendicitis
A ureteral stone
Pyelonephritis
Biliary obstruction
The correct answer is c)
Explanation:
Stones, especially tiny ones, may not cause any symptoms. Stones in the bladder may cause pain in the lower abdomen.
Stones that obstruct the ureter or renal pelvis or any of the kidney's drainage tubes may cause back pain or renal colic.
Renal colic is characterized by an excruciating intermittent pain, usually in the flank (the area between the ribs and hip),
that spreads across the abdomen, often to the genital area and inner thigh. The pain tends to come in waves, gradually
increasing to a peak intensity, then fading, over about 20 to 60 minutes. The pain may radiate down the abdomen toward
the
groin
or
testicle
or
vulva.
Other symptoms include nausea and vomiting, restlessness, sweating, and blood in the urine. A person may have an urge
to urinate frequently, particularly as a stone passes down the ureter. Chills, fever, and abdominal distention sometimes
occur.
Question #111
QID: 15486
Topic: Organophosphate poisoning
Subject: Medicine
What
a)
b)
c)
d)
is
the
mechanism
of
action
in
organophosphate
poisoning?
Cholinesterase inhibition
Cholinesterase activation
Catecholamine inhibition
Catecholamine activation
The correct answer is a)
Explanation:
Organophosphate compounds are a diverse group of chemicals used in both domestic and industrial settings. Examples of
organophosphates include: insecticides, nerve gases and herbicides. Nerve agents have also been used in battle, notably in
Iraq in the 1980s. Additionally, chemical weapons still pose a very real concern in this age of terrorist activity.
The primary mechanism of action of organophosphate pesticides is inhibition of acetylcholinesterase (AChE). AChE is an
enzyme that degrades the neurotransmitter acetylcholine (ACh) into choline and acetic acid. ACh is found in the central
and
peripheral
nervous
system,
neuromuscular
junctions,
and
red
blood
cells
(RBCs).
Organophosphates inactivate AChE by phosphorylating the serine hydroxyl group located at the active site of AChE. This
leads to an increase in the amount of Acetylcholine in the body and a wide variety of reactions.
Organophosphate Poisoning
Question #112
QID: 15487
Topic: Hemochromatosis
Subject: Medicine
A 42-year-old man presents with dark skin (skin hyperpigmentation) and a palpable liver. His father died of cirrhosis.
What is the most likely diagnosis?
a) Wilson disease
b) Hemochromatosis
c) Diabetes mellitus
d) Hepatic cirrhosis
The correct answer is b)
Explanation:
Hemochromatosis is an inherited disorder characterized by excessive iron accumulation causing tissue damage.
Symptoms do not develop until organ damage, often irreversible, develops. Symptoms include fatigue, hepatomegaly,
bronze skin pigmentation, loss of libido, arthalgias, and manifestations of cirrhosis, diabetes, or cardiomyopathy.
90% of patients will present with excessive skin pigmentation. Diagnostic testing will reveal that the serum iron is
increased (> 300 mg/dL). Phlebotomy is the simplest method of excess iron removal in most cases.
The other choices would not typically present with dark skin pigmentation.
Question #113
QID: 15793
Topic: Hemochromatosis
Subject: Medicine
A 42-year-old man presents with fatigue and joint pain. On physical exam he is found to have dark skin and a palpable
liver.
His
urine
shows
glucosuria.
Which
a)
b)
c)
d)
of
Ferritin level
Ceruloplasmin
Alpha-trypsine
Hb Electrophoresis
the
following
will
help
you
in
the
diagnosis?
The correct answer is a)
Explanation:
Primary hemochromatosis is an inherited disorder characterized by excessive iron accumulation causing tissue damage.
Symptoms do not develop until organ damage, often irreversible, develops. Symptoms include fatigue, hepatomegaly,
bronze skin pigmentation, loss of libido, arthralgias, and manifestations of cirrhosis, diabetes, or cardiomyopathy.
Diagnosis is based on serum iron studies and gene assay. Treatment is with serial phlebotomies.
Because iron accumulates in multiple sites, symptoms can develop referable to many possible organs or systemically. In
women, fatigue and nonspecific constitutional symptoms develop early; in men, cirrhosis or diabetes is often the initial
presentation.
Serum iron is increased (> 300 mg/dL). Serum transferrin saturation is usually > 50% and often > 90%. Serum ferritin is
increased.
Question #114
QID: 15825
Topic: Hemochromatosis
Subject: Medicine
A 50-year-old man with a history of hemochromatosis presents to the emergency room vomiting up bright red blood. He
had his most recent phlebotomy yesterday. His blood pressure is 110/85 mmHg, his pulse 115 beats per minute; his face is
flushed, and he is diaphoretic. During the physical examination, splenomegaly and a venous pattern on his chest and
abdomen are noted. He seems somewhat drowsy and confused but has no focal neurologic signs.
What
is
the
most
likely
cause
of
this
patient's
bleeding?
a)
b)
c)
d)
e)
Portal hypertension
Hemoglobin deficiency
Gastric ulcer
Bronchogenic carcinoma
Factor VIII deficiency
The correct answer is a)
Explanation:
Long term complications of hemochromatosis include liver cirrhosis. Portal hypertension is caused most often by cirrhosis
(in developed countries), schistosomiasis (in endemic areas), or hepatic vascular abnormalities. Consequences include
esophageal
varices
and
portal-systemic
encephalopathy.
Portal hypertension is asymptomatic; symptoms and signs result from its complications. The most dangerous is acute
esophageal variceal bleeding. Patients typically present with sudden painless upper GI bleeding, often massive. Bleeding
from portal hypertensive gastropathy is often subacute or chronic. Ascites, splenomegaly, or portal-systemic
encephalopathy
may
be
present.
Portal hypertension is inferred in a patient with chronic liver disease by the presence of collateral circulation,
splenomegaly, ascites, or portal-systemic encephalopathy. Proof requires direct portal pressure measurement by a
transjugular catheter, which is invasive and usually not performed. Imaging may help when cirrhosis is suspected.
Ultrasound or CT often reveals dilated intra-abdominal collaterals, and Doppler ultrasound can determine portal vein
patency
and
flow.
Diagnosis is based on clinical criteria, often in conjunction with imaging studies and endoscopy. Treatment involves
prevention of GI bleeding with endoscopy, drugs, or both, and sometimes with portocaval shunting.
Question #115
QID: 17276
Topic: Hemochromatosis
Subject: Medicine
Which one of the following is the best initial screening test for hemochromatosis?
a) Total iron binding capacity
b) Hemoglobin electrophoresis
c) Serum iron concentration
d) Serum ferritin concentration
e) Serum transferrin saturation
The correct answer is e)
Explanation:
The diagnosis of hereditary hemochromatosis is based on a combination of clinical, laboratory, and pathologic criteria,
including elevated serum transferrin saturation and elevated serum ferritin concentration. Elevated serum transferrin
saturation is the earliest phenotypic abnormality. While this is the best initial screening test, results may be normal early in
the course of the disease. In addition, because serum iron concentrations vary throughout the day and measurements may
be affected by the ingestion of food, a test showing elevated serum transferrin saturation should be repeated as a fasting
early-morning determination. Furthermore, the serum ferritin concentration and serum transferrin saturation may be
elevated in 30%-50% of patients with acute or chronic viral hepatitis or alcoholic liver disease.
Serum ferritin concentration is a sensitive measure of iron overload, but it is also an acute-phase reactant and is therefore
elevated in a variety of infectious and inflammatory conditions in the absence of iron overload. Consequently, it should
not be used as the initial screening test to detect hereditary hemochromatosis.
Question #116
QID: 18049
Topic: Hemochromatosis
Subject: Medicine
Currently, which one of the following is the best screening test for hereditary hemochromatosis?
a) Serum iron
b) Serum transferrin saturation
c) Serum alkaline phosphatase
d) Serum ALT (SGPT)
e) HFE gene testing
The correct answer is b)
Explanation:
The best screening test for hereditary hemochromatosis is serum transferrin saturation, which is the calculated ratio of
serum iron to total serum iron-binding capacity. An elevated serum transferring saturation is usually the earliest
phenotypic expression of the disease, with a sensitivity for iron overload of 94%-98%, and a specificity of 70%-98%. In
the Caucasian population these values translate into a positive predictive value of approximately 20% and a negative
predictive value of 99.9%. Elevated serum ferritin generally occurs later in the course of iron overload than does elevated
transferrin saturation and liver enzymes become elevated only after liver toxicity has occurred. HFE gene testing is now
available, but its higher cost currently precludes using it as a screening tool, and not all cases of hereditary
hemochromatosis result from the same mutation.
Question #117
QID: 18226
Topic: Hemochromatosis
Subject: Medicine
A 42-year-old male presents with complaints of painful wrist joints and knee joints. He says that he began to feel
discomfort 2 months ago but it has gotten progressively worse in the past week. He also says that he noticed he looks like
someone who has been “sun tanning” although he is an office worker and spends most of the time indoors. His past
medical history is only significant for glucose intolerance found 1 year ago that he has been managing with lifestyle
modifications; however as he puts it "the joint pains are making it hard for him to exercise." Family history reveals a
father who died of heart disease at the age of 57 and had a long history of diabetes. The patient has a 65-year-old mother
who is healthy.
Physical examination reveals hyperpigmentation of skin and pain on palpation of the proximal interphalangeal joints,
wrist joints and knee joints. Imaging studies and laboratory studies are ordered. Which of the following is the most
important step in management of this patient?
a) Ibuprofen
b) ACTH inhibitors
c) Colchicine
d) Phlebotomy
e) Metyrapone
The correct answer is d)
Explanation:
Based on the patient’s history of glucose intolerance, hyperpigmentation of skin, arthropathy, and family history of heart
disease, hereditary hemochromatosis which is known to cause “bronze diabetes” should be considered as the likely
diagnosis. Hemochromatosis is an autosomal recessive genetic disorder characterized by iron overload and accumulation
in parenchymal organs. While as many as 75% of patients are asymptomatic, those with symptoms often present with skin
bronzing, diabetes mellitus, cardiomyopathy, liver disease, and infertility. Transferrin saturation which is the ratio of
serum iron and total iron-binding capacity suggests the diagnosis. It may be confirmed by liver biopsy and genotypic
investigation
for
HFE
mutations
on
chromosome
6.
Management of this condition consists of removal of accumulated iron via phlebotomy (choice D) or, rarely, iron
chelation and reducing iron absorption by dietary limitations. Phlebotomy continues for life based on ferritin levels.
→ Ibuprofen (choice A) is a NSAID that may be used to treat osteoarthritis and other arthropathies. It is important to
acknowledge that arthropathy in this patient is due to iron overload and management should focus on the cause.
→ ACTH inhibitors such as pasireotide (choice B) are approved for treating Cushing’s syndrome. While Cushing
syndrome increases the risks of insulin resistance and developing diabetes and is associated with hyperpigmentation, this
patient’s
family
history
and
arthropathy
suggest
hereditary
hemochromatosis.
→ Colchicine (choice C) may be used in hemochromatosis patients who have had recurrent acute episodes of joint
involvement; however, this is not the initial treatment once hemochromatosis is confirmed. Phlebotomy should be done
first
to
decrease
iron
stores.
→ Metyrapone (choice E) blocks 11-beta-hydroxylase activity, the final step in cortisol synthesis and is used in the
treatment of Cushing’s syndrome, it is not appropriate as initial management of this patient.
Key point:
Hereditary hemochromatosis is characterized by iron overload and deposition of iron in different organs of the body. This
may result in diabetes due to pancreatic islet cell failure, liver disease, dilated cardiomyopathy, and arthropathy. The
initial treatment is phlebotomy.
Question #118
QID: 18245
Topic: Hemochromatosis
Subject: Medicine
A 40-year-old white male presents to your department with concerns of darkening of the skin recently. He denies pain
anywhere in his body but reports of being unusually thirsty and urinating more often, including waking up a couple of
times at night to urinate. His father died of cirrhosis at the age of 50 and his mother died of lung cancer.
On physical examination you note skin hyperpigmentation and an enlarged liver. Which of the following is the most likely
diagnosis?
a)
b)
c)
d)
e)
Cushing’s syndrome
Porphyria cutanea tarda
Primary biliary cirrhosis
Hemochromatosis
Wilson’s disease
The correct answer is d)
Explanation:
This patient is presenting with skin hyperpigmentation, polyuria, polydipsia, and hepatomegaly on physical examination.
By combining this patient’s history of present illness and his family history of a father who died of liver cirrhosis, the
most likely diagnosis is bronze diabetes from hemochromatosis (choice D). This is an autosomal recessive genetic
disorder characterized by accumulation of iron in parenchymal organs. Other common symptoms are fatigue, impotence,
arthralgia, and symptoms related to cardiomyopathy. Definitive diagnosis is made when laboratory studies of transferrin
saturation, serum ferritin, and the HFE gene mutation for hemochromatosis are done. Skin and liver biopsy can also be
done for diagnosis but currently, genetic testing is considered enough to reach the final diagnosis.
→ Cushing’s syndrome (choice A) is caused by prolonged exposure to elevated levels of either endogenous
glucocorticoids or exogenous glucocorticoids. It may cause skin hyperpigmentation, diabetes, infertility, and impotence,
which are also seen in hemochromatosis; however, it is not known to cause hepatomegaly and is not a hereditary disease.
→ Porphyria cutanea tarda (choice B) is a familial disorder characterized by uroporphyrinogen decarboxylase deficiency.
Patients with this disease present with cutaneous fragility and blistering, sunlight exposure often plays a role in the
appearance
of
skin
lesions.
→ Primary biliary cirrhosis (choice C) is an autoimmune disease that leads to progressive cholestasis and often end-stage
liver disease. While it may present with hyperpigmentation in 25% of patients or hepatomegaly in 25% of patients, the
most common symptom is pruritus in 60% of patients due to hyperbilirubinemia. Sicca symptoms (dry mucosa) are also
found
in
50%
to
75%
of
patients.
→ Wilson’s disease (choice E) is an autosomal recessive inherited disorder of copper metabolism that is characterized by
excessive deposition of copper in the liver. Kayser-Fleischer rings are seen in at least 98% of symptomatic patients who
have not received chelation therapy. Frequent early symptoms include difficulty speaking, excessive salivation, ataxia,
mask-like facies, clumsiness with the hands, and personality changes.
Key point:
Hemochromatosis is an autosomal recessive genetic disorder characterized by accumulation of iron in parenchymal
organs. It may present with hyperpigmentation, arthralgia, impotence, and diabetes.
Question #119
QID: 15493
Topic: Renal cell carcinoma
Subject: Medicine
A 50-year-old-man develops hematuria. He is found to have a mass in the kidney which has an increased blood supply.
What
a)
b)
c)
d)
is
the
most
likely
cause?
Medication side effect
Infection
Nephrolithiasis
Renal cell carcinoma
The correct answer is d)
Explanation:
Renal cell carcinoma is the most common renal cancer. Symptoms appear late and include hematuria, flank pain, a
palpable mass, and fever. Diagnosis is by CT or MRI and occasionally by biopsy. Treatment is with surgery. Infection,
stones and drugs are all causes of hematuria, but are unlikely to show a mass with increased blood supply.
Question #120
QID: 15498
Topic: Venous ulcers
Subject: Medicine
An elderly woman develops a stasis ulcer on her lower extremity that causes pigmentary changes. See picture:
The
a)
b)
c)
d)
most
appropriate
intervention
in
the
prevention
and
treatment
of
this
condition
is:
Pneumatic stockings
Stripping saphenous vein
Topical antibiotics
Anticoagulants
The correct answer is a)
Explanation:
Venous ulcers form when blood flow through the legs is reduced, causing blood to pool in the leg veins. Then, pressure
increases in the veins and capillaries (tiny blood vessels that connect arteries and veins). The increased pressure causes
fluid
to
leak
from
the
blood
vessels
into
surrounding
tissue,
and
swelling
develops.
If venous ulcers result from chronic venous insufficiency, the legs are swollen, and the skin is dark reddish brown and
very firm (a condition called stasis dermatitis). The skin may itch, and the ulcers are usually very painful.
The goals of prevention and treatment are to reduce leg swelling and reduce the pressure in veins. If swelling is reduced
enough, a venous ulcer may never form or may heal on its own. Often, specially designed bandages and pneumatic
(compression)
stockings
help
reduce
swelling.
If cellulitis or signs of an infection of deeper tissues (such as pus) are present, antibiotics are taken by mouth or given
intravenously. Drugs, such as nonprescription antibiotics, should not be applied directly to the skin of the leg. These drugs
can cause allergic reactions that worsen the problem, particularly when the skin is cracked or there is an open sore.
Question #121
QID: 16343
Topic: Pneumothorax
Subject: Medicine
Tension
a) Stat CT scan
b) Chest x-ray
c) Watch and wait
pneumothorax
is
best
diagnosed
with:
d) Clinical exam
e) None of the above
The correct answer is d)
Explanation:
Tension pneumothorax is a pneumothorax causing progressive rise in intrapleural pressure to levels that become positive
throughout the respiratory cycle and collapse the lung, shift the mediastinum, and impair venous return to the heart. Air
continues to get into the pleural space but cannot exit. Without proper treatment, the impaired venous return can cause
systemic
hypotension
and
respiratory
and
cardiac
arrest
within
minutes.
Tension pneumothorax most commonly occurs in patients receiving positive-pressure mechanical ventilation (particularly
during resuscitation). It is rarely a complication of traumatic pneumothorax, when a chest wound acts as a one-way valve
that
traps
increasing
volumes
of
air
in
the
pleural
space
with
inspiration.
Tension pneumothorax is diagnosed clinically with hypertympany on the side of the lesion, deviation of the trachea away
from the lesion, and decreased breath sounds on the affected side. There is usually associated elevated jugular venous
pressure in the neck veins. This is a clinical diagnosis, and once made an immediate needle thoracostomy or tube
thoracostomy should be performed to relieve the tension pneumothorax.
Pneumothorax
Question #122
QID: 16453
Topic: Pneumothorax
Subject: Medicine
A 35-year-old male consults you about a vague chest pain he developed while sitting at his desk earlier in the day. The
pain is right-sided and was sharp for a brief time when it began, but it rapidly subsided. There was no hemoptysis and the
pain does not seem pleuritic. His physical examination, EKG, and oxygen saturation are unremarkable. A chest film
shows
a
10%
right
pneumothorax.
Which
a)
b)
c)
d)
e)
one
of
the
following
is
true
in
this
situation?
He is likely to be an overweight smoker with a chronic cough
Rupture of subpleural bullae would be an unlikely cause of his problem
Outpatient observation with a repeat chest radiograph in 24 hours is indicated
A chest tube should be placed expeditiously
After treatment his probability of recurrence is less than 15%
The correct answer is c)
Explanation:
The majority of patients presenting with spontaneous pneumothorax are tall, thin individuals under 40 years of age. Most
do not have clinically apparent lung disease, and the chest pain is sometimes minimal at onset and may resolve within 24
hours even if untreated. Patients with small pneumothorax involving less than 15% of the hemithorax may have a normal
physical examination, although tachycardia is occasionally noted. The diagnosis is confirmed by chest radiographs.
Studies of recurrence have found that an average of 30% of patients will have a recurrence within 6 months to 2 years.
The treatment of an initial pneumothorax of less than 20% may be monitored if a patient has few symptoms. Follow-up
should include a chest radiograph to assess stability at 24-48 hours. Indications for treatment include progression, delayed
expansion, or the development of symptoms. The majority of patients with spontaneous pneumothoraces, and perhaps
almost all of them, will have subpleural bullae on a CT scan.
Pneumothorax
Question #123
QID: 17561
Topic: Pneumothorax
Subject: Medicine
A 40-year-old male developed acute respiratory distress syndrome after a severe attack of pancreatitis. He was admitted to
the ICU, intubated and ventilated with PEEP (Positive end-expiratory pressure) of 14 cm water, and FiO2 of 70%.
Suddenly, his pulse increases from 90 to 150/min; systolic blood pressure drops from 120 to 60 mm Hg; central venous
pressure increases from 20 to 50cm water. Physical exam shows tracheal deviation to the left side and absent breath
sounds
on
the
right
side.
JVD
is
noted.
What is the most appropriate next step in management?
a) Chest tube
b) Chest X-ray
c) EKG, CPK MB and Troponin
d) IV heparin
e) Needle thoracostomy
The correct answer is e)
Explanation:
Tension pneumothorax is not an uncommon complication of mechanical ventilation when high PEEP is used. This occurs
due
to
barotrauma.
Tracheal
The
deviation
patient
is
+
dying.
absent
There
breath
is
no
sounds
time
for
+
hypotension
diagnostic
tests.
and
JVD
Needle
A chest tube placement is appropriate after needle decompression of the pleural space.
Question #124
QID: 17691
Topic: Pneumothorax
=
Tension
thoracentesis
pneumothorax.
is
life
saving.
Subject: Medicine
A 25-year-old male comes to the emergency department with the sudden onset of moderate to severe right-sided chest
pain and mild dyspnea. Vital signs are normal. A chest film shows a loss of markings along the right lung margins,
involving about 10%-15% of the lung space. The mediastinum has not shifted. The best INITIAL treatment would be:
a) strict bed rest
b) oxygen supplementation and close observation
c) decompression of the chest by insertion of a large-bore intravenous catheter into the right second intercostal space at
the midclavicular line
d) immediate chest tube insertion using a water seal
e) thoracotomy for wedge resection of pulmonary blebs
The correct answer is b)
Explanation:
A small spontaneous pneumothorax involving less than 15%-20% of lung volume can be managed by administering
oxygen and observing the patient. The pneumothorax will usually resorb in about 10 days if no ongoing air leak is present.
Oxygen lowers the pressure gradient for nitrogen and favors transfer of gas from the pleural space to the capillaries.
Decompression with anterior placement of an intravenous catheter is usually reserved for tension pneumothorax. Chest
tube placement is used if observation is not successful or for larger pneumothoraces. Strict bed rest is not indicated.
Question #125
QID: 18249
Topic: Pneumothorax
Subject: Medicine
A 69-year-old male presents to the emergency department with complaints of suddenly increased shortness of breath. He
was diagnosed with COPD 10 years ago. His medications are tiotropium, formoterol, and albuterol. Usually when he is
short of breath he uses albuterol, which alleviates the symptoms. However, "it has not helped much this time." He has
smoked
40
packs
of
cigarettes
a
year
for
the
last
45
years.
On physical examination he has hyperresonance to percussion and decreased breath sounds on auscultation at the right
side. His oxygen saturation is 87%. Which of the following is the most appropriate next step in management?
a)
b)
c)
d)
e)
Albuterol inhaler, ipratropium, and oral prednisone
Sputum cultures and initiation of azithromycin
Order chest radiograph
Intubation and mechanical ventilation with 100% oxygen
Oxygen administration at 3L/min nasal cannula
The correct answer is e)
Explanation:
This patient’s history of smoking and COPD, the presentation with shortness of breath, decreased breath sounds on the
right, and hyperresonance to percussion point to a diagnosis of spontaneous pneumothorax. COPD is the most common
cause of secondary spontaneous pneumothorax accounting for 60% of cases on average. Rupture of apical blebs is the
usual cause. Out of the choices given, oxygen administration at 3L/min nasal cannula (choice E) is the most appropriate
initial step in management of this patient. Oxygen treats hypoxemia and is associated with a 4-fold increase in the rate of
pleural air absorption compared with room air alone. If the patient doesn't respond to oxygen supplementation, chest tube
placement would be the most appropriate next-in-line treatment.
→ Albuterol inhaler, ipratropium, and oral prednisone (choice A) would be appropriate for the management of COPD
exacerbation.
→ Sputum cultures and initiation of azithromycin (choice B) would be appropriate if community acquired pneumonia is
suspected.
This
patient’s
clinical
scenario
suggests
spontaneous
pneumothorax.
→ Order chest radiograph (choice C) should be part of the management plan of this patient’s condition, but oxygen
should
be
given
prior
to
imaging
investigations.
→ Intubation and mechanical ventilation with 100% oxygen (choice D) is incorrect. The appropriate initial oxygen
supplementation should be done by nasal cannula.
Key point:
Sudden increase of shortness of breath, unilateral decreased breath sounds on auscultation and hyperresonance to
percussion in a patient with COPD history is suggestive of spontaneous pneumothorax. Oxygen supplementation (through
a nasal cannula) is an appropriate initial treatment of spontaneous pneumothorax.
Question #126
QID: 18430
Topic: Pneumothorax
Subject: Medicine
You are called to the bedside of a 72-year-old female on mechanical ventilation for three days, who suddenly develops
chest pain. Her face is contorted in pain, and she points to her chest. She has a 40-pack/year history of smoking, and long
standing COPD. Vital signs show blood pressure of 85/55 mmHg, heart rate of 120 beats per minute, respiratory rate of 24
breaths per minute, and oxygen saturation of 80% with an FiO2 of 40%. Physical exam reveals absent breath sounds over
the left side of the chest, and normal S1 and S2 heart sounds without any murmurs.
What is the next best step in the management of this patient?
a) Obtain a chest CT
b) Obtain a chest X-ray
c) Insert a chest tube in the left 5th intercostal space in the midaxillary line
d) Insert a large-bore needle into the left 2nd intercostal space
e) Insert a needle under the xiphoid process directed upward and to the patient's left
The correct answer is d)
Explanation:
A history of mechanical ventilation, especially in addition to underlying lung pathology, and a physical exam showing
absent breath sounds on one side of the chest suggests a diagnosis of tension pneumothorax. This patient is hypotensive,
tachycardic, and tachypneic, so this is a medical emergency. Before any other imaging or intervention is attempted, an
immediate needle thoracostomy performed by inserting a 16-18 gauge needle into the 2nd intercostal space (choice D) of
the affected side is required to treat this patient. Once this has been accomplished, a rush of air out of the pleural space is
expected. Following needle thoracostomy, a chest tube can be inserted, and chest C-ray can be performed.
→ Obtaining a chest CT (choice A) would be inappropriate at this time, as this patient is clinically unstable (hypotension,
tachypnea, tachycardia), and needs immediate treatment. In the context of a pneumothorax, a chest CT can be used if there
is
clinical
uncertainty,
and
the
patient
is
stable.
→ Obtaining a chest X-ray (choice B) does need to be done, but the first step is needle thoracostomy. Had a chest X-ray
been performed, it would have shown deviation of the trachea to the right (the side opposite of the pneumothorax), as well
as
increased
radiolucency
on
the
left
side
of
the
chest.
→ Inserting a chest tube into the 5th intercostal space in the midaxillary line (choice c) should be done after the initial
needle thoracostomy, as the needle decompression can cause a simple pneumothorax which can be treated with chest tube
insertion. When a chest tube is inserted, it should be inserted above the rib, as the neurovascular bundle can be struck if
insertion
occurs
below
the
rib.
→ Pericardiocentesis - inserting a needle under the xiphoid process, upward and leftward (choice E) is incorrect, as this
patient does not have cardiac tamponade. The diagnosis of tamponade would require hypotension, decreased heart sounds,
and distended neck veins, as well, lungs should be clear to auscultation, which are not seen in this patient.
Key point:
Sudden onset of chest pain and decreased or absent breath sounds on one side suggest tension pneumothorax. The first
step in treatment is insertion of a large-gauge needle into the second intercostal space of the affected side.
Question #127
QID: 15507
Topic: Deep Venous Thrombosis
Subject: Medicine
The
a)
b)
c)
d)
appropriate
initial
management
of
deep
venous
thrombosis
is
to:
Give heparin
Give warfarin
IVC filter
Pneumatic/compression stockings
The correct answer is a)
Explanation:
Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis.
DVT is the primary cause of pulmonary embolism (PE). DVT results from conditions that impair venous return, lead to
endothelial
injury
or
dysfunction,
or
cause
hypercoagulability.
DVT may be asymptomatic or cause pain and swelling in an extremity. Diagnosis is by history, physical examination, and
duplex
ultrasonography,
with
d-dimer
or
other
testing
as
necessary.
All patients with DVT are given anticoagulants, initially an injectable heparin (unfractionated or low molecular weight),
followed
by
warfarin.
An Inferior vena cava filter (IVCF) may help prevent PE in patients with lower extremity DVT and contraindications to
anticoagulants or with recurrent DVT (or emboli) despite adequate anticoagulation. Patients at higher risk of DVT should
have compression devices or stockings placed for prevention.
Question #128
QID: 16574
Topic: Deep Venous Thrombosis
Subject: Medicine
Which one of the following should be considered in geriatric patients when a long airline flight is planned?
a)
b)
c)
d)
e)
Hypoxia with desaturation
Temporal disorientation
Barotitis
Dehydration
Deep venous thrombosis
The correct answer is e)
Explanation:
“Coach class thrombosis”, deep venous thrombosis (choice E) or pulmonary embolism associated with cramped
conditions on long airline flights, is in fact a real phenomenon. However, the risk is small and only those already at
increased
risk
of
venous
thromboembolism
need
to
be
concerned
about
it.
The known complications of venous stasis must be avoided by the prophylactic use of ambulation and exercises during
long flights. Patients at increased risk or presently on antithrombotic medications must be carefully monitored prior to
their trip.
Question #129
QID: 16676
Topic: Deep Venous Thrombosis
Subject: Medicine
A 35-year-old black female has just returned home from a vacation in Hawaii. She presents to your office with a swollen
left lower extremity. She has no previous history of similar problems. Homan’s sign is positive, and ultrasonography
reveals
a
noncompressible
vein
in
the
left
popliteal
fossa
extending
distally.
Which
one
of
the
following
is
true
in
this
situation?
a) Monotherapy with an initial 10-mg loading dose of warfarin (Coumadin) would be appropriate
b) Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/k subcutaneously twice a day
c) The incidence of thrombocytopenia is the same with low-molecular-weight heparin as with unfractioned heparin
d) The dosage of warfarin should be adjusted to maintain the INR at 2.5-3.5
e) Anticoagulant therapy should be started as soon as possible and maintained for 1 year to prevent deep vein thrombosis
(DVT) recurrence
The correct answer is b)
Explanation:
The use of low-molecular-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as
outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patient chosen for outpatient care should have good
cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin
can
be
initiated
on
the
first
day
of
treatment
after
heparin
loading
is
completed.
Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low-molecular-weight heparin is
lower than with conventional heparin. The INR should be maintained at 2.0-3.0 in this patient. The 2.5-3.5 range is used
for patients with mechanical heart valves. The therapeutic INR should be maintained for 3-6 month in a patient with a first
DVT related to travel.
Question #130
QID: 17189
Topic: Deep Venous Thrombosis
Subject: Medicine
An otherwise healthy 62-year-old male has been hospitalized with community-acquired pneumonia for 2 days. He has
remained bedridden. When you see him while making rounds, he mentions that he has noticed increased swelling and pain
in his left lower extremity. Lower extremity ultrasonography reveals a deep venous thrombosis (DVT) in his calf. He has
no
previous
history
of
blood
clots.
Which
a)
b)
c)
d)
e)
one
of
the
following
is
the
best
management
of
this
patient’s
DVT?
Compression stockings and repeat ultrasonography in 2 days
Heparin therapy followed by oral anticoagulation for 3 months
Indefinite oral anticoagulation
Intravenous thrombolytic therapy
Insertion of an inferior vena cava filter
The correct answer is b)
Explanation:
Without anticoagulation, patients with an uncomplicated calf deep vein thrombosis (DVT) have a significant risk of
further clot extension, acute pulmonary embolus, or recurrence of the thrombus. They are also at risk for late
complications such as the post-thrombotic syndrome or chronic thromboembolic hypertension. For this reason, monitoring
a DVT by repeat ultrasonography is not a good option unless there are contraindications to anticoagulation, such as recent
surgery,
hemorrhagic
stroke,
active
bleeding,
or
heparin-induced
thrombocytopenia.
The recommended treatment for DVT is heparin (intravenous unfractionated or subcutaneous low molecular weight)
followed by oral anticoagulation with warfarin once adequate anticoagulation is achieved. For a first episode of DVT due
to an idiopathic cause or transient risk factor, such as short-term immobilization, the recommended length of treatment is
3-6 months. The benefit-to-risk ratio declines after 6 months unless the patient has a recurrent DVT or a known chronic
risk
factor,
such
as
a
thrombophilic
condition
or
cancer.
Thrombolytic therapy with intravenous tissue plasminogen activator (tPA), urokinase, or streptokinase typically is
reserved for patients with life-threatening pulmonary embolism. Inferior vena cava filters are used in patients who have a
contraindication to anticoagulant therapy, recurrent venous thromboembolism despite adequate anticoagulation, or such
limited pulmonary vascular reserve that they may not survive additional thromboemboli.
Question #131
QID: 17530
Topic: Deep Venous Thrombosis
Subject: Medicine
A 55-year-old male needs treatment for venous thromboembolic disease. What is the loading dose of unfractionated
heparin
to
be
administered
if
his
weight
is
75kg?
a)
b)
c)
d)
e)
4000 unit bolus given through IV
5000 unit bolus given through IV
3000 unit bolus given through IV
8000 unit bolus given through IV
6000 unit bolus given through IV
The correct answer is e)
Explanation:
Answer:
E
Initial
DVT
treatment
with
unfractionated
heparin
(UFH):
-requires bolus (80U/kg) followed by continuous IV infusion (18 U/kg/hr(APTT in 6 hrs.)
-weight-based
heparin
nomograms
help
to
achieve
proper
dosing
-advantages:
rapidly
reversible
by
protamine
in
case
of
bleeding
-disadvantages: must monitor aPTT with adjustment of dose to reach therapeutic level (~2x control value); monitor
platelet counts for development of thrombocytopenia.
Question #132
QID: 17808
Topic: Deep Venous Thrombosis
Subject: Medicine
You are treating a 53-year-old female for a deep-vein thrombosis in her left leg. The use of compression stockings for this
problem has been shown to:
a) Increase the risk of pulmonary embolism
b) Increase the level of pain
c) Increase complications if used prior to completion of a course of anticoagulation therapy
d) Decrease the risk of post-thrombotic syndrome
The correct answer is d)
Explanation:
Post-thrombotic syndrome (PTS) is a complication of acute deep-vein thrombosis (DVT), and is characterized by chronic
pain, swelling, and skin changes in the affected limb. Within 5 years of experiencing a DVT, one in three patients will
develop PTS. A Cochrane review identified three randomized, controlled trials examining the use of compression therapy
in patients diagnosed with a new DVT. The use of elastic compression stockings was associated with a highly statistically
significant reduction in the incidence of PTS, with an odds ratio of 0.31 (confidence interval of 0.20-0.48). A separate trial
cited in the Cochrane review documented no increased incidence of pulmonary embolism, and a reduction in pain and
swelling in the treatment group. The studies did not examine the rates of recurrent DVT. Compression stockings should be
started after anticoagulant therapy, within two weeks of the diagnosis, and continued for two years.
Question #133
QID: 17876
Topic: Deep Venous Thrombosis
Subject: Medicine
A 30-year-old female who had a deep venous thrombosis in her left leg during pregnancy has an uneventful delivery.
During the pregnancy she was treated with low molecular weight heparin. Just after delivery her left leg is pain free and is
not
swollen.
She
plans
to
resume
normal
activities
soon.
Which one of the following would be most appropriate with regard to anticoagulation?
a) Discontinuing treatment, with no further evaluation
b) Discontinuing treatment if venous Doppler ultrasonography is negative for thrombus
c) Continuing low molecular weight heparin for 6 more weeks
d) Switching to low-dose unfractionated heparin for 6 weeks
e) Switching to aspirin for 6 weeks
The correct answer is c)
Explanation:
The risk of pulmonary embolism continues in the postpartum period, and may actually increase during that time. For
patients who have had a deep-vein thrombosis during pregnancy, treatment should be continued for 6 weeks after
delivery, with either warfarin or low molecular weight heparin.
Question #134
QID: 18064
Topic: Deep Venous Thrombosis
Subject: Medicine
Risk factors for venous thromboembolism include which one of the following?
a) Anemia
b) The use of oral hypoglycemic agents
c) Being underweight
d) Young age
e) Spinal cord injury
The correct answer is e)
Explanation:
There are many risk factors for thromboembolism, including polycythemia vera, oral contraceptive use, obesity, advanced
age, and spinal cord injury. Spinal cord injury induces immobility, as do obesity and advanced age. Oral contraceptives
make blood more coagulable, particularly in patients with clotting factor abnormalities such as factor V Leiden.
Polycythemia vera increases sludging of blood cells and increases the risk of forming clots. Clot risk is not increased by
oral hypoglycemic agents, low BMI, youth, or anemia.
Question #135
QID: 18302
Topic: Deep Venous Thrombosis
Subject: Medicine
A 45-year-old woman comes to you after an episode of calf pain that began after arriving from a 16 hour flight. She is a
non-smoker with no relevant personal or family history, and takes no medications. Her vital signs are stable and you find
an area of erythema and induration on the affected leg. After a Doppler venous study of the lower limb you confirm the
diagnosis
of
Deep
Venous
Thrombosis.
What
would
be
the
preferred
management
in
this
patient?
a)
b)
c)
d)
e)
Inpatient management with compression stocking, Warfarin, and Unfractioned Heparin
Inpatient management with leg elevation, Unfractioned Heparin, and Warfarin
Inpatient management with compression stocking, Low Molecular Weight Heparin, and Warfarin
Outpatient management with compression stocking, Low Molecular weight Heparin, and Warfarin
Outpatient management with leg elevation, Low Molecular Weight Heparin, and Warfarin
The correct answer is d)
Explanation:
When any of the following is present, a patient should be managed on inpatient basis:
•
Presence
of
massive
DVT
(eg,
iliofemoral
DVT)
•
Presence
of
symptomatic
pulmonary
embolism
•
High
risk
of
bleeding
with
anticoagulant
therapy
•
Presence
of
comorbid
conditions
or
other
factors
that
warrant
in-hospital
care
Patients who have none of the mentioned criteria (as in this patient) are safe to be managed in the outpatient setting.
Low Molecular Weight Heparin, rather than Warfarin alone or Unfractioned Heparin, is the preferred initial agent for the
outpatient management of Deep Venous Thrombosis. Warfarin should be started at the same time with Low Molecular
Weight Heparin when not contraindicated. Compression stockings are recommended for at least 1 year in symptomatic
DVT
for
the
prevention
of
post-thrombotic
syndrome.
→ This patient has no indications for inpatient management (choices A, B, and C). Her management should include Low
Molecular Weight Heparin, Warfarin and Compression Stocks. Compression stockings are recommended for at least 1
year
in
symptomatic
DVT
for
the
prevention
of
post-thrombotic
syndrome.
Key
point:
It is important to know when a patient with DVT can be managed in the outpatient setting. It is also important to consider
the use of compression stockings (additional to the treatment with LMWH and warfarin) to prevent post-thrombotic
syndrome.
Question #136
QID: 15513
Topic: Irritable Bowel Syndrome
Subject: Medicine
All of the following are present in irritable bowel syndrome (IBS), except:
a) Recurrent type of nature
b) Bloody diarrhea
c) Bloating
d) Constipation
e) Cramping
The correct answer is b)
Explanation:
The Rome criteria are standardized symptom-based criteria for diagnosing irritable bowel syndrome (IBS). The Rome
criteria require the presence of abdominal pain or discomfort for at least 3 days per month in the last 3 months along with
≥2 of the following: (1) improvement with defecation; (2) onset (of each episode of discomfort) associated with a change
in
frequency
of
defecation,
or
(3)
change
in
consistency
of
stool.
Other symptoms of IBS include abdominal pain or cramping, a bloated feeling, gas (flatulence), diarrhea or constipation,
with sometimes alternating bouts of constipation and diarrhea and mucus in the stool.
Symptoms not consistent with irritable bowel syndrome should alert you to the possibility of an organic pathology.
Inconsistent symptoms include the following:











Onset in middle age or older
Acute symptoms (irritable bowel syndrome is defined by chronicity)
Progressive symptoms
Nocturnal symptoms
Anorexia or weight loss
Fever
Rectal bleeding
Painless diarrhea
Steatorrhea
Lactose and/or fructose intolerance
Gluten intolerance
Question #137
QID: 16538
Topic: Irritable Bowel Syndrome
Subject: Medicine
A 24-year-old white female presents to the office with a 6 month history of abdominal pain. A physical examination,
including pelvic and rectal examinations, is normal. Which one of the following would indicate a need for further
evaluation?
a)
b)
c)
d)
e)
Relief of symptoms with defecation
Changes in stool consistency from loose and watery to constipation
Passage of mucus with bowel movements
Abdominal bloating
Worsening symptoms at night and weight loss
The correct answer is e)
Explanation:
Irritable bowel syndrome (IBS) is a benign, chronic symptom complex of altered bowel habits and abdominal pain. It is
the
most
common
functional
disorder
of
the
gastrointestinal
tract.
Symptoms not consistent with irritable bowel syndrome should alert the clinician to the possibility of an organic
pathology. Inconsistent symptoms include the following:
Onset
in
middle
age
or
older
Acute
symptoms
(irritable
bowel
syndrome
is
defined
by
chronicity)
Progressive
symptoms
Nocturnal
symptoms
Anorexia
or
weight
loss
Fever
Rectal
bleeding
Painless
diarrhea
Steatorrhea
Lactose
and/or
fructose
intolerance
Gluten
intolerance
> Meals
may
precipitate
pain,
and
defecation
commonly
improves
pain
(choice
A)
> Altered bowel habits (choice B) are characteristic of IBS. Postprandial urgency is common, as is alternation between
constipation
and
diarrhea.
> Clear or white mucorrhea (choice C) of a noninflammatory etiology is commonly reported.
> Patients frequently report increased amounts of bloating (choice D) and gas.
Question #138
QID: 17597
Topic: Irritable Bowel Syndrome
Subject: Medicine
A 26-year-old female presents with a 1-year history of recurring abdominal pain associated with intermittent diarrhea, 5-7
days per month. Her pain improves with defecation. She denies blood in her stool and weigh loss. Laboratory tests
(including a CBC, chemistry profile, TSH level, and antibodies for celiac disease) came back normal. Which one of the
following would be most appropriate at this point?
a) Colonoscopy
b) An upper GI series with small-bowel follow-through
c) Abdominal CT with contrast
d) A gluten-free diet
e) Loperamide
The correct answer is e)
Explanation:
This patient has classic symptoms of irritable bowel syndrome (IBS) and meets the Rome criteria by having 3 days per
month of abdominal pain for the past 3 months, a change in the frequency of stool, and improvement with defecation.
According to current clinical guidelines IBS can be diagnosed by history, physical examination, and routine laboratory
testing, as long as there are no warning signs. Warning signs include rectal bleeding, anemia, weight loss, fever, a family
history of colon cancer, onset of symptoms after age 50, and a major change in symptoms. Antidiarrheal agents such as
loperamide are generally safe and effective in the management of diarrheal symptoms in IBS.
→
Colonoscopy,
CT,
and
GI
contrast
studies
are
not
→ A gluten-free diet would not be indicated since the antibody tests for celiac disease are negative.
indicated.
Question #139
QID: 18391
Topic: Irritable Bowel Syndrome
Subject: Medicine
A 41-year-old woman presents with a six months history of recurrent episodes of abdominal pain, bloating, and abdominal
distention. She says her pain is worse after eating and is most often felt on the left side. It improves with passage of stool;
however, she feels that the bowel evacuation is not complete. She reports alternation between loose and hard stools. She
denies
fever
and
weight
loss.
She notes that in the past she had one episode of traveler’s diarrhea when she visited India at the age of 30. Other than that
she did not have gastrointestinal symptoms in the past. Your presumptive diagnosis is irritable bowel syndrome (IBS).
Diagnosis of IBS can be made on the basis of symptoms alone, in the absence of which one of the following alarm
features?
a)
b)
c)
d)
e)
Age of onset of symptoms
Changing site of abdominal pain
Feeling of incomplete bowel evacuation
Diarrhea
Constipation
The correct answer is a)
Explanation:
Irritable bowel syndrome (IBS) is considered a functional gastrointestinal disorder, as it does not have a known organic
cause. The primary symptoms of IBS are abdominal discomfort or pain in association with change in bowel habits with
frequent diarrhea or constipation. There are several associated symptoms such as urgency of bowel movements, a feeling
of incomplete evacuation, bloating and flatulence. In some cases, symptoms worsen with food intake and are relieved by
defecation.
Diagnosis of IBS can be made on the basis of symptoms alone, if there are no alarm features such as age of onset greater
than 50 years (choice A), weight loss, gross blood in stool, systemic signs of infection or colitis, or family history of
Inflammatory bowel disease. IBS can affect people of all ages but is more common between 15-40 years of age. Age older
than 50 years is considered an alarm feature due to possibility of colon cancer.
→ The abdominal pain in IBS is chronic, mild to moderate in intensity and can involve any part of abdomen. The site of
pain
may
change
from
time
to
time
(choice
B).
→ Lower abdominal pain relieved by defecation is considered characteristic of IBS. Feeling that a bowel movement is
incomplete
(choice
C)
is
a
common
feature
of
IBS.
→ Approximately one third of IBS patients have diarrhea as predominant bowel habit (choice D), approximately one third
have constipation as predominant bowel habit (choice E) and the remainder have diarrhea alternating with constipation as
is present in the case described.
Key point:
Irritable bowel syndrome may be diagnosed on the basis of symptoms alone, if there are no alarm features such as age of
onset greater than 50 years, weight loss, gross blood in stool, systemic signs of infection or colitis, or family history of
Inflammatory bowel disease.
Question #140
QID: 15517
Topic: HTN, asthma
Subject: Medicine
Which of the following beta blockers used to treat hypertension is contraindicated in an asthma patient?
a)
b)
c)
d)
e)
Acebutolol
Atenolol
Esmolol
Metoprolol
Labetalol
The correct answer is e)
Explanation:
Beta blockers are either beta 1 selective where they only block the receptors on the heart. Or they can be non-selective and
block both beta 1 and beta 2 receptors. Blockade of beta 1 receptors leads to a decrease in heart rate. Blockade of the beta
2
receptor
leads
to
bronchoconstriction.
This
should
be
avoided
in
asthmatic
patients.
Therefore it is best to only given beta 1 selective beta blockers to asthma patients when treating their hypertension. This
group includes the following four: acebutolol, atenolol, esmolol and metoprolol.
Question #141
QID: 15518
Topic: Labyrinthitis, viral
Subject: Medicine
In a patient with vertigo, what sign or symptom would not lead to a diagnosis of viral labyrinthitis?
a)
b)
c)
d)
Otorrhea
Nystagmus
Hearing loss
Tinnitus
The correct answer is a)
Explanation:
Labyrinthitis is a balance disorder. It is an inflammatory process affecting the labyrinths that house the vestibular system
(which
sense
changes
in
head
position)
of
the
inner
ear.
In addition to balance control problems, a labyrinthitis patient may encounter hearing loss and tinnitus. Labyrinthitis is
caused by a virus, but it can also arise from bacterial infection, head injury, an allergy or as a reaction to a particular
medicine. Both bacterial and viral labyrinthitis can cause permanent hearing loss, although this is rare. Labyrinthitis often
follows
an
upper
respiratory
tract
infection
(URI).
When working properly, the vestibular system also relays information on head movement to the eye muscle, forming the
vestibulo-ocular reflex, in order to retain continuous visual focus during motion. When the vestibular system is affected
by labyrinthitis, rapid, undesired eye motion (nystagmus), often results from the improper indications of rotational motion.
Question #142
QID: 15519
Topic: Aortic Dissection
Subject: Medicine
Which
a)
b)
c)
d)
e)
of
the
following
is
the
most
sensitive
method
for
diagnosing
aortic
dissection?
MRI
CT scan
TEE
CXR
TTE
The correct answer is a)
Explanation:
Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and
creation of a false lumen. The intimal tear may be a primary event or secondary to hemorrhage within the media. The
dissection may occur anywhere along the aorta and extend proximally or distally into other arteries.
Diagnosis is by imaging tests (eg, transesophageal echocardiography, CT angiography, MRI, contrast aortography).
MRI is the gold standard test for the detection and assessment of aortic dissection, which has approximately 98%
sensitivity and specificity. It is the most sensitive method for diagnosing aortic dissection and has similar specificity to CT
scanning. It is a non-invasive test (does not require the use of iodinated contrast material) and can detect and quantitate
the
degree
of
aortic
insufficiency.
→ Transesophageal echocardiography (TEE) has greater sensitivity (97% versus 80%) and specificity (97-100% versus
90%) than transthoracic echocardiography (TTE). TEE is as accurate as CT scanning in terms of sensitivity and
specificity, and it can be used at the bedside, which makes it ideal for hemodynamically unstable patients.
→ Widening of the mediastinum on an x-ray of the chest has moderate sensitivity in the setting of an ascending aortic
dissection. However, it has low specificity, as many other conditions can cause a widening of the mediastinum on chest xray
Aortic Dissection
Question #143
QID: 15520
Topic: Wolff-Parkinson-White Syndrome
Subject: Medicine
Which of the following is contraindicated in an adult patient with Wolff-Parkinson-White Syndrome (WPW)?
a)
b)
c)
d)
e)
Cardioversion
Procainamide
Amiodarone
Digoxin
Adenosine
The correct answer is d)
Explanation:
Wolff-Parkinson-White (WPW) syndrome is a disorder in which an extra electrical connection between the atria and the
ventricles
is
present
at
birth.
Digoxin is contraindicated in patients with WPW syndrome. It may shorten the refractory period and enhance conduction
over the bypass tract, which may cause an even faster tachydysrhythmia or deterioration into ventricular fibrillation.
→ The
treatment
of
choice
is
direct-current
cardioversion.
→ If cardioversion is not possible, drugs that prolong the refractory period of the accessory connection should be used.
Examples
are
IV
procainamide
and
amiodarone.
→ Adenosine is the first-line agent and is effective in approximately 90% of reentrant narrow-complex tachycardia
Question #144
QID: 16747
Topic: Wolff-Parkinson-White Syndrome
Subject: Medicine
Patients with Wolff-Parkinson-White syndrome who have episodic symptomatic supraventricular tachycardia or atrial
fibrillation
benefit
most
from:
a) Episodic intravenous digoxin
b) Long-term oral digitalis
c) Episodic beta-blockers
d) Radiofrequency catheter ablation of bypass tracts
The correct answer is d)
Explanation:
Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective
than surgery, with a similar success rate. Intravenous and oral digoxin can shorten the refractory period of the accessory
pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta-blockers will not control the ventricular
response during atrial fibrillation when conduction proceeds over the bypass tract.
Question #145
QID: 15521
Topic: Guillain-Barré syndrome
Subject: Medicine
A 43-year-old man presents 2 weeks after you see him for infectious diarrhea caused by C. jejuni. He has now developed
bilateral proximal lower limb weakness and bilateral distal parasthesia and decreased ankle tendon reflex.
What
a)
b)
c)
d)
is
the
most
likely
diagnosis?
Guillain-Barré syndrome
Multiple Sclerosis
Myasthenia Gravis
Systemic Lupus Erythematosus
The correct answer is a)
Explanation:
Guillain-Barré syndrome is the most common acquired inflammatory neuropathy. It is an acute, usually rapidly
progressive inflammatory polyneuropathy characterized by muscular weakness and mild distal sensory loss.
In most patients, the syndrome begins 1-3 weeks after an infectious disorder, surgery, or vaccination. Infection is the
trigger in > 50% of patients, common pathogens include Campylobacter jejuni, enteric viruses, herpesviruses, and
Mycoplasma.
Flaccid weakness predominates in most patients, it is always more prominent than sensory abnormalities and may be most
prominent proximally. Relatively symmetric weakness with paresthesias usually begins in the legs and progresses to the
arms,
but
it
occasionally
begins
in
the
arms
or
head.
Diagnosis is clinical. If Guillain-Barré syndrome is suspected, patients should be admitted to a hospital for
electromyography
(EMG),
CSF
analysis,
and
measurement
of
forced
vital
capacity.
Guillain-Barré syndrome is a medical emergency, requiring constant monitoring and support of vital functions, typically
in an ICU. Plasmapheresis helps when done early in the syndrome and is the treatment of choice in acutely ill patients.
Immune globulin is also effective when given early.
Guillain-Barré syndrome
Question #146
QID: 15528
Topic: Pulmonary Embolism
Subject: Medicine
An elderly man traveled to North America from Australia. After 5 days he develops dyspnea, chest pain, tachycardia and
is
rushed
to
the
hospital.
What
a)
b)
c)
d)
is
the
most
likely
diagnosis?
Pulmonary embolism
Pneumonia
Myocardial infarction
Aortic dissection
The correct answer is a)
Explanation:
Pulmonary embolism (PE) is the occlusion of one or more pulmonary arteries by thrombi that originate elsewhere,
typically in the large veins of the lower extremities or pelvis. Nearly all PEs arise from thrombi in the lower extremity or
pelvic
veins
(deep
venous
thrombosis
(DVT).
'Virchow's triad' of stasis, hypercoagulability and endotheloal damage are risk factors for developing DVT.
This man has sat on a very long airplane flight from Australia to North America. Meeting the criteria for stasis. His
symptoms are classic for PE which can include: acute dyspnea, pleuritic chest pain, tachycardia and tachypnea. The first
symptom in an older patient may be altered mental status.
Pulmonary Embolism
Question #147
QID: 16187
Topic: Pulmonary Embolism
Subject: Medicine
A 44-year-old man sustained a comminuted fracture of his left tibia and fibula 4 months ago. For the past 3 months he has
been in the rehabilitation unit with his leg fully immobilized. Three hours ago he suddenly developed chest pain and
shortness of breath, and he has just been brought to the emergency department for further evaluation. On examination he
describes an aching discomfort over the right superior anterior chest and the right scapula posteriorly. The family history
is
strongly
positive
for
heart
disease.
The presence of a right pleural friction rub in this patient would suggest which of the following?
a)
b)
c)
d)
e)
Pericarditis
Pneumonia
Pneumothorax
Pulmonary embolus with infarction
Pulmonary embolus without infarction
The correct answer is d)
Explanation:
Pain and pleural
frictional
rub
is
almost
diagnostic
of
infarction
of
the
overlying
pleura.
> Pericardial rub due to pericarditis is localized to the lower left side of the heart; there is no evidence for this diagnosis
here.
> Pneumonia, which is another complication of immobility, may present with similar signs and symptoms, but should be
accompanied
with
fever
and
leukocytosis.
> A pneumothorax and a pulmonary embolus without infarction do not typically present with a pleural friction rub.
Pulmonary Embolism
Question #148
QID: 17177
Topic: Pulmonary Embolism
Subject: Medicine
A 45-year-old female presents to an urgent care center complaining of left-sided chest pain for the past 2 days. The pain is
nonradiating and sharp in character, and increases with deep inspiration. She has no associated shortness of breath, cough,
nausea, diaphoresis, or dizziness. She has no significant past medical history or recent travel history.
On examination she is afebrile, with a pulse rate of 92 beats/min, a blood pressure of 116/72 mm Hg, and a respiratory
rate of 12/min. Her lungs are clear and her heartbeat is regular with no murmurs. Her lower extremities have no edema,
tenderness,
or
varicosities.
Which
a)
b)
c)
d)
e)
one
of
the
following
is
the
most
appropriate
A high-sensitivity D-dimer test
A troponin I level
Ultrasound examination of the veins of the lower extremities
A multidetector helical CT of the chest
An antinuclear antibody (ANA) level
The correct answer is a)
next
step
in
her
evaluation?
Explanation:
This patient has a low pretest probability of pulmonary embolism based on the Wells criteria. She would be a good
candidate for a high-sensitivity D-dimer test, with a negative test indicating a low probability of venous
thromboembolism.
→ In patients with a low pretest probability of venous thromboembolism, an ultrasound or helical CT would not be the
recommended
initial
evaluation.
→ Neither troponin I nor an ANA level would be part of the recommended initial evaluation.
Question #149
QID: 17580
Topic: Pulmonary Embolism
Subject: Medicine
A 60-year-old female presents to the emergency department complaining of shortness of breath. She arrived from
Australia yesterday after a long visit at her daughter’s. She has developed swelling of her left leg yesterday evening
followed by shortness of breath that began today. Her past medical history is unremarkable.
Vital signs are significant for pulse of 120/min and a RR of 24/min. Physical exam is non contributory except for the
swollen
tender
left
leg.
Chest
x-ray
is
normal.
Which of the following arterial blood gas test findings would suggest pulmonary embolism?
a)
b)
c)
d)
e)
Decreased A-a gradient
Decreased PaCO2
Increased PaCO2
Normal PaO2
pH less than 7.38
The correct answer is b)
Explanation:
The patient is most likely having pulmonary embolism. The shortness of breath that follows the leg swelling with the
associated tachycardia and tachypnea suggests the diagnosis of PE. Arterial blood gas determinations characteristically
reveal
hypoxemia,
hypocapnia(choice
B),
and
respiratory
alkalosis.
> The A-a gradient (choice A) is usually increased due to the ventilation/perfusion mismatch.
> PaO2 (choice D) is almost always decreased in PE because of the low perfusion i.e. less oxygenation.
> Respiratory alkalosis and not acidosis (choice E) is usually seen in PE.
Question #150
QID: 17825
Topic: Pulmonary Embolism
Subject: Medicine
A 42-year-old female presents to the emergency department with pleuritic chest pain. Her probability of pulmonary
embolism
is
determined
to
be
low.
Which one of the following should be ordered to further evaluate this patient?
a) Brain natriuretic peptide (BNP)
b) CT pulmonary angiography
c) ELISA-based D-dimer
d) A cardiac troponin level
e) A ventilation-perfusion lung scan
The correct answer is c)
Explanation:
Patients who have a low or moderate pretest probability of pulmonary embolism should have d-dimer testing as the next
step in establishing a diagnosis.
Question #151
QID: 15529
Topic: Warfarin
Subject: Medicine
What is the drug interaction
(trimethoprim/sulfamethoxazole)?
a)
b)
c)
d)
commonly
seen
when
a
patient
on
warfarin
is
given
Bactrim
Increases effect of warfarin, causing bleeding
Decreases effect of warfarin, potential for clot formation
Increases efficacy of bactrim
Decreases efficacy of bactrim
The correct answer is a)
Explanation:
Taking warfarin and bactrim may cause more of a chance for bleeding. It has been reported that bactrim can prolong the
prothrombin
time
in
patients
who
are
receiving
the
anticoagulant
warfarin.
Using warfarin together with sulfamethoxazole is usually not recommended, but may be required in some cases. Potential
interaction can cause the patient to feel dizzy or lightheaded, have blood in the urine, have bloody, black or sticky bowel
movements, have unusual bleeding in the vagina, have unusual bruising.
Question #152
QID: 15948
Topic: Warfarin
Subject: Medicine
A 35-year-old man is seen in the Emergency Department after attempting suicide by taking an overdose of warfarin.
Which
one
of
the
following
is
used
as
a
treatment
for
this
circumstance?
a)
b)
c)
d)
e)
Heparin
Allopurinol
Coumarin
Vitamin E
Vitamin K
The correct answer is e)
Explanation:
Warfarin overdose is evident mainly as excessive bleeding, which may first be noticed as bleeding gums with brushing or
easy bruising. Vitamin K is used to reduce INR in cases of warfarin overdose.
Question #153
QID: 16015
Topic: Warfarin
Subject: Medicine
A 48-year-old alcoholic man has had a deep venous thrombosis (DVT) and the INR is well-controlled on warfarin. He is
noted
to
have
an
INR
of
6.0
following
a
weekend
binge.
Which
a)
b)
c)
d)
e)
one
of
the
following
is
the
most
likely
pharmacological
explanation
of
this
finding?
Alcohol intake decreases the volume of distribution of warfarin
Alcohol intake increases the absorption of warfarin from the gut
Alcohol competes for and reduces the hepatic metabolism of warfarin
Alcohol reduces the plasma protein binding of warfarin
Alcohol reduces the renal excretion of warfarin
The correct answer is c)
Explanation:
Intermediate
use
(2-3
drinks
per
day)
probably
does
not
alter
the
INR
at
all.
Intermittent large amount of alcohol drinking leads to an increase in INR, because the alcohol interferes with warfarin
metabolism, i.e. warfarin is metabolized less rapidly. This excessive warfarin activity results from alcohol-related
inhibition of warfarin metabolism by cytochrome P450 (CYP) in the liver. In the absence of alcohol, CYP activity is
relatively low. CYP breaks down the medication, and the resulting products (i.e., metabolites) are excreted. After
moderate alcohol consumption, CYP metabo- lizes alcohol in addition to the medication. As a result of competition for
CYP between alcohol and the medication, the medication’s metabolism is reduced, and the production of metabolites as
well as their excretion declines, resulting in higher medi- cation levels in the body.
Question #154
QID: 16935
Topic: Warfarin
Subject: Medicine
Which one of the following is the best choice for rapidly restoring normal coagulation in a patient on warfarin
(Coumadin)
with
serious
gastrointestinal
bleeding?
a)
b)
c)
d)
e)
Tissue plasminogen activator (tPA)
Methylprednisolone (Solu-Medrol)
Fresh frozen plasma
Vitamin K orally
Packed red blood cells
The correct answer is c)
Explanation:
Treatment with coumarin oral anticoagulants, such as warfarin, is effective antithrombotic therapy, but patients treated
with
these
drugs
are
at
significant
risk
of
bleeding.
With serious bleeding, immediate reversal of the anticoagulant effect of warfarin is necessary. The only effective strategy
is to give fresh frozen plasma intravenously (choice C), restoring the vitamin K-dependent factors VII, IX, and X which
are
depleted
in
patients
taking
warfarin.
→ Tissue plasminogen activator (choice A) is a thrombolytic agent, and would make any serious bleeding condition
worse.
→ Methylprednisolone (choice B) is a corticosteroid that has no effect on the synthesis of vitamin K-dependent factors
→ Oral vitamin K (choice D) is an effective method of reversing the effects of warfarin, but takes 24 hours to reach full
effect.
→ Packed red blood cells(choice E) is incorrect. The transfusion of red cell concentrates is indicated in order to achieve a
fast increase in the supply of oxygen to the tissues, when the concentration of haemoglobin is low and/or the oxygen
carrying capacity is reduced, in the presence of inadequate physiological mechanisms of compensation. This is not the
most appropriate treatment in a patient who needs warfarin reversal.
Question #155
QID: 17117
Topic: Warfarin
Subject: Medicine
A 66-year-old male is hospitalized for new-onset atrial fibrillation. His heart rate is controlled, and he is anticoagulated
first with low molecular weight heparin and then with warfarin (Coumadin). His INR at discharge is 2.3. He presents 3
days
later
for
follow-up
and
states
that
he
feels
well.
His
INR
is
now
10.0.
The most appropriate management at this time would be to withhold warfarin until his INR is therapeutic and to:
a) readmit for monitoring, give vitamin K, and start enoxaparin (Lovenox)
b) administer 2 units of fresh frozen plasma and vitamin K subcutaneously
c) administer vitamin K intravenously
d) administer vitamin K intramuscularly
e) administer vitamin K orally
The correct answer is e)
Explanation:
The most cost-effective management for excessive anticoagulation is to administer oral vitamin K and retest the
prothrombin time. This patient is not hemorrhaging, and a recent analysis has shown oral vitamin K to be as effective as
intravenous or subcutaneous vitamin K. An INR greater than 8.0 does carry a risk of bleeding, so simply withholding
warfarin would not be appropriate, and neither would readmission, given the high likelihood of correcting the patient’s
excessive anticoagulation with oral vitamin K alone.
Question #156
QID: 17268
Topic: Warfarin
Subject: Medicine
In a patient with a mechanical mitral valve replacement who is taking warfarin (Coumadin), the recommended INR range
is:
a) 1.0 - 2.0
b) 1.5 - 2.5
c) 2.0 - 3.0
d) 2.5 - 3.5
e) 3.0 - 4.0
The correct answer is d)
Explanation:
Most conditions (DVT or PE, atrial fibrillation) requiring warfarin therapy are adequately treated at INR values between
2.0
and
3.0;
Patients with mechanical heart valves, especially mitral valves, may benefit from higher values (up to 3.5).
Patients with thrombophilia due to antiphospholipid antibody syndrome may require a higher INR (3.0-4.0) for optimal
therapy.
Question #157
QID: 17531
Topic: Warfarin
Subject: Medicine
Warfarin is used for prophylaxis and treatment of venous thrombosis and its extension, prophylaxis and treatment of
pulmonary embolism, prophylaxis and treatment of thromboembolic complications associated with atrial fibrillation
and/or cardiac valve replacement, and as an adjunct in the treatment of coronary occlusion.
What
a)
b)
c)
d)
is
its
mechanism
of
It alters the synthesis of blood coagulation factors I and VIII.
It antagonizing the vitamin D production.
It acts as the Vitamin K agonist.
It inhibits epoxide reductase, thereby diminishing available Vitamin K amounts.
action?
e) It alters the synthesis of blood coagulation factors III, IV and V.
The correct answer is d)
Explanation:
Warfarin is a coumarin-derivative anticoagulant that alters the synthesis of blood coagulation factors II (prothrombin),
VII, IX, and X in the liver by interfering with the action of vitamin K. Warfarin inhibits epoxide reductase, thereby
diminishing available vitamin K amounts and inhibiting production of functioning coagulation factors.
Question #158
QID: 15533
Topic: Candidiasis
Subject: Medicine
A
man
develops
the
following
rash.
See
picture:
You diagnose him with an intertriginous candida infection. All of the following treatments are appropriate, except:
a)
b)
c)
d)
e)
Topical clotrimazole
Topical ketoconazole
Topical miconazole
Systemic amphotericin
Nystatin topical powder
The correct answer is d)
Explanation:
Candidiasis of intertriginous skin occurs as poorly marginated, bright red plaques with satellite papules and pustules
scattered around the periphery of the main lesion. Candidiasis is most commonly seen in the groin but also occasionally
occurs in the axillary folds and interdigital web spaces. In men, groin lesions are located in the inguinal-scrotal fold with
later involvement of the inner thighs, gluteal cleft, and scrotum. In women, Candida vaginitis usually precedes
involvement of the labia minora and majora. Spread subsequently occurs to the inner thighs and gluteal cleft. Pruritus is
generally
present.
A clinical diagnosis can be confirmed by KOH preparations or cultures. These studies are more likely to be positive if
they are performed on material recovered from intact pustules. Topical imidazoles (clotrimazole, ketoconazole,
miconazole) applied twice a day are effective in the treatment of candidiasis. In those patients for whom inflammation is
prominent or pruritus is severe, the addition of a topically applied steroid such as hydrocortisone reduces the discomfort
and shortens the time for healing. Topical drying agents also play an important role in the treatment of intertrigo, as
moisture and maceration are key aspects of the pathogenesis of this disorder. Various agents have been employed to keep
the skin folds dry, clean, and cool. These include antifungal powders (including miconazole, nystatin, undecylenic acid,
tolnaftate, and 12% benzoic acid), aluminum sulfate calcium acetate solution, gentian violet solution, carbol-fuchsin
solution,
and
antiseptic
drying
agents
such
as
potassium
permanganate
solution.
Orally administered amphotericin (choice D) or ketoconazole are only rarely indicated in uncomplicated cases.
Question #159
QID: 15538
Topic: Male Infertility
Subject: Medicine
A man has a semen analysis done. It shows abnormal motility and shape, and a total sperm count of 950,000 sperm
(normal
sperm
count
is
greater
than
20,000,000).
What
a)
b)
c)
d)
do
you
advise
him
about
his
future
fertility?
Chance of fertility is 10%
Chance of fertility is 50%
He is impotent
He could have a child with in-vitro fertilization (IVF)
The correct answer is d)
Explanation:
Abnormal morphology (shape) and motility can prevent the sperm from reaching the egg. The sperm need motility to be
able to swim well and survive for a number of hours in the female reproductive tract. If they do meet, abnormal-looking
sperm
might
be
incapable
of
fertilization.
The motility of this man’s sperm is poor and therefore he is unlikely to be able to be fertile. In addition, infertility
specialists have stated that 1 million motile sperm is the minimum amount of sperm associated with a reasonable chance
of
pregnancy
success
at
intrauterine
insemination.
However in-vitro fertilization (IVF) can be used to treat infertility due to his oligospermia. The procedure would involve
controlled ovarian hyperstimulation, oocyte retrieval, fertilization with sperm, embryo culture, and embryo transfer.
Impotence is defined as an inability to achieve and/or maintain an erection.
Question #160
QID: 15540
Topic: Hypertension, secondary
Subject: Medicine
You suspect a secondary cause in one of your patients who has developed hypertension. Which of the following tests
would not be
part
of
your
diagnostic
work-up?
a)
b)
c)
d)
e)
CT imaging
5-hydroxyindoleacetic acid
Urine catecholamines
Renal ultrasound
24 hour urinary free cortisol level
The correct answer is b)
Explanation:
Only 5% of causes of hypertension are from a secondary cause. Remember the mnemonic C.H.A.P.S. for the causes of
secondary hypertension. Those are Cushing's, Hyperaldosteronism, Aortic coarctation, Pheochromocytoma, Stenosis of
renal
artery.
The diagnostic tests used to work up the above causes of secondary hypertension are 24 hour urinary cortisol level, basic
metabolic panel, CT imaging, urinary catecholamines, renal ultrasound for Cushing's, Hyperaldosteronism, Aortic
coarctation,
Pheochromocytoma
and
Stenosis
of
renal
artery,
respectively.
5-hydroxyindoleacetic acid (5-HIAA) (choice B) is a break-down product of the chemical messenger serotonin in the
urine. 5-HIAA levels to detect tumors in the digestive tract (carcinoid tumors).
Question #161
QID: 16186
Topic: Hypertension, secondary
Subject: Medicine
A 38-year-old nurse comes to the emergency department after leaving work early because of a "bad headache." She has
had a "cold" with sinus congestion for the past week, and yesterday she began taking an over-the-counter combination of
diphenhydramine and pseudoephedrine. She tells you she has a history of "migraines," multiple allergies, premenstrual
syndrome and depression, for which she takes phenelzine (a monoamine oxidase inhibitor). Vital signs are: temperature
37.2°C (99.0°F), pulse 90/min, respirations 16/min and blood pressure 210/118 mm Hg.
Which
a)
b)
c)
d)
e)
of
the
following
is
Administer meperidine, intramuscularly
Administer phentolamine, intravenously
Order CT scan of the head
Order transillumination of the sinuses
Prescribe oral oxycodone and nasal corticosteroids
The correct answer is b)
Explanation:
the
most
appropriate
action?
This patient has hypertension secondary to the effects of the pseudoephedrine and her monoamine oxidase inhibitor. The
inhibition of MAO-A causes the rise of norepinephrine, dopamine and serotonin in the synaptic cleft, of MAO-B only of
dopamine. Pseudoephedrine displaces norepinephrine from synaptic terminals. For this reasons, nasal sprays such as the
one this patient is taking are to be avoided when MAOIs are used. Phentolamine is a reversible alpha-adrenergic receptor
blocker that will blunt the effects of the excess catecholamines on arteriolar vasoconstriction.
Question #162
QID: 15557
Topic: Amaurosis Fugax
Subject: Medicine
A 58-year-old man presents to your office with a history of having an episode of sudden visual loss in his right eye. The
patient describes the loss of vision as similar to someone pulling a cover over his right eye. Vision returned to the right
eye
after
10
minutes.
This
a)
b)
c)
d)
e)
visual
field
defect
is
secondary
to
which
one
of
the
following?
Scotoma
Amaurosis fugax
Strabismus
Esotropia
Nyctalopia
The correct answer is b)
Explanation:
Amaurosis fugax refers to a transient loss of vision in one or both eyes. Patients with transient visual loss almost always
present after the episode has resolved; that's why the neurologic and ophthalmologic examination is usually
normal. Transient visual obscurations due to papilledema typically last seconds. Thromboembolic events from carotid
disease or elsewhere generally last 1 to 15 minutes and only rarely an hour or more. Migraine aura typically lasts 10 to 30
minutes. Transient visual loss from any cause can be described as mild blurring or fogging to complete blackness, and
may involve a part of or all of the visual field. Transient monocular visual loss descending over the field of vision (like a
curtain or shade) or, less commonly, ascending from below, is highly suggestive of retinal ischemia.
> Scotoma is an area of depressed vision in the visual field, surrounded by an area of less depressed or of normal vision
(blind
spot).
> Strabismus is a condition in which the visual axes of the eyes are not parallel and the eyes appear to be looking in
different
directions.
> Esotropia
(cross-eye)
is
a
form
of
strabismus.
> Nyctalopia - night blindness, impaired vision in dim light and in the dark, due to impaired function of certain
specialized vision cells in the retina.
Question #163
QID: 15558
Topic: Idiopathic Pulmonary Fibrosis
Subject: Medicine
A 51-year-old man complains of a 6-month-history of shortness of breath and cough. Physical examination reveals
hypertension,
digital
clubbing
and
fine
bibasilar
inspiratory
crackles.
Which
a)
b)
c)
d)
e)
one
of
the
following
is
the
most
likely
diagnosis?
Asthma
Reflux-induced cough
Chronic bronchitis
Idiopathic pulmonary fibrosis
Sarcoidosis
The correct answer is d)
Explanation:
Idiopathic pulmonary fibrosis (IPF), also known as cryptogenic fibrosing alveolitis, is a chronic, progressive interstitial
lung disease with an unknown cause. It is one of the two classic interstitial lung diseases, the other being sarcoidosis.
IPF is slightly more common in males and usually presents in patients greater than 50 years of age. Average survival from
time of diagnosis varies between 2.5 and 3.5 years, depending on severity, although some patients live greater than 10
years.
Symptoms are gradual in onset. The most common are dyspnea (difficulty breathing), but also include nonproductive
cough, clubbing (a disfigurement of the fingers), and fine bibasilar inspiratory crackles (Velcro crackles).
→ In COPD thoracic examination reveals barrel chest (hyperinflation), wheezing, which is frequently heard on forced and
unforced expiration, diffusely decreased breath sounds, hyperresonance on percussion, and prolonged expiration. In
addition, coarse crackles (not fine as in IPF) beginning with inspiration may be heard.
→ Sarcoidosis is an immune system disorder characterized by non-caseating granulomas (small inflammatory nodules). It
most commonly arises in young adults. The cause of the disease is still unknown. Virtually any organ can be affected;
however, granulomas most often appear in the lungs or the lymph nodes. Common symptoms are vague, such as fatigue
unchanged by sleep, lack of energy, weight loss, aches and pains, arthralgia, dry eyes, blurry vision, shortness of breath, a
dry hacking cough or skin lesions such as erythema nodosum.
Question #164
QID: 15560
Topic: Addison's Disease
Subject: Medicine
A 35-year-old woman is brought to the ER in severe distress. She has had the "flu" for three days. Past history reveals a
six month history of fatigue and malaise. Physical exam reveals BP 120/65 mm Hg supine, 90/58 mm Hg standing, and
darkened areas of skin on the knuckles, creases of the palm, elbows and an abdominal scar. Laboratory values are Na 122
mmol/L,
K
5.8
mmol/L,
Cl
95
mmol/L,
CO2
18
mmol/L.
Which one of the following laboratory tests is most likely to assist in confirming your diagnosis?
a) Plasma follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
b)
c)
d)
e)
24 hour urine metanephrines and vanillylmandelic acid (VMA)
Plasma catecholamines, total and fractionated
Plasma cortisol and adrenocorticotropic hormone (ACTH)
Plasma 17OH progesterone
The correct answer is d)
Explanation:
Addison's disease (adrenal insufficiency) is an insidious, usually progressive hypofunctioning of the adrenal cortex. It
produces various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis with
cardiovascular
collapse.
Diagnosis is clinical and is made by finding elevated plasma ACTH with low plasma cortisol. Treatment depends on the
cause but generally includes hydrocortisone and sometimes other hormones.
Question #165
QID: 16932
Topic: Addison's Disease
Subject: Medicine
A 40-year-old female presents with the gradual onset of weakness, fatigue, anorexia, and nausea. She has lost 15 lb (7 kg)
over
the
past
3
months.
A physical examination is unremarkable except for the patient's tired appearance, a blood pressure of 90/60 mm Hg, and
diffuse hyperpigmentation of the skin and mucous membranes. Laboratory evaluation includes a sodium level of 130
mmol/L
(N
136-145)
and
a
potassium
level
of
5.8
mmol/L
(N
3.5-5.1)
Which
a)
b)
c)
d)
one
of
the
following
is
the
best
test
to
further
evaluate
this
patient's
condition?
A TSH level
A cosyntropin (Cortrosyn) stimulation test
A plasma ACTH level
A dexamethasone suppression test
The correct answer is b)
Explanation:
Primary adrenal insufficiency (Addison's disease) is an uncommon condition in clinical practice, and typically has an
autoimmune etiology. Patients often experience the insidious onset of weakness, fatigue, and gastrointestinal symptoms.
Physical findings typically include hypotension and diffuse hyperpigmentation of the patient's skin and mucous
membranes. Due to the loss of aldosterone, serum sodium levels tend to be low, and hyperkalemia is common.
Cosyntropin is a synthetic analogue of ACTH. The cosyntropin stimulation test is performed by administering 250 μg of
cosyntropin intravenously or intramuscularly and measuring serum cortisol 30-60 minutes later. A normal response is
serum
cortisol
>
500
nmol/L.
A
lower
level
suggests
adrenal
insufficiency.
In primary adrenal insufficiency, TSH and ACTH levels may be elevated, but this is variable and ACTH continues to
demonstrate diurnal variation. The dexamethasone suppression test is used in the evaluation of cortisol excess.
Question #166
QID: 17240
Topic: Addison's Disease
Subject: Medicine
A 54-year-old African-Canadian female is admitted to the hospital for intravenous heparin therapy for a deep-vein
thrombosis of her leg. She had previously been very healthy. Shortly after admission she begins to experience profound
orthostatic hypotension and gastrointestinal distress. Serial hemoglobin tests are stable, but serum sodium and bicarbonate
levels
are
low.
Her
potassium
level
is
slightly
elevated.
Which one of the following tests would most quickly determine if she has suffered from acute adrenal cortex insufficiency
(Addison’s disease)?
a) A cosyntropin stimulation test
b) A dexamethasone suppression test
c) A renin:aldosterone ratio
d) A serum adrenocorticotropic hormone (ACTH) level
e) Measurement of 24-hour urinary excretion of catecholamines
The correct answer is a)
Explanation:
Destruction of the adrenal cortex by acute causes (infarction, hemorrhage, infection) or chronic ones (granulomatous
disease, immune destruction) results in a loss of circulating levels of cortisol and aldosterone. The effects of this
deficiency can include electrolyte disturbances such as those seen in this patient, gastrointestinal distress (including “acute
abdomen,” diarrhea, nausea, etc.), orthostatic hypotension, and patient fatigue. If the process is gradual, ACTH levels will
increase, resulting in a darkened skin tone. Measuring serum levels of ACTH may be helpful in determining the cause of
decreased cortisol levels, but is not a good first test of adrenal cortex function. The dexamethasone suppresion test is used
to
evaluate
glucocorticoid
excess.
The cosyntropin stimulation test does assess adrenal cortex function. This test involves injecting cosyntropin, 250 µg
intramuscularly or intravenously, and measuring cortisol levels 60 minutes later. If the result shows an inadequate
response (cortisol level < 495 nmol/L), adrenal cortical function is proven to be at least 90% diminished.
Question #167
QID: 15566
Topic: Otosclerosis
Subject: Medicine
Which
a)
b)
c)
d)
of
the
following
Abnormal eardrum with conductive hearing loss
Normal eardrum with conductive hearing loss
Abnormal eardrum with sensorineural hearing loss
Normal eardrum with sensorineural hearing loss
scenarios
best
describes
otosclerosis?
The correct answer is b)
Explanation:
Otosclerosis is a disease of the bone of the otic capsule that produces an abnormal accumulation of new bone within the
oval window.
In otosclerosis, the new bone traps and restricts the movement of the stapes, causing conductive hearing loss. Otosclerosis
also may produce a sensorineural hearing loss, particularly when the foci of otosclerotic bone are adjacent to the scala
media. Half of all cases are inherited. The measles virus may play an inciting role in patients with a genetic predisposition
for
otosclerosis.
Although about 10% of white adults have some otosclerosis (compared with 1% of blacks), only about 10% of affected
people develop conductive hearing loss. Hearing loss from otosclerosis may manifest as early as age 7 or 8, but most
cases do not become evident until the late teen or early adult years, when slowly progressive, asymmetric hearing loss is
diagnosed.
Fixation
of
the
stapes
may
progress
rapidly
during
pregnancy.
A hearing aid may restore hearing. Alternatively, microsurgery to remove some or all of the stapes and to replace it with a
prosthesis may be beneficial.
Question #168
QID: 15573
Topic: Huntington Chorea
Subject: Medicine
A patient previously diagnosed with Huntington chorea (HC) comes for a family planning consult with his wife. He states
that his father had the disease and his mother was unaffected. They ask you "what is the likelihood having a son with this
condition"?
a) Zero
b) 25%
c) 50%
d) 75%
e) 100%
The correct answer is b)
Explanation:
Huntington chorea (HC), is an inherited disease characterized by choreiform movements and progressive dementia. It is
inherited as an autosomal dominant disorder. There is a 50% chance of the man passing the disease to his child. There is a
50%
chance
of
having
a
son. 0.5x0.5=0.25
=
25%
Therefore, there is a 25% chance of the man passing the disease to his son.
Question #169
QID: 15574
Topic: Duchenne Muscular Dystrophy
Subject: Medicine
What is the chance of having offspring affected by Duchenne Muscular Dystrophy (DMD), if the father is affected and the
mother is not (not a carrier)?
a)
b)
c)
d)
e)
Zero
25%
33%
50%
100%
The correct answer is a)
Explanation:
Duchenne muscular dystrophy is inherited in an X-linked recessive pattern. The following table illustrates the outcomes
for
an
affected
male
with
a
normal
female
and
an
affected
female
with
a
normal
male:
In first scenario (concerning this question), the affected male mates with a normal female. The female offspring will be
carriers
and
the
male
offspring
will
be
normal.
No
offspring
will
be affected.
In the second scenario, a normal male mates with an affected female resulting in male offspring that are affected and
female offspring that are carriers.
Duchenne Muscular Dystrophy
Question #170
QID: 15575
Topic: Streptococcal Pharyngitis
Subject: Medicine
Which
a)
b)
c)
d)
of
the
following
is
associated
with
streptococcal
pharyngitis?
Cough
Cervical lymphadenopathy
Afebrile patient
Group B strep
The correct answer is b)
Explanation:
Streptococci are gram-positive aerobic organisms that cause many disorders, including pharyngitis, pneumonia, wound
and skin infections, sepsis, and endocarditis. Symptoms vary with the organ infected. Sequelae include rheumatic fever
and
glomerulonephritis.
Clinical
diagnoses
are
confirmed
by
Gram
stain
and
culture.
Strep throat (Streptococcal pharyngitis) is a form of Group A streptococcal infection that affects the pharynx. Symptoms
include: severe sore throat, yellow and white patches in the throat, difficulty swallowing, tender cervical
lymphadenopathy, red and enlarged tonsils, halitosis, fever of 38°C (101F) or greater, rash and absence of cough.
Question #171
QID: 16455
Topic: Streptococcal Pharyngitis
Subject: Medicine
A healthy 24-year-old male presents with a sore throat of 2 days’ duration. He reports mild congestion and a dry cough.
On examination, his temperature is 37.2°C (99.0°F). His pharynx is red without exudates, and there are no anterior
cervical
nodes.
His
tympanic
membranes
are
normal,
and
his
chest
is
clear.
Which
a)
b)
c)
d)
one
of
the
following
would
you
do?
Treat with analgesics and supportive care
Treat with azithromycin (Zithromax)
Perform a throat culture and begin treatment with penicillin
Perform a rapid strep test
The correct answer is a)
Explanation:
The Centers for Disease Control and Prevention (CDC) assembled a panel of national health experts to develop evidencebased guidelines for evaluating and treating adults with acute respiratory disease. In clinical screening, the most reliable
predictors of streptococcal pharyngitis are the Centor criteria. These include tonsillar exudates, tender anterior cervical
lymphadenopathy,
absence
of
cough,
and
history
of
fever.
Patients with four positive criteria should be treated with antibiotics, those with three positive criteria should be tested and
treated if positive, and those with 0-1 positive criteria should be treated with analgesics and supportive care only. This
patient has only one of the Centor criteria, and according to the panel should not be tested or treated with antibiotics.
Question #172
QID: 16356
Topic: Atrial Fibrillation
Subject: Medicine
For long-term therapy, the most effective control of heart rate in atrial fibrillation, both at rest and with exercise, occurs
with
which
one
of
the
following?
a)
b)
c)
d)
Digitalis
Beta-adrenergic blockers
Calcium channel blockers
Class 1A antiarrhythmics
The correct answer is b)
Explanation:
For long-term therapy, beta-adrenergic antagonist drugs provide the most effective control of heart rate in atrial
fibrillation, both at rest and during exercise. Although calcium channel blockers also lower heart rate both at rest and with
exercise, they are not as effective as Beta-blockers. Digitalis is primarily effective in controlling the heart rate at rest, and
often does not adequately control heart rate with exercise. The Class 1 antiarrhythmics are most useful in maintaining
sinus rhythm and, in fact, may paradoxically increase heart rate.
Question #173
QID: 16922
Topic: Atrial Fibrillation
Subject: Medicine
Which
a)
b)
c)
d)
e)
one
of
the
following
diseases
is
most
commonly
associated
with
atrial
fibrillation?
Crohn's disease (regional enteritis)
Tuberculosis
Hypothyroidism
Systemic hypertension
Rheumatoid arthritis
The correct answer is d)
Explanation:
Atrial fibrillation can be a cardiac sequela of primary noncardiac diseases. Systemic hypertension is present in 45% of
patients with atrial fibrillation. Atrial fibrillation is also associated with diabetes mellitus, pulmonary diseases (specifically
COPD, primary pulmonary hypertension, and acute pulmonary embolism), and acute ethanol ingestion. Atrial fibrillation
is not commonly associated with Crohn's disease, tuberculosis, hypothyroidism (2% of patients), or rheumatoid arthritis.
Question #174
QID: 16987
Topic: Atrial Fibrillation
Subject: Medicine
Compared to patients with permanent atrial fibrillation, patients with paroxysmal atrial fibrillation have a risk of stroke
that is:
a) 50% less
b) 25% less
c) 25% greater
d) 50% greater
e) Similar
The correct answer is e)
Explanation:
Patients with paroxysmal atrial fibrillation (i.e., self-terminating) and persisting atrial fibrillation (i.e., that lasts more than
7 days or requires cardioversion) appear to have a risk of stroke that is similar to that of patients with permanent atrial
fibrillation.
Question #175
QID: 17848
Topic: Atrial Fibrillation
Subject: Medicine
A 77-year-old male presents to your clinic in atrial fibrillation with a rate of 132 beats/min. He has hypertension, but no
history of heart failure or structural heart disease. He is otherwise healthy and active.
The best initial approach to his atrial fibrillation would be:
a) Rhythm control with antiarrythmics and warfarin (Coumadin) only if he cannot be consistently maintained in sinus
rhythm
b) Rhythm control with antiarrythmics and warfarin regardless of maintenance of sinus rhythm
c) Ventricular rate control with amiodarone, and warfarin for anticoagulation
d) Ventricular rate control with digoxin, and aspirin for anticoagulation
e) Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation
The correct answer is e)
Explanation:
Regardless of the long-term management strategy chosen, control of ventricular rate is a critical component of
management of new-onset atrial fibrillation (AF). Rate-controlling agents act primarily by increasing AV nodal
refractoriness.
Beta-blockers and calcium channel blockers are first-line agents for rate control in AF. They are effective at rest and with
exertion. Intravenous diltiazem or metoprolol are commonly used for AF with a rapid ventricular response. Caution
should be exercised in patients with reactive airway disease who are given beta-blockers.
→ Digoxin can be used in the acute setting but does little to control the ventricular rate in active patients. As such, it is
rarely used as monotherapy. Digoxin is indicated in patients with heart failure and reduced LV function.
→ Amiodarone is recommended for use as a rate-controlling agent for patients who are intolerant of or unresponsive to
other agents, such as patients with CHF who may otherwise not tolerate diltiazem or metoprolol.
Several risk factor assessment algorithms have been developed to aid the clinician on decisions on anticoagulation for
patients with AF. The CHADS2 index (Cardiac failure, Diabetes, Stroke [or S2 = transient ischemic attack]) is the most
widely used of these algorithms. The CHADS2 index uses a point system to determine yearly thromboembolic risk. Two
points are assigned for a history of stroke or transient ischemic attack (TIA), and one point is given for age older than 75
years
or
a
history
of
hypertension,
diabetes,
or
heart
failure.
This patient's CHADS2 score is 2 and therefore, anticoagulation therapy should be initiated.
Question #176
QID: 18043
Topic: Atrial Fibrillation
Subject: Medicine
In a patient with atrial fibrillation, which one of the following confers the greatest risk for stroke?
a) Age over 75
b) Diabetes mellitus
c) Previous history of stroke
d) Congestive heart failure
e) Hypertension
The correct answer is c)
Explanation:
It is well established that atrial fibrillation is associated with a heightened risk of stroke. Anticoagulant therapy is not
without risk, and for this reason a risk-scoring system has been developed to aid the clinician in deciding on therapy.
Points are assigned using the acronym “CHADS2”. One point each is given for a history of Congestive heart failure,
Hypertension (both treated and untreated), Age greater than 75, and Diabetes mellitus, and 2 points for a previous history
of Stroke or TIA.
Question #177
QID: 15578
Topic: Malignant Melanoma
Subject: Medicine
An elderly man presents with a skin lesion on his arm. He states that it has been growing in the last few months. The
lesion is asymmetric, has no distinct border, varies in color and is greater than 6mm.
What
a)
b)
c)
d)
e)
is
Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
Pityriasis Rosea
Nevus
The correct answer is c)
Explanation:
the
most
likely
diagnosis?
The ABCD criteria is used to diagnose a malignant melanoma. ABCD is an abbreviation for asymmetry, border, color and
diameter.
Malignant melanoma arises from melanocytes in a pigmented area: skin, mucous membranes, eyes, and CNS. Metastasis
is
correlated
with
depth
of
dermal
invasion.
With
spread,
prognosis
is
poor.
Diagnosis is by biopsy. Wide surgical excision is the rule for operable tumors. Metastatic disease requires chemotherapy
but is difficult to cure.
Question #178
QID: 15583
Topic: Superior Vena Cava Syndrome
Subject: Medicine
A chronic smoker presents with cough, dyspnea and swelling in the face and neck. You suspect superior vena cava
obstruction.
What
is
your
next
step?
a)
b)
c)
d)
Chest x-ray
Pulmonary function tests
V/Q Scan
Arteriogram
The correct answer is a)
Explanation:
Superior vena cava syndrome (SVCS) is a collection of symptoms caused by the partial blockage or compression of the
superior vena cava, the major vein that carries blood from the head, neck, upper chest, and arms to the heart. Nearly 95%
of
SVCS
cases
are
caused
by
cancer.
The most common symptoms are these: problems breathing, coughing and swelling in the face, neck, upper body, and
arms.
Approximately 90% of cases are associated with a cancerous tumor that is compressing the superior vena cava. A chest xray usually shows a mediastinal mass (tumor) that is compressing the superior vena cava.
Question #179
QID: 15586
Topic: Acute Pancreatitis
Subject: Medicine
A 43-year-old woman with severe abdominal pain that radiates to her back is found to have high amylase and lipase
levels. Which of the following is generally not part of the treatment of this illness?
a)
b)
c)
d)
e)
Analgesics
Antibiotics
Nutritional support
IV fluids
Close monitoring (vitals, oxygen saturation, electrolytes, serum glucose, urine output)
The correct answer is b)
Explanation:
Acute pancreatitis is inflammation of the pancreas (and, sometimes, adjacent tissues) caused by the release of activated
pancreatic enzymes. The most common triggers are biliary tract disease and chronic heavy alcohol intake.
The condition ranges from mild (abdominal pain and vomiting) to severe (pancreatic necrosis and a systemic
inflammatory
process
with
shock
and
multiorgan
failure).
Diagnosis is based on clinical presentation and serum amylase and lipase levels. Initial management of a patient with
acute pancreatitis consists of supportive care with fluid resuscitation, pain control, and nutritional support. Patients with
acute
pancreatitis
should
be
monitored
closely
in
the
first
24
to
48
hours.
Antibiotics are generally not indicated. Antibiotics, usually drugs of the imipenem class, should be used in any case of
pancreatitis complicated by infected pancreatic necrosis. However, they should not be given routinely for fever, especially
early in the disease course, because this symptom is almost universally secondary to the inflammatory response and
typically does not reflect an infectious process.
Question #180
QID: 15627
Topic: Acute Pancreatitis
Subject: Medicine
A 50-year-old man presents to the emergency room with severe epigastric pain, low-grade fever, tachycardia, and mild
hypotension. The patient relates a history of moderate to heavy social drinking. The chief resident suspects acute
pancreatitis.
Which one of the following laboratory findings is generally considered diagnostic of acute pancreatitis?
a)
b)
c)
d)
e)
Hyperlipidemia
Hyperbilirubinemia
Severe increase in serum amylase or lipase
Elevated serum phospholipase A
Elevated serum alkaline phosphatase
The correct answer is c)
Explanation:
Acute pancreatitis is inflammation of the pancreas (and, sometimes, adjacent tissues) caused by the release of activated
pancreatic enzymes. The most common triggers are biliary tract disease and chronic heavy alcohol intake. The condition
ranges from mild (abdominal pain and vomiting) to severe (pancreatic necrosis and a systemic inflammatory process with
shock
and
multiorgan
failure).
Serum amylase and lipase levels are typically elevated in persons with acute pancreatitis. However, these elevations may
only indicate pancreastasis. In research studies, amylase or lipase levels at least 3 times above the reference range are
generally
considered
diagnostic
of
acute
pancreatitis.
Treatment is supportive, with IV fluids, analgesics, and fasting.
Question #181
QID: 15729
Topic: Acute Pancreatitis
Subject: Medicine
A 38-year-old alcoholic woman presents with complaints of epigastric pain radiating to her back with nausea and
vomiting.
Physical
exam
reveals
epigastric
tenderness.
What
is
the
most
likely
diagnosis?
a) Cholangitis
b) Pancreatitis
c) Choledocholithiasis
d) Hepatitis
e) Cholecystitis
The correct answer is b)
Explanation:
Acute pancreatitis is inflammation of the pancreas (and, sometimes, adjacent tissues) caused by the release of activated
pancreatic enzymes. The most common triggers are biliary tract disease and chronic heavy alcohol intake. The condition
ranges from mild (abdominal pain and vomiting) to severe (pancreatic necrosis and a systemic inflammatory process with
shock
and
multiorgan
failure).
Diagnosis is based on clinical presentation and serum amylase and lipase levels. Treatment is supportive, with IV fluids,
analgesics, and fasting.
Question #182
QID: 15959
Topic: Acute Pancreatitis
Subject: Medicine
A 60-year-old man is seen in the emergency room and is diagnosed as having acute pancreatitis. Which one of the
following results of the assessment on admission would suggest more severe illness?
a) Serum amylase level > 2000
b) Hyperglycemia and glycosuria
c) High urinary amylase level
d) Serum lipase level > 20,000
e) Hypercalcemia
The correct answer is b)
Explanation:
Ranson’s criteria for predicting the mortality of a patient involves assessment on admission and then again at 48 hours,
with
the
following
criteria:
On
Age
WBC
LDH
SGOT(AST)
Glucose
At
Hct
BUN
Ca
Arterial
Base
>
>
>
350
>
250
>11
48
16,000/uL on
IU/L on
IU/L on
mmol/L on
hours
After
drop
increase
<
pO2
Admission:
>
>
1.98
2
<
deficit >4
Admission:
55
admission
admission
admission
admission
60
10%
mmol/L
mmol/L
mmHg
mmol/L
Fluid
needs
>
6L
Of the answer choices, on admission a high glucose level would contribute to this patients mortality.
Question #183
QID: 16158
Topic: Acute Pancreatitis
Subject: Medicine
A 60-year-old man is admitted to the hospital because of acute pancreatitis. Laboratory studies show:
Amylase
Calcium
BUN
1,000
2.1
U/L
mmol/L,
Hematocrit
WBC 14
1.78
x
42%
109/L
mmol/L
Results of serum liver chemistry profile are normal. After 48 hours of fluid therapy and observation, a poor prognosis
would
be
indicated
by
which
of
the
following
laboratory
studies?
a)
b)
c)
d)
e)
Serum alanine aminotransferase (ALT) of 106 U/L
Serum amylase of 2,000 U/L
Serum bilirubin of 71.8 μmol/L
Serum calcium of 1.65 mmol/L
Serum glucose of 11.1 mmol/L
The correct answer is d)
Explanation:
Of the listed laboratory abnormalities (elevated ALT amylase, bilirubin, and glucose) the one that is most suggestive of
severe pancreatic inflammation, and even necrosis, is hypocalcemia. This is presumably due to the results of
saponification of calcium by released fatty acids.
Question #184
QID: 16861
Topic: Acute Pancreatitis
Subject: Medicine
A 45-year-old white male presents with a 3-day history of new-onset acute upper abdominal pain radiating to the back.
His pulse rate is 110 beats/min and other vital signs are normal. Bowel sounds are hypoactive and epigastric tenderness
without
guarding
is
present.
Which one of the following is most accurate regarding laboratory testing for possible pancreatitis in this situation?
a)
b)
c)
d)
Elevated serum triglyceride levels can cause falsely elevated serum amylase levels
There is a direct correlation between serum amylase levels and the severity of the pancreatitis
Serum amylase and lipase levels may be falsely low in renal failure
A serum lipase level that is three times normal is highly specific for pancreatitis
e) A serum amylase level that is three times normal is highly specific for pancreatitis
The correct answer is d)
Explanation:
A serum lipase level is a more specific test for pancreatitis than an amylase level. Amylase is more likely to be elevated in
other acute abdominal conditions. Amylase levels may also be elevated with salivary gland abnormalities, chronic
sialadenitis,
renal
failure,
and
liver
disease.
Although elevated triglyceride levels are associated with pancreatitis, patients with hypertriglyceridemia and proven
pancreatitis have been found to have deceptively low levels of amylase, and sometimes of lipase activity. There is no
significant correlation between the magnitude of serum amylase elevation and the severity of pancreatitis. In fact, a milder
form of acute pancreatitis is often associated with higher levels of serum amylase than those seen in a more severe form of
the disease. Serum trypsinogen is secreted specifically by the pancreas and is helpful in determining when elevated
amylase levels are coming from non-pancreatic sources. Because amylase, lipase, and trypsinogen are all cleared by the
kidneys, renal failure, particularly with a creatinine clearance < 50 mL/min, may result in delayed clearance and false
elevations of enzymes.
Question #185
QID: 17680
Topic: Acute Pancreatitis
Subject: Medicine
When considering a diagnosis of pancreatitis, amylase levels:
a) can help determine the severity of the disease
b) are less likely to be elevated in alcoholics
c) are more sensitive and specific than serum lipase levels
d) are less likely to be affected by nonpancreatic conditions such as renal insufficiency
The correct answer is b)
Explanation:
Amylase and lipase levels are used to help make the diagnosis of acute pancreatitis. The serum lipase level is more
specific and more sensitive than the amylase level. Amylase elevations can be seen with other abdominal illnesses, such
as inflammation of the small bowel. Alcoholics with recurrent pancreatitis may have normal serum amylase levels; in
such
cases,
serum
lipase
would
be
a
better
test.
There are several scoring systems for the severity of pancreatitis, including the CT severity index, the APACHE II score,
the Imrie Scoring System, and Ranson’s Criteria, but none of these use serum amylase in their calculation. The elevation
of serum amylase does not correspond well with the severity of the pancreatitis.
Question #186
QID: 17700
Topic: Acute Pancreatitis
Subject: Medicine
Which one of the following is a risk factor for acute pancreatitis?
a) Gastroesophageal reflux disease
b) Intravenous drug abuse
c) Angiotensin receptor blocker (ARB) use
d) Pyelonephritis
e) Gallstones
The correct answer is e)
Explanation:
Pancreatitis is most closely associated with gallstones and excessive alcohol use. Gastroesophageal reflux disease,
pyelonephritis, drug abuse (other than alcohol), and angiotensin receptor blocker use are not risk factors for the
development of pancreatitis.
Question #187
QID: 17997
Topic: Urinary Retention
Subject: Medicine
Which of the following drugs will NOT promote urine retention?
a) Sympathomimetics
b) Anticholinergics
c) Cholinergic agonists
d) TCAs
e) Smooth muscle depressants
The correct answer is c)
Explanation:
Urinary retention is a common side effect that occurs with drugs that have anticholinergic properties. Drugs with such side
effect profiles include sympathomimetic, anticholinergics, TCAs, smooth muscle depressants.
Question #188
QID: 15590
Topic: Foot Drop
Subject: Medicine
During the physical exam of a patient’s foot, you notice an inability to dorsiflex. What nerve root(s) is most likely
affected?
a)
b)
c)
d)
T12
L1
L2
L3 - L4
e) L4 - L5
The correct answer is e)
Explanation:
Foot drop can be associated with a variety of conditions such as dorsiflexor injuries, peripheral nerve injuries, stroke,
neuropathies,
drug
toxicities,
or
diabetes.
Often drop foot is caused by injury to the common peroneal nerve (also called common fibular nerve, peroneal nerve,
external popliteal nerve, lateral popliteal nerve), which is derived from the dorsal branches of the fourth and fifth
lumbar and
the
first
and
second
sacral
nerves.
The common peroneal nerve branches from the sciatic nerve. It includes the deep and superficial peroneal branches. These
nerves provide sensation to the anterior and lateral parts of the legs and to the top of the feet.
Symptoms of common peroneal nerve injury (foot drop) may include:






Inability to point toes toward the body (dorsiflexion)
Pain
Weakness
Numbness (on the shin or top of the foot)
Loss of function of foot
High-stepping walk (called steppage gait or footdrop gait)
Question #189
QID: 15588
Topic: Renal Artery Stenosis
Subject: Medicine
A 25-year-old woman with family history of kidney disease is found to be hypertensive and is started on a beta blocker.
What
is
your
next
step
in
the
work-up
of
her
condition?
a)
b)
c)
d)
Urinary metanephrines
Renal doppler ultrasound
CT of abdomen
Serum cortisol
The correct answer is b)
Explanation:
This woman, being so young, most likely has high blood pressure from a secondary cause of renal artery stenosis.
Renovascular hypertension is blood pressure elevation due to partial or complete occlusion of one or more renal arteries
or their branches. It is usually asymptomatic unless long-standing. A bruit can be heard over one or both renal arteries in <
50%
of
patients.
Diagnosis is by physical examination and renal imaging with duplex ultrasonography, radionuclide imaging, or magnetic
resonance angiography. Angiography is done before definitive treatment with surgery or angioplasty.
Question #190
QID: 15764
Topic: Renal Artery Stenosis
Subject: Medicine
On her annual physical exam, a young white patient asks you to help her quit smoking. On her physical exam, she is
found to have right flank continuous bruit. She is known for refractory hypertension and you suspect a secondary cause
for
her
hypertension.
Which
of
the
following
is
most
likely?
a)
b)
c)
d)
e)
Hyperaldosteronism
Cushing syndrome
Renal artery stenosis
Aortic coarctation
Pheochromocytoma
The correct answer is c)
Explanation:
Renovascular hypertension (RVH) is the most common form of curable high blood pressure and is estimated to affect 1%
of all hypertensive individuals. It occurs when significant unilateral or bilateral renal artery stenosis causes renal ischemia.
RVH develops as a result of significant stenosis (generally >60%) of one main renal artery and occasionally arises from
lesions of a distal branch. Two thirds of renal artery stenoses result from atherosclerosis, whereas the various forms of
fibromuscular dysplasia (FMD) are responsible for approximately one third. Atherosclerotic lesions are typically proximal
and found more frequently in older men with evidence of extensive vascular involvement. Bilateral disease, azotemia, and
recurrent
pulmonary
edema
are
also
more
frequent
in
this
group.
Conversely, patients with FMD tend to be young white women with no family history of essential hypertension; lesions
usually involve the middle and distal segments of the renal artery. Smoking increases the risk of renovascular
hypertension
in
both
groups.
Physical examination may show abdominal or flank continuous bruit and/or advanced retinopathy (grades III, IV by KWB
classification).
Renal Artery Stenosis
Question #191
QID: 15591
Topic: Peripheral Vascular Disease
Subject: Medicine
A 55-year-old man who is a smoker, comes in with a complaint of pain in his right calf. He says that it comes and goes
and
happens
when
he
walks
up
a
flight
of
stairs.
What
a)
b)
c)
d)
is
the
next
step
to
diagnose
your
suspicion
of
intermittent
claudication?
MRI of leg
V/Q Scan
CT of lumbar spine
Ankle Brachial index
The correct answer is d)
Explanation:
Intermittent claudication, the most common symptom of peripheral arterial disease, results from gradual narrowing of a
leg artery. It is a painful, aching, cramping, or tired feeling in the muscles of the leg, not in the joints. Intermittent
claudication occurs regularly and predictably during physical activity but is always relieved promptly by rest. The muscles
ache when a person walks, and the pain begins more quickly and is more severe when the person walks quickly or uphill.
Usually, after 1 to 5 minutes of rest (sitting is not necessary), the person can walk the same distance already covered,
although continued walking will again provoke the