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Pediatric Clinical Pearls, Exams of Medicine

Rasmussen College - Florida Medicine

A series of clinical vignettes with questions and answers related to pediatric medicine. Topics include diagnosis of vascular ring, treatment of poisoning, screening tests for developmental delays, and appropriate antibiotic regimens for pneumonia. The document also covers genetic mutations associated with specific clinical presentations, as well as common causes of bloody diarrhea in children. The questions and answers are concise and provide useful information for medical students and residents studying pediatrics.

Typology: Exams

2021/2022

Available from 06/23/2022

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PC-PNCB Exam Topics

BACKGROUND:

- stridor, coarse wheezing & croupy cough that worsens in supine position

- feeding difficulties (dysphagia + vom) recurrent

- Barium swallow = Esophageal compression

- CXR = abnormal aortic arch

QUESTION: What is the diagnosis?

A) Vascular Ring

B) Esophageal Atresia

C) Laryngotracheoesophageal cleft

D) Laryngocele✅ - CORRECT ANSWER(S):

WRONG ANSWERS:

BACKGROUND:

GI = N/V/Ab Pain

Renal = Diabetes Insipidus

Neuro = tremor, ataxia, coma

QUESTION: Most effective tx for this type of poisoning?

A) Activated Charcoal

B) Sodium Bicar

C) Glucagon

D) Hemodialysis✅ - CORRECT ANSWER(S):

D) Hemodialysis bc this is lithium toxicity -- other mgmt includes whole bowel irrigation

w/polyethylene glycol & IV saline rehydration.

WRONG ANSWERS:

A) Used for ______ overdose

B) Used for TCA overdose

C) Used for Bblocker overdose

BACKGROUND:

- 1 wk old infant

- "Clunk" with adducting legs while applying downward and lateral pressure on knees

Discover Exams of Medicine Rasmussen College - Florida

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PC-PNCB Exam Topics

BACKGROUND:

stridor, coarse wheezing & croupy cough that worsens in supine position
feeding difficulties (dysphagia + vom) recurrent
Barium swallow = Esophageal compression
CXR = abnormal aortic arch QUESTION: What is the diagnosis? A) Vascular Ring B) Esophageal Atresia C) Laryngotracheoesophageal cleft D) Laryngocele✅ - CORRECT ANSWER(S): A) WRONG ANSWERS: B) C) D) BACKGROUND: GI = N/V/Ab Pain Renal = Diabetes Insipidus Neuro = tremor, ataxia, coma QUESTION: Most effective tx for this type of poisoning? A) Activated Charcoal B) Sodium Bicar C) Glucagon D) Hemodialysis✅ - CORRECT ANSWER(S): D) Hemodialysis bc this is lithium toxicity -- other mgmt includes whole bowel irrigation w/polyethylene glycol & IV saline rehydration. WRONG ANSWERS: A) Used for ______ overdose B) Used for TCA overdose C) Used for Bblocker overdose BACKGROUND:
1 wk old infant
"Clunk" with adducting legs while applying downward and lateral pressure on knees

QUESTION: What sign is this? A) Barlow B) Psoas C) Ortolani D) Galeazzi✅ - CORRECT ANSWER(S): A) Barlow --> DDH WRONG ANSWERS: B) Pain elicited by passively extending thigh of pt lying on side --> appendicitis C) Hip relocation and "clunk" w/abduction of legs and lifting up on trochanters -->DDH D) Discrepancy in height of flexed thighs (affected limb is shortened) -->DDH BACKGROUND:

1mo Caucasian F
3cm pink-red macule on thigh
Explain to mom, not get bigger, but will darken to a purple color over time
Mom asks about assoc'd conditions QUESTION: Which of the following constellation of symptoms is seen in a syndrome that is also assoc'd w/this birthmark? A) Axillary freckling, iris hamartomas B) Posterior fossa malformations, coarc of aorta, and eye abnorm C) Facial angiofibromas, shagreen patches, subependymal nodules, epilepsy D) Varicose veins, soft tissue hypertrophy on trunk✅ - CORRECT ANSWER(S): D) This is a port-wine stain WRONG ANSWERS: A) This is NF B) This is PHACE Syndrome C) This is Tuberous Sclerosis BACKGROUND:
1wk term male in NICU for aortic stenosis & poor feeding
Cards waiting until older to correct heart since adequate systemic BP
PO feeds poor, requiring most feeds via NG
Labs show consistent hypercalcemia QUESTION: What diagnosis explains cardiac anomaly + hypercalcemia? A) Down Syndrome B) 22q11 deletion C) Prader Willi D) Williams Syndrome✅ - CORRECT ANSWER(S): D) Williams Syndrome

D) This is Beckwith-Wiedemann Syndrome (11p15) --> Wilms and Hepatoblastoma (do US and measure serum AFP) WRONG ANSWERS: A) B) C) BACKGROUND:

2 wk old infant
spontaneous vag deliv at 38 wks
Exclusively breastfeeds
Elevated phenylalanine levels
No PE abnormalities QUESTION: What is the next step in mgmt? A) Order plasma amino acids B) Order assay for dihydropteridine reductase C) Switch to low-phenylalanine formula D) Switch to soy formula✅ - CORRECT ANSWER(S): A) Do this to confirm PKU (def of phenylalanine hydroxylase) WRONG ANSWERS: B) C) Don't do this until confirmed DX D) This is required for those with galactosemia, no PKU BACKGROUND:
2yo male
eyes moving rapidly/randomly/erratically in all directions
yesterday, arms/legs jerk sporadically and involuntarily
today, difficulty walking
2 months ago, had strep pharyngitis treated with 10days of amox QUESTION: What is the next best step? A) Measure urinary vanillylmandelic acid B) Obtain an ASO titer C) Perform EEG D) Reassurance✅ - CORRECT ANSWER(S): A) This is opsoclonus-myoclonus syndrome ("dancing eyes, dancing feet") -- presents prior to 3yo -- 40 - 50% have neuroblastoma, which secretes vanillylmandelic acid (excreted in urine) -- get a 24-hr measurement of catecholamine levels

-- can also get CT/MRI, US, or PET WRONG ANSWERS: B) Pt will have +ASO titer due to recent strep (w/in last 6 mo) C) D) BACKGROUND:

2yo white boy w/fever 102.8 x24 hrs
Irritable, left otalgia w/fair appetite
Mild rhinorrhea, L TM = dull yellow/bulging
Pneumatoscopy = movement with + pressure only QUESTION: Most sensitive & specific physical finding for AOM? A) Color of TM B) Lucency of TM C) Rhinorrhea D) Abnormal mobility of the TM on pneumatic otoscopy✅ - CORRECT ANSWER(S): D) WRONG ANSWERS: A) B) C) BACKGROUND:
3 wk old boy
Poor feeding, lethargy, and vomiting over the last week
Jittery and shaking a bit
Unsuccessful at breastfeeding, so giving him 2-3oz cow's milk q 3-4 hours
Labs: Serum calcium = 4 Ionized calcium = 1. QUESTION: Which of the following is true? A) Majority of serum calcium is bound to phosphate B) Vit D should be supplemented C) S/S d/t high levels of phosphate in cow's milk D) TX = IV Calcium Gluconate over 1-2 min✅ - CORRECT ANSWER(S): C) Normal Calcium levels = 8.5- 10 Cow's milk = hyperphosphatemia --> hypocalcemia (which is why we don't give cow's milk for first year of life)

QUESTION: What important screening test can you do on older kids with dev delays? A) TSH B) Metabolic Studies C) Venous Blood Lead Levels D) ECG✅ - CORRECT ANSWER(S): C) WRONG ANSWERS: A, B) Not indicated in child growing well w/normal NS D) Not indicated w/o hx of staring spells or other suspicious behav BACKGROUND:

3yo c/o fever/cough
CXR = PNA
Tolerating PO w/o difficulty & appears non-toxic QUESTION: What is most appropriate abx regimen? A) Doxycycline B) Erythromycin C) Levofloxacin D) High-Dose Amoxicillin✅ - CORRECT ANSWER(S): D) for S. PNA WRONG ANSWERS: A, C) Contraindicated for children B) Erythromycin for kids <4mo (C. Trachomatis) or >5yr (M. PNA) BACKGROUND:
3yo girl
short stature, macroceph, flat midface w/prominent forehead, rhizomelic shortening of limbs
signs of hydrocephalus
MRI = narrowing of foramen magnum & compression of brainstem --> neurosurgery QUESTION: Patient most likely has a mutation in which gene? A) FGFR B) FBN C) FMR D) MECP E) MTTL1✅ - CORRECT ANSWER(S): A) These are characteristic of Achondroplasia, a result of mutation in FGFR WRONG ANSWERS:

B) FBN1 Mutations = Marfans C) FMR1 Mutations = Fragile X D) MECP2 Mutations = Rett Syndrome E) MTTL1 Mutations = MELAS BACKGROUND:

4 day old male
ab pain w/sudden green/yellow vomiting
fussy all day, ill a few hours earlier
mildly distended abdomen
backwards L on ab XR QUESTION: What is the next best step in mgmt? A) Barium enema B) Emergency Surgery C) Broad Spectrum abx for presumed NEC D) Obtain US to r/o pyloric stenosis✅ - CORRECT ANSWER(S): B) Gastric and Duodenal dilation on XR = malrotation w/midgut volvulus
Double Bubble on XR
Surg reduces volvulus & relieves ischemia caused by constriction of the bowel's mesenteric blood supply
Necrosis can occur in as little as 3 hours BACKGROUND:
4yo male
Progressive periorbital edema, wt gain, anorexia, & nausea for several weeks
PE = HTN
UA = 4+ Protein QUESTION: What is also most likely? A) Hyperalbuminemia B) Thrombophilia C) Hypotriglyceridemia D) Urinary bacteria✅ - CORRECT ANSWER(S): B) This is Nephrotic Syndrome -- May have microscopic hematuria -- Acute mgmt = fluid restriction, systemic corticosteroid therapy, and admission for possible renal biopsy WRONG ANSWERS: A) Should be HYPOalbuminemia C) Should be HYPOlipidemia D) UTI usually not assoc'd

5yo boy
bloody diarrhea x several days
fatigue, pallor, and malaise
several kids at school = similar complaints
Labs = severe anemia, thrombocytopenia, renal insuff QUESTION: Which of the following most likely cause of symptoms? A) Shigella B) Salmonella C) E. coli D) Rotavirus✅ - CORRECT ANSWER(S): C) E Coli
Triad of anemia, thrombocytopenia, and renal insuff = HUS or TTP (E. Coli is responsible for most HUS)
Tx = supportive & preventing complications of anemia + thrombocytopenia WRONG ANSWERS: A) Shigella (less common) B, D) Salmonella species & RV are not implicated BACKGROUND:
5yo girl
Fever + pruritic rash on several areas of her trunk
Sick contact w/similar symptoms at school
No cough, SOB, HA, or stiff neck
PE = nontoxic/playful child, crop of vesicles in 1 area & dried crusted lesions in other areas QUESTION: What is the most appropriate management? A) Aspirin B) Acetaminophen C) IV Acyclovir D) Varicella-Zoster Vaccine✅ - CORRECT ANSWER(S): B) This is chickenpox/Varicella-Zoster Virus
Fever, myalgias, maculopapular rash progressing to vesicles that rupture & form dry/crusted lesions WRONG ANSWERS: A) C) Only used for immune-compromised pts & those w/signs of encephalitis or pneumonitis D) Indicated for prevention, not acute mgmt BACKGROUND:
6 yo girl

mod, constant periumb pain for sev hrs assoc'd w/nausea
rash on legs/butt for several days
PE = afebrile, diffuse ab tenderness w/o rebounding or guarding, palpable purpura on legs/butt

diffuse jt tenderness QUESTION: What is the next step in evaluation? A) UA B) CT of ab/pelv C) ASO Titers D) Blood Cultures✅ - CORRECT ANSWER(S): A) This is HSP - immune mediated vasculitis - UA reveals hematuria (glomeruloneph); TX = admin corticosteroids or IVIG WRONG ANSWERS: B) C) D) Only do if systemic infxn suspected (fever & focal abd tenderness) BACKGROUND:

6 yo presents p sz
Acute gastroenteritis x2 days
Electrolytes are normal QUESTION: What is most likely the cause? A) Salmonella B) Shigella C) Campylobacter D) Yersinia✅ - CORRECT ANSWER(S): B) Most common bacteria causing acute gastroenteritis, esp w/sz when electrolytes are normal WRONG ANSWERS: A) Not usually assoc w/sz C, D) Mimics appendicitis BACKGROUND:
6yo boy
Unilateral hip pain relieved by rest, referred to knee/groin QUESTION:? A) Boys>Girls B) Usually bilateral C) Most common in obese children D) Almost all pts require surgy✅ - CORRECT ANSWER(S):

B) Verbal consent from babysitter over phone C) Court Order to tx the pt D) Reduce fx & complete a thorough eval✅ - CORRECT ANSWER(S): D) Should tx d/t pt's pain & potential for deformity - HCP has duty to deliver care when life or limb is threatened, regardless of consent. WRONG ANSWERS: A) B) C) BACKGROUND:

9 day old neonate + seizures
remains afebrile
mom has been diluting formula QUESTION: What is most likely cause of seizures? A) Hypokalemia B) Hyponatremia C) Hypocalcemia D) Hypomagnesemia✅ - CORRECT ANSWER(S): B) In newborn w/o fever, hyponatremia = most common cause for seizure
Water intoxication is most common cause of hyponatremia during infancy (unable to concentrate urine adequately) WRONG ANSWERS: A) Uncommon in infancy & does not typically cause seizures C) Possible, but would be more likely if mom was diabetic, baby was preterm or had hx of anoxic enceph D) Possible, but even less likely than Hypocalcemia BACKGROUND:
9 yo fever x2 days, peaking at 103.6F + occasional productive cough & rhinorrhea
somewhat lethargic, eating poorly, drinking well
Pulse ox at 89%, appears moderately ill, bibasilar rales w/scattered rhonchi
Bacterial PNA suspected --> pt hospitalized
CXR = discrete infiltrate in right middle lobe w/air bronchograms QUESTION: What is this pattern termed? A) Lobar PNA B) Pneumatocele C) Miliary PNA D) Interstitial PNA✅ - CORRECT ANSWER(S):

A) Lobar = discrete, unilateral infiltrate in single lobe (usually bacterial) WRONG ANSWERS: B) Pneumatocele = gas-filled cavity in lung parenchyma C) MIliary PNA = MULTIPLE discrete lesions d/t hematogenous spread of pathogen to lungs D) Interstitial PNA = patchy or diffuse infiltrates of the interstitium in preference to the parenchyma (usually viral) BACKGROUND:

9yo returned from India 1 wk ago
2 day hx of progressive fever, H/A, malaise, N without V, and generalized ab pain w/minimal loose stools (no frank diarrhea)
UTD on immunizations + Hep A & Yellow Fever prior to trip
Took Mefloquine for malaria prophylaxis throughout her visit
PE = dehydrated, HR in 50s, faint/blanching/erythematous rash over chest & upper ab
Labs = mild high WBC and mod high LFTs QUESTION: Which of the following is true? A) Req admission for likely dengue fever, start IV clinda B) Relative bradycardia + high fever may indicated typhoid fever C) Contracted strain of malaria resistant to mefloquine D) WBC diff most likely reveals a high eosinophils✅ - CORRECT ANSWER(S): B) Typhoid Fever WRONG ANSWERS: A) Dengue = viral, not tx'd with abx (mosquito-borne infxn); usually present w/fever, malaise, and severe myalgias/arthralgias C) Unlikely since prophylaxis (mefloquine is very effective) D) Traveler's w/fever and elevated eosinophils = helminth infxn (ascaris or hookworm) BACKGROUND:
10 day old infant born at home
green discharge & bilateral conjunctival erythema for last 2 days
Culture = C. trachomatis QUESTION: If born in hospital, what intervention would have prevented this infxn? A) Vit K B) Hep B Imm C) Spinal Tap & Intubation D) None of the Above✅ - CORRECT ANSWER(S): D) Should have received the erythromycin ointment on his eyes at birth to protect against N. gonorrhea conjunctivitis. This erythro may have helped prevent Trachomatis too though

BACKGROUND:

10yo male w/Constitutional Growth Delay QUESTION: Kid asks, "When will I be as tall as my Dad?" A) Eventually, you'll hit a growth spurt B) Little chance you'll be as tall as your dad C) Unsure what final height will be, but should be less than Dad D) Eat well, otherwise you'll always be short✅ - CORRECT ANSWER(S): A BACKGROUND:
12 yo F
Low grade fevers on/off x5 wks
Butterfly rash on cheeks, jt pain, ankle edema, HA, fatigue QUESTION: What condition do you suspect? A) Thrombocytosis B) Elevated ANA C) + Blood Cultures D) Skin scrapings + for scabies✅ - CORRECT ANSWER(S): B) This is SLE WRONG ANSWERS: A) Should have thrombocytopenia C) No an infection D) Not scabies BACKGROUND:
12 yo male
orange colored tonsils, hepatosplenomegaly, sensory def in upper limbs QUESTION: Which is correct re: this condition? A) Caused by def of low-density lipoproteins B) Autosomal dominant inheritance C) Peripheral nerves not involved D) Mutation in ATP cassette transporter protein✅ - CORRECT ANSWER(S): D) This is Tangier Disease WRONG ANSWERS: A) B) C)

BACKGROUND:

12yo eval for fever x2 days, peaking at 103.5 + productive cough & rhinorrhea
somewhat lethargic and eating poorly, but drinking well
Pulse = 112, Normal BP, T 102.2, O2 at 89%
Appears moderately ill, rhinorrhea, bibasilar rales w/scattered rhonchi
CXR = patchy infiltrates in R upper and R/L lower lobes QUESTION: What is this pattern termed? A) Pleural Effusion B) Bronchopneumonia C) Miliary PNA D) Lobar PNA✅ - CORRECT ANSWER(S): B) WRONG ANSWERS: A) C) Multiple lobes with discrete lesions (no patchy infiltrates) D) Discrete, unilateral infiltrate in 1 lobe BACKGROUND:
14mo w/head injury after fall QUESTION: When assessing children with injuries, which of the following findings does the nurse consider most concerning for possible child abuse or neglect? A) Bruise in crawling, but not walking child B) Delay by parents in seeking care C) Bruising on legs D) Any scald injury in child under age of 5✅ - CORRECT ANSWER(S): B) WRONG ANSWERS: A) 2 or more bruises in child not yet crawling = red flag C) Red Flag Bruising on torso, neck, ears, or buttocks; bite marks also D) Immersion scald injuries w/clear demarcation line (rather than splatter patter) are consistent w/abuse BACKGROUND:
14yo F w/fever x1 day (39.1) + HA + stiff neck
PE = nuchal rigidity, eyes w/normal discs, normal CT QUESTION: Which of the following would you expect on a LP with aseptic meningitis? A) Decreased Glucose (<40), increased WBCs

B) Single herald patch followed by numerous slightly scaly, salmon-colored lesions in a Christmas tree pattern (caused by human herpes virus 6 or 7) C) Caused by a deeper fungal infxn characterized by pruritic reddish patches w/central clearing and vesicles at borders D) Hypopigmentation only (permanent & autoimmune basis) BACKGROUND:

16 yo F w/secondary amenorrhea, acne, hirsutism, & wt gain for endo eval
Never sexually active
LH:FSH = 3:1, estradiol normal, androgens mildly elevated QUESTION: What is most likely DX? A) PCOS B) Late-Onset CAH C) Turner Syndrome D) Hypothyroidism E) Outflow Tract Obstrxn✅ - CORRECT ANSWER(S): A) WRONG ANSWERS: B) Late-onset CAH ruled out based on normal 17-OH-progesterone levels C) Assoc w/PRIMARY amenorrhea D) Detected via elevated TSH level E) Typically assoc'd w/PRIMARY amenorrhea & dx'd via US BACKGROUND:
16yo girl w/von Willebrand disease
bruising, gingival bleeding, menorrhagia refractory to desmopressin therapy QUESTION: Which of the following is the next step in tx? A) Factor VIII w/von Willebrand factor complex B) Ristocetin co-factor assay C) Drotecogin alpha D) Factor 8 Replacement Therapy✅ - CORRECT ANSWER(S): A) WRONG ANSWERS: B) Used to initially dx vWF C) No longer available in US D) Used for Hemophilia A

BACKGROUND:

17yo F
Menarche at 11yo, very irregular since then
No menstruation in 4 months
Comedonal acne over forehead, cheeks, & chin + scattered pigmented hair on chin & upper lip
UPT is negative
LH, FSH, Estrogen, DHEA-S, TSH normal ranges
LH:FSH = >2:
Prolactin, Total Test, & Free Test slightly elevated QUESTION:? A) Reassurance, irreg menses is norm until reg menses is established B) CT to eval for prolactinoma or pit tumor C) Start continuous progestin-only OCP D) Start combined OCP + Wt Loss + Exercise✅ - CORRECT ANSWER(S): D) This is Secondary Amenorrhea (caused by either pregnancy, anorexia, or PCOS). PCOS because obese, excessive androgens (acne, hirsutism), and LH:FHS >2: WRONG ANSWERS: A) Irreg menses is norm only in 1st 2 years after menarche + amenorrhea for >3mo is always uncommon B) Rare cause of amenorrhea, and only mildly elevated prolactin levels C) This may exacerbate symptoms BACKGROUND:
17yoF
Severe ab pain + n/v + fever + tachycardia
Previously eval'd for appendicitis, & other GYN causes
No cutaneous manifestations
Labs: increase aminolevulinic acid & PBG concentrations in urine; no increase in urinary/fecal coproporphyrin III. QUESTION: Which of the following is correct regarding this condition? A) Affected enzyme = PBG deaminase B) Affected enzyme = coproporphyrinogen oxidase C) Affected enzyme = protoporphyrinogen oxidase D) Sz can occur & should be tx'd w/phenobarb✅ - CORRECT ANSWER(S): A) This is acute intermittent porphyria (AIP) WRONG ANSWERS: B) C) D)

Pediatric Clinical Pearls, Exams of Medicine

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PC-PNCB Exam Topics

BACKGROUND:

BACKGROUND:

BACKGROUND:

BACKGROUND: