Czhu- Usmle 2 - Pediatrics

Front 1

A healthy, well-developed 6-year child arrives as a new patient to your clinic. His immunization cards reveals that he received an immunization at birth and some when he was 2 months old, but none since. Which vaccine is generally not recommended at 5 years at older?

Back 1

Haemophilus influenzae type B

Front 2

Appropriate advice for a mother of a 2 week old child here for a "well-child" visit includes which is of the following?

Back 2

1. Juices (undiluted) are avoided until approximately 6 months of age (in a cup and not in a bottle).
2. Infants sleep thru the night by age 2-3 months
3. Realistic targets for development include rolling over at 4 months and sitting by 6 months.
4. Potty training starts when the child shows interest, usually no earlier than 2 years.
5. Parents are told to place healthy children on their backs (or side) for sleep to reduce the incidence of sudden infant death syndrome.

Front 3

During a "well-child" visit, the parents of a healthy 5 month old offer a great info. Is limited eye contact with parents a major concern?

Back 3

Children fix and follow on the human face from birth. A 5-month old child who does not engage in eye contact is abnormal.

Front 4

What are considered true contraindications for vaccinations?

Back 4

They are rare but include:
- Hypersensitivity rxns to the vaccine, the vaccine component, or the preservative in the agent.

Front 5

Conditions that are NOT contraindications for vaccinations include...

Back 5

1. mild upper respiratory infections
2. gastroenteritis
3. low-grade fevers

Front 6

Which two populations should not receive live vaccinations?

Back 6

1. Pregnancy and severely immunocompromised patients
2. Vaccines can be given to children living in the home with a pregnant woman.
3. MMR and varicella vaccinations can be given to asymptomatic patients wit HIV.

Front 7

How is Croup characterized?

Back 7

- hoarseness, inspiratory stridor, and a "barky" cough - often preceded by a prodrome of upper respiratory symptoms.

Front 8

What are possible etiologies in the diff dx of Croup to consider? And which are more concerning?

Back 8

1. Epiglottitis (char. by drooling and sitting in a tripod or upright position), bacterial tracheitis, and foreign-body aspiration.
2. Epiglottitis and bacterial tracheitis require stabilization in a calm environment by an expert skilled in airway management.

Front 9

What are effective therapies for moderate and severe Croup?

Back 9

- Aerosolized epinephrine and systemic or nebulized steroids.

Front 10

What are some common bacterial pathogens causing Otitis Media?

Back 10

- Strep. pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarhalis.

Front 11

What are some exam findings of Otitis Media?

Back 11

1. red, bulging TM that does not move well with pneumatic otoscopy
2. an opaque TM with pus behind it
3. obscured middle-ear landmarks,
4. and if the TM has ruptured, pus is the ear canal.

Front 12

What is the initial tx for Otitis Media?

Back 12

- Amoxicillin. If a clinical failure seen day 3, a change to amoxicillin -clavulanate, cefuroxime axetil, ceftriaxone, or a tympanocentesis is indicated.

Front 13

What are some complications of Otitis Media?

Back 13

- they are rare but include mastoiditis, temporal bone osteomyelitis, facial nerve palsy.

Front 14

In the US, is inorganic or organic the more common cause of Failure to Thrive?

Back 14

- In the US, psychosocial failure to thrive is more common than organic failure to thrive; it often is associated with poverty or poor parent-child interaction.
- Up to 1/3 patients with psychosocial failure to thrive have development delay as well as social and emotional problems.

Front 15

What are some first steps for healthy-appearing infants with Failure to Thrive?

Back 15

- inexpensive lab screening tests, dietary counseling, and close observation of weight changes.

Front 16

What is a common organic cause of Failure to Thrive?

Back 16

- Renal tubular acidosis, can have proximal tubule defects (type 2) caused by impaired tubular bicarbonate reabsorption or distal tubule defects (type 1) caused by impaired hydrogen ion secretion. Type 4 is also a distal tubule problem associated with impaired ammoniagenesis.

Front 17

The etiologies of pnenumonia varies according to the patient's age. What are common causes for each age group?

Back 17

1. Neonates have the greatest risk for group B steptococcus
2. Toddlers (newborns to ~5 years) - RSV, influenza, parainfluenza
3. Adolescents (5+ yrs) - Mycoplasma ("walking pnuemonia")
4. Intubated ICU patient with central lines - Pseudomonas aeruginosa
5. Skin findings and pnuemonia - Varicella-zoster virus
6. concomitant retinitis - Cytomegalovirus
7. Exposure to stagnant water - Legionella pneumophila
8. Refractory asthma or a classic "fungal ball" on CXR - Aspergillus
9. Travel to Southwest US - Coccidioides immitis
10. Infected sheep or cattle - Coxiella brunetti
11. Spelunking or working farm east of Rocky Mtns - Histoplasma capsulatum.

Front 18

What are the most commonly used and most common illicit drug used in adolescence?

Back 18

1. Cigarettes and alcohol
2. Marijuana

Front 19

What are some substance abuse behaviors?

Back 19

- drug dealing, prostitution, burglary, unprotected sex, auto accidents, and physical violence.

Front 20

Significant behavior problems, learning difficulties, and impaired family functioning describe children at risk for what?

Back 20

Drug use

Front 21

A 14-y.o. has ataxia. He is brought to the local ER, where he appears euphoric, emotionally labile, and a bit disoriented. He has nystagmus and hypersalivation. Many notice his abusive language. What substance is causing this?

Back 21

PCP is associated with hyperactivity, hallucinations, abusive language, and nystagmus.

Front 22

Parents bring their 16 y.o. daughter for a WCC. She looks normal on exam. As part of your routine care you plan a UA. The father pulls you aside and asks you to secretly run a UDS on his daughter. Is this appropriate?

Back 22

The adolescent's permission should be obtained before the drug-testing. Testing "secretly" in this situation destroys the doctor-patient relationship.

Front 23

Name some perinatal complications for Infants of Diabetic Mothers (IDM).

Back 23

Hypoglycemia, hyperbilirubinemia, birth trauma, and congenital malformations.

Front 24

When are mothers screened for gestational diabetes?

Back 24

B/w 24 and 28 weeks of pregnancy.

Front 25

Are head circumferences grow in size like the rest of the body for IDM? and why?

Back 25

No, they are usually normal b/c insulin does not affect brain growth, the rest of the body is usually heavier and longer.
IDM can be small for gestational age if placental insufficiency is present.

Front 26

Why are IDM hypoglycemic?

Back 26

Fetal hyper insulinism is a response to poorly controlled maternal hyperglycemia resulting in fetal macrosomia and increased fetal oxygen requirements.
High infant insulin levels cause him to become hypoglycemic when he is removed from the high-sugar in utero environment and must be managed immediately to prevent further complications.

Front 27

What are 3 things you need for its Dx of exclusion of SIDS?

Back 27

You need an postmortem investigation, postnatal hx, and crime scene investigation fails to yield another explanation.

Front 28

What is Sudden Infant Death Syndrome (SIDS)?

Back 28

SIDS is the most common cause of death of infants b/w 1 week and 1 year of age, and it more commonly affects boys and Native and African-americans children.

Front 29

A pregnant woman comes to you for a prenatal visit. As her family pediatrician, your advice to her should include which one of the following info about reducing the risk of SIDS?
a. reduce the infant's exposure to prenatal and environment smoke, and always place the baby in the supine position when she sleeps.
b. always keep the baby in the prone position even while awake.
c. administer supplement infant vitamins
d. attempt to make breast milk the infant's primary source of nutrition
e. protect the infant from people who are ill.

Back 29

A. although your advice to this woman might also include C, D and E, these measure have not been shown to reduce the infant's risks of SIDS.

Front 30

The parents of a 3 year old child are worried about the child's apparent clumsiness with frequent falls and a waddling gait. What is consistent with Duchenne muscular dystrophy?

Back 30

Duchenne muscular dystrophy is an X-linked recessive disease and is clinically evident only in males. Affected boys may have calf hypertrophy that occurs as a compensation for proximal muscle weakness. They will generally develop a Gower sign.

Front 31

What is the best screening test for Duchenne Muscular Dystropy?

Back 31

A definitive dx can be made only using muscle biopsy tissue, but serum creatine kinase measurement is preferred b/c it is less invasive and results can be obtained rapidly. EMG will reveal nonspecific myopathy.

Front 32

A 12 y.o. healthy boy has noticed some muscle weakness. He has experienced increasing difficulty lifting his backpack and walking long distances. He has no trouble with schoolwork, and he continues to play the piano and video games w/o tiring. His 38 y.o. maternal uncle recently became wheelchair-bound for unclear reason. Which of the following is the most likely dx?
a. cerebral palsy
b. DMD
c. myasthenia gravis
d. becker MD
e. guillian-barre syndrome

Back 32

This patient does not have muscle weakness that precludes extended use of distal muscles (hands) or limits his manual dexterity. The child's presentation at age 12 years and a 38 y.o., wheelchair-bound maternal uncle suggest a dx of Becker MD.

Front 33

What is prognosis for Becker MD?

Back 33

Patients with Becker MD have a genetic defect at or near the Xp21.2 locus resulting in abnormal dystrophin. The clinical course is more benign than with DMD. Patients with Becker MD have elevated creatine kinase levels and marked calve hypertrophy. Loss of ambulation is common by the early fourth decade of life.

Front 34

Please describe physiologic jaundice.

Back 34

P.J. is observed during the first week of life in the majority of infants, results from higher bilirubin production rates and a limited ability of excretion.
Comprises primarily unconjugated hyperbilirubinemia observed during the first week of life in approx. 60% of full term infants and 80% of preterm infants.
Full term newborns usually have peak bilirubin [ ] of 5-6 mg/dL b/w 2nd and 4th days of life.

Front 35

What findings are suggestive of nonphysiologic jaundice?

Back 35

1. appearance in the first 24-36 hrs of life.
2. bilirubin rate of rise greater than 5 mg/dL/24 h
3. bilirubin greater than 12 mg/dL in a full-term infant w/o other physiologic jaundice risk factors listed and;
4. jaundice persists after 10-14 days of life.

Front 36

What are some etiologies of nonphysiologic jaundice?

Back 36

Septicemia, biliary atresia, hepatitis, galactosemia, hypothyroidism, cystic fibrosis, congenital hemolytic anemia, drug-induced hemolytic anemia, or antibodies directed at the fetal RBC.

Front 37

What is Kernicterus and its relation to bilirubin?

Back 37

High levels of unconjugated bilirubin may lead to Kernicterus, an irreversible neurologic syndrome resulting from brain cell bilirubin deposition, especially in the basal ganglia, globus pallidus, putamen, and caudate nuclei.
Less mature or sick infants are at a greater risk. The signs and symptoms of Kernicterus may be subtle and similar to those of sepsis, asphyxia, hypoglycemia, and intracranial hemorrhage.

Front 38

A 3 day old infant is noted to have significant hyperbilirubinemia. He is dxed with Gilbert syndrome. Which of the following is the most likely mech. of the elevated bilirubin level?

Back 38

Gilbert disease is associated with a hepatic abnormalities of bilirubin transport.

Front 39

The hyperbilirubinemia associated with Crigler-Najjar syndrom type 1 is caused by what?

Back 39

Although all infants are relatively deficient in uridine diphosphate glucuronosyltransferase, those with Crigler-Najjar syndrome type 1 have a severe deficiency, causing high bilirubin levels and encephalopathy. Treatment is phototherapy. Encephalopathy is rare and C-N type II, in which bilirubin rarely exceed 20 mg/dL.

Front 40

What is the importance of the Triple Screen b/w the 15th and 20th weeks of pregnancy?

Back 40

Measurements of AFP, hCG, and estriol levels, screen for a variety of genetic problems. Approx. 60% Down syndrom and 80-90% of babies with neural tube defects will be identified by this testing.

Front 41

What is Down syndrome? What are some common features and common problems?

Back 41

Down syndrome is the most common autosomal chromosome abnormality in liveborn infants, increasing in incidence with advanced maternal age.
The most common neonatal features are hypotonia with poor Moro reflex, flat facies, slanted palpebral fissures, laxity of joints, and excessive skin on the back of neck.
Common problems associated with Down Syndrome include cardiac defects and duodenal atresia (double-bubble sign)

Front 42

A small for gestational age infant is born to a 35 y.o. woman. He has low-set and malformed ears, microcephaly, rocker-bottom feet, inguinal hernias, cleft lip/palate, and micrognathia. Chromosomal analysis reveals what?

Back 42

The child has trisomy 18 (Edwards). Other features include clenched hands with overlapping digits, small palpebral fissures, prominent occiput, short sternum, and cardiac defects (VSD, ASD, PDA, or coarctation of the aorta)

Front 43

A small for gestational age, dysmorphic newborn infant has microcephaly and sloping forehead, cutis aplasia (missing portion of the skin and hair) of the scalp, polydactyly, microphthalmia, and omphalocele. What is the most likely dx?

Back 43

The appearance of cutis aplasia and polydactyly suggests trisomy 13 (Patau). Other common features include holoprosencephaly, cleft lip/cleft, postaxial polydactyly, flexed and overlapping fingers, coloboma, and cardiac defects (VSD, ASD, PDA, and dextrocardia)

Front 44

What is the major source of lead exposure in the US?

Back 44

Lead-containing paint in older homes <1970s.
Blood lead levels is the dx test of choice.

Front 45

What are some behavioral signs of lead toxicity?
What are some physical symptoms?

Back 45

Behavioral signs of lead toxicity include hyperirritability, altered sleep patterns, decreased play activity, loss of developmental milestones (especially speech), and altered state of consciousness.
Physical symptoms include vomiting, intermittent abdominal pain, constipation, ataxia, coma, and seizures.

Front 46

What does chelation therapy in an asymptomatic child with elevated lead levels consists of?

Back 46

intramuscular calcium disodium ethylene diaminetetracetic acid (CaEDTA) or oral meso-2,3- dimercaptosuccinic acid (succimer). Hospitalized patients with symptomatic disease are often treated with 2,3- dimercaptopropanol (BAL) and CaEDTA.