Prep 2004 Question 155
Answer A
The girl described in the vignette is displaying normal motor development for a 12-month-old. She pulls to a
stand (8 months), cruises (9 months), and takes a few steps alone (12 months). She likely walked with two
hands held at 10 months and with one hand held at 11 months. She drinks from a cup held by another person (9
to 12 months). Between 12 and 15 months of age, she likely will be able to drink from a cup by herself with some
spillage.
The fine motor skill that is most consistent with normal motor development at this age is a neat pincer grasp
between her forefinger and thumb. Children can remove a rattle from their chests with a raking motion of the
entire hand at 4 months of age. At 5 months, they grasp objects using the ulnar aspect of the hand, and at 6
months they use the radial aspect of the hand to rake objects toward them. At 9 months of age, they use an
immature pincer with a scissoring motion of the thumb and forefinger. At 10 months, the pincer grasp generally
matures, allowing the child to hold a pellet between the pads of the thumb and index finger. This grasp continues
to mature into a neat pincer grasp with the tips of the thumb and forefinger at 12 months.
A child who experiences a delay in motor skills should be examined for changes in tone, strength, and symmetry.
Besides delayed acquisition of motor skills, warning signs for abnormal motor development include rolling prior to
3 months of age (may indicate hypertonia), poor head control at 5 months, persistence of primitive reflexes at 10
months, failure to develop postural reactions at 12 months, and preferential hand use before 18 months (may
indicate problems with the contralateral side).
Prep 2004 Question 171
Answer D
The infant described in the vignette has intrauterine growth retardation, hearing loss, and cerebral calcifications
consistent with congenital intrauterine infection. Among the many causes of intrauterine infection, the more
common ones are cytomegalovirus (CMV), Toxoplasma gondii, rubella, and herpes simplex virus (HSV). Other
causes of congenital infection include human immunodeficiency virus, parvovirus, and syphilis. Infants who have
any of these infections may experience developmental sequelae, whether asymptomatic or obviously ill. It is
important to recognize these sequelae so that infants are evaluated properly both in the hospital and after
discharge.
Infants who have symptomatic congenital CMV infection may have microcephaly, intracranial calcifications, and
chorioretinitis. Approximately 50% of children who have symptomatic CMV infection have associated
sensorineural hearing loss. The hearing loss is progressive, and children known to have been infected with CMV
should receive repeated audiologic examinations.
Infants who have toxoplasmosis present with many of the same signs as infants infected with CMV. Although
most infants have subclinical infection, many have evidence of ophthalmologic or central nervous system changes
on more in-depth evaluation. Infants who have symptomatic toxoplasmosis may present with microcephaly,
intracranial calcifications, seizures, chorioretinitis, optic atrophy, microphthalmia, and sensorineural hearing loss.
Infants who have congenital rubella infection may experience encephalitis, cataracts, microphthalmia, and
sensorineural hearing loss.
Although HSV more typically is transmitted perinatally, infants who have congenital HSV infection may
experience hydrocephalus, encephalitis, microcephaly, chorioretinitis, and microphthalmia.
Because ophthalmologic complications are common in infants who have congenital infections, the infant in the
vignette should receive an ophthalmologic examination. Infants who have pneumonitis may require chest
radiography. Similarly, echocardiography and abdominal and renal ultrasonography may be indicated clinically for
specific patients, but they are not routinely indicated.
Prep 2006 Question 4
Answer C
Term newborns have accrued sufficient iron stores in the latter part of gestation to sustain them for 3 to 4
months after birth; this is true even when the mother has anemia. Although human milk contains lower
quantities of iron, its bioavailability is greater and, therefore, breastfed infants do not require replacement
therapy until 4 months of age. Preterm infants miss out on iron accretion in utero during the last trimester of
pregnancy and may require iron supplementation if they are taking full-volume enteral feedings as early as 2 to 4
weeks of age. Iron supplementation is not required at birth except in the rare circumstance of congenital anemia.
Iron supplementation is required for normal hematopoiesis and brain growth and function, and if not provided by
6 months of age, characteristically leads to iron deficiency anemia.
Prep 2006 Question 61
Answer B
Mumps is a systemic illness characterized by swelling of salivary glands. Such swelling (Item C61A) is seen in
approximately 60% to 70% of cases. The parotid glands are the most common salivary glands involved, and
although one side may swell earlier than the other, ultimately both sides usually are involved. Unilateral parotid
swelling occurs in less than 25% of symptomatic cases. Patients usually do not have high spiking fevers, and
prodromal symptoms are uncommon. Maximum parotid swelling occurs within 1 to 3 days of initial symptoms,
pushing the earlobe upward and outward and making the angle of the mandible no longer visible. Stensen's duct
may appear erythematous and swollen, but it should not have a purulent drainage. Purulent drainage from
Stensen's duct should alert the clinician to the diagnosis of acute suppurative parotitis, which usually is caused by
Staphylococcus aureus.
Prep 2006: Question 68
Answer D
The nonstress test is a measure of spontaneous fetal movement and fetal heart rate reactivity; thus, it is an
indicator of fetal autonomic nervous system integrity, not fetal maturity. In contrast, the contraction stress test
measures fetal heart rate reactivity to uterine contraction and, therefore, can assess uteroplacental sufficiency
and tolerance of labor. The decreased fetal movement described in the vignette requires investigation. A
nonstress test should be the initial evaluation to look for a baseline fetal heart rate, short- and long-term fetal
heart rate variability, and reactivity to any noted fetal movement. Results of the test may be reactive
(reassuring) or nonreactive (concerning), with the latter result result requiring further evaluation by
ultrasonography. Based on this, a biophysical profile score is assigned, which is comprised of amniotic fluid
volume, fetal movement, and fetal breathing activity, together with the results of the nonstress test.