T3 - R1.2 - Peds Clinic

Front 1

Students attending a school built in 1951 are at risk for which of the following?

A. Arsenic
B. Asbestos
C. Dichlorodiphenyltrichloroethane (DDT)
D. Mercury
E. Polychlorinated biphenyls(PCBs)

Back 1

B. Between 1947 and 1973 asbestos was commonly sprayed on school ceilings as a fire retardant. Deterioration results in release of microscopic fibers into the air. Drop ceilings or placement of barriers usually is sufficient protection against this carcinogen.

Front 2

An 8-year-old, mentally delayed child ingests the contents of a mercury thermometer. Which of the following symptoms are most likely to be seen?

A. Ataxia, dysarthria, and paresthesias
B. Chest pain and dyspnea
C. Gingivostomatitis, tremor, and neuropsychiatric disturbances
D. No symptoms
E. Pulmonary fibrosis

Back 2

D. The child in the question is unlikely to develop symptoms (the quantity of mercury is small); a larger acute elemental ingestion might result in a variety of gastrointestinal (GI) complaints. If the elemental mercury were in vapor form, GI complaints would be seen, along with fever, chills, headaches, visual changes, cough, chest pain, and possibly pneumonitis and pulmonary edema. Exposure to inorganic mercury salts (pesticides, disinfectants, explosives, dry batteries) can cause gastroesophageal burns, nausea, vomiting, abdomi- nal pain, hematemesis, hematochezia, cardiovascular collapse, or death. Ataxia, dysarthria, and paresthesias are seen in methyl mer- cury intoxication (contaminated fish exposure). Gingivostomatitis, tremor, and neuropsychiatric disturbances are seen with chronic inorganic mercury intoxication; indeed, the term “mad as a hatter” originates from the occupational hazard of workers’ exposure in the early industrial period to mercury-containing vapors during the process of felt hat making.

Front 3

A 4-year-old child is found with a bottle of insecticide that contains arsenic. Which of the following symptoms is most likely to occur?

A. Bradycardia with third-degree heart block
B. Constipation
C. Hemorrhagic gastroenteritis with third spacing of fluids
D. Hyperreflexia
E. Hypothermia

Back 3

C. Acute arsenic ingestions can cause nausea, vomiting, abdominal pain, and diarrhea. The third spacing and hemorrhage in the gut can lead to hypovolemic shock. Cardiac symptoms include ventricular tachycardia (QT prolongation) and congestive heart failure (CHF). These patients can develop seizures, cerebral edema, encephalopa- thy, and coma. Early on, patients develop loss of deep tendon reflexes, paralysis, painful dysesthesias, and respiratory failure similar to Guillain-Barré syndrome. Fever, anemia, alopecia, hepatitis, and renal failure also can be seen.

Front 4

Exposure to environmental toxins can occur in a number of ways. Which of the following is the most likely mechanism of exposure?

A. Asbestos exposure from hazardous arts and crafts materials
B. Exposure of a child to beryllium from the child’s parents’ clothing
C. Iron intoxication from vehicular emissions
D. Lead toxicity from ingesting pieces of a pencil
E. Transplacental exposure to benzene

Back 4

B. Fat-soluble compounds can be transmitted transplacentally (but benzene would be unusual). Parents’ work clothes can transmit potentially hazardous compounds. Arts and crafts supplies likely do not contain asbestos. Vehicular emissions are responsible for a num- ber of pollutants, many of which are carcinogens, but iron intoxication would be unusual. Pencil “lead” is actually graphite (carbon) and not elemental lead.

Front 5

An 8-year-old boy has severe pain with ear movement. He has no fever, nausea, vomiting, or other symptoms. He has been in good health, having just returned from summer camp where he swam, rode horses, and water-skied. Ear examination reveals a somewhat red pinna that is extremely tender with movement, a very red and swollen ear canal, but an essentially normal TM. Which of the following is the most appropriate next course of therapy?

A. Administration of topical mixture of polymyxin and corticosteroids
B. High-dose oral amoxicillin
C. Intramuscular ceftriaxone
D. Intravenous vancomycin
E. Tympanocentesis and culture

Back 5

A. The patient likely has an otitis externa that was caused by his swimming (also known as swimmer’s ear). Treatment is the applica- tion of a topical agent as described. Insertion of a wick may assist in excess fluid absorption in the macerated ear canal. Causative organ- isms include Pseudomonas species (or other gram-negative organisms), S aureus, and occasionally fungus (Candida or Aspergillus species).

Front 6

Three days after beginning oral amoxicillin therapy for OM, a 4-year- old boy has continued fever, ear pain, and swelling with redness behind his ear. His ear lobe is pushed superiorly and laterally. He seems to be doing well otherwise. Which of the following is the most appro- priate course of action?

A. Change to oral amoxicillin-clavulanate
B. Myringotomy and parenteral antibiotics
C. Nuclear scan of the head
D. Topical steroids
E. Tympanocentesis

Back 6

B. The child has mastoiditis, a clinical diagnosis that can require CT scan confirmation. Treatment includes myringotomy, fluid cul- ture, and parenteral antibiotics. Surgical drainage of the mastoid air cells may be needed if improvement is not seen in 24 to 48 hours.

Front 7

A 5-year-old girl developed high fever, ear pain, and vomiting 1 week ago. She was diagnosed with OM and started on amoxicillin-clavulanate. On the third day of this medication she continued with findings of OM, fever, and pain. She received ceftriaxone intramuscularly and switched to oral cefuroxime. Now, 48 hours later, she has fever, pain, and no improvement in her OM; otherwise she is doing well. Which of the fol- lowing is the most logical next step in her management?

A. Addition of intranasal topical steroids to the oral cefuroxime
B. Adenoidectomy
C. High-dose oral amoxicillin
D. Oral trimethoprim-sulfamethoxazole
E. Tympanocentesis and culture of middle ear fluid

Back 7

E. After failing several antibiotic regimens, tympanocentesis and culture of the middle ear fluid are indicated.

Front 8

A 1-month-old boy has a fever to 102.7°F (39.3°C), is irritable, has diarrhea, and has not been eating well. On examination he has an immobile red TM that has pus behind it. Which of the following is the most appropriate course of action?

A. Admission to the hospital with complete sepsis evaluation
B. Intramuscular ceftriaxone and close outpatient follow-up
C. Oral amoxicillin-clavulanate
D. Oral cefuroxime
E. High-doseoralamoxicillin

Back 8

A. Very young children with OM (especially if irritable or lethargic) are at higher risk for bacteremia or other serious infection. Hospitalization and parenteral antibiotics often are needed.

Front 9

A 12-year-old asthmatic girl presents to the ED with tachypnea, intra- costal retractions, perioral cyanosis, and minimal wheezing. You administer oxygen, inhaled albuterol, and intravenous prednisone. Upon reassessment, wheezing increases in all fields, and the child’s color has improved. Which of the following is the appropriate explanation for these findings?

A. The girl is not having an asthma attack.
B. The girlis not responding to the albuterol, and her symptoms are
worsening.
C. The girl is responding to the albuterol, and her symptoms are
improving.
D. The girl did not receive enough albuterol.
E. The albuterol was inadvertently left out of the inhalation treatment, and the girl received only saline.

Back 9

C. This child presented in severe respiratory distress. Her improved color indicates reversible symptoms, confirming the diagnosis of asthma. Increased wheezing is auscultated after albuterol treatment because lung areas previously obstructed are now opening, allowing additional airflow. Less-experienced examiners may misinterpret lack of air movement as “clear” breath sounds, further delaying appropriate medical management.

Front 10

A previously healthy 2-year-old girl presents with the complaint of acute-onset wheezing. Her mother denies previous wheezing episodes and denies a family history of asthma or atopy. The mother says that she left the child playing in her older brother’s room. Approximately 20 minutes later she heard the child coughing and wheezing. Which of the following is the best next step in management?

A. Determining what the girl was playing with and ordering a chest radiograph
B. Referring the child to a pulmonologist
C. Prescribing antibiotics for a likely pneumonia D. Administeringaninjectionofintramuscularprednisoneandsending
her home
E. Accusing the mother of poor supervision of her child’s health,
because this obviously is not the first time the child has experienced these symptoms

Back 10

A. Young children, generally between 4 months and 3 years of age, normally put objects in their mouth, and they are prone to develop- ing foreign-body aspirations. A pulmonologist ultimately may be needed to retrieve the object, but this would not be a first step.

Front 11

A well-developed 4-month-old boy presents to the ED on a cold winter’s night with the complaint of worsening respiratory distress and decreased oral intake. His parents report that he was well until yesterday, when he developed upper respiratory symptoms and a low-grade fever. Upon examination of the child, you note pallor and perioral cyanosis, a respi- ratory rate of 65 breaths/min, and tight wheezes throughout the chest. An arterial blood gas shows a pH of 7.15, a PCO2 of 65 mm Hg, and a serum bicarbonate of 20 mmol/L. Which of the following is the the most likely explanation regarding the child’s condition?

A. The child most likely has bronchiolitis, and is at risk of respiratory failure.
B. The child most likely has bronchiolitis, and his symptoms should resolve in the emergency department with a couple more albuterol treatments.
C. The child should undergo upper endoscopy, as you suspect a tracheoesophageal fistula.
D. The child most likely has gastroesophageal reflux and has aspirated.
E. The child has a metabolic acidosis that is most likely due to bacterial sepsis.

Back 11

A. The differential diagnosis for a wheezing baby is extensive. However, the sudden onset of respiratory symptoms in a previously healthy infant, particularly in association with fever, is most consis- tent with the diagnosis of bronchiolitis. Initial treatment for this baby includes oxygen and nebulized albuterol or epinephrine. A blood gas measurement should be obtained immediately for any patient who presents in severe respiratory distress. This child’s blood gas indices show a marked respiratory acidosis. He will likely require mechanical ventilation and monitoring in an intensive care setting until his symptoms improve. Infants with wheezing caused by bron- chiolitis do not always respond to β-agonists. Chest radiographs in infants with bronchiolitis typically show hyperinflated lungs with areas of atelectasis. Respiratory syncytial virus (RSV) and influenza A are common causes of bronchiolitis in infants in the wintertime, but several other viral causes are also possible. A careful history should be obtained to rule out less common causes of wheezing in an infant, such as recurrent aspiration or a congenital anomaly.

Front 12

A 15-year-old adolescent male uses his albuterol inhaler shortly after he mows the lawn because of a mild feeling of chest “tightness.” He later returns home early from dinner at a friend’s house when he has the sudden onset of wheezing, cough, and chest pain. Which of the following is the most likely explanation for these circumstances?

A. He likely aspirated a piece of grass.
B. His albuterol inhaler must be empty.
C. His albuterol inhaler must be outdated.
D. He is having a late-phase reaction.
E. He has been exposed to a new allergen that is more irritating than
grass.

Back 12

D. A late-phase reaction typically occurs 2 to 4 hours after an initial wheezing episode. It is caused by accumulation of inflammatory cells in the airway.

Front 13

A developmentally normal two-year-old child is in your inner city office for a well-child check. As part of the visit, you obtain a blood lead level and a hemoglobin level in accordance with your state’s Medicaid screening guidelines. The following week, the state lab calls your office to report the child’s blood lead level is 14 Ìg/dL. Appropriate management of this level should include which of the following actions?

A. Initiate chelation therapy.
B. Perform long bone radiographs.
C. Reassure the parents that no action is required.
D. Repeat the blood lead level in three months.
E. Report to the local health department for environmental investigation.

Back 13

D. The patient’s lead screen is mildly elevated. Appropriate man- agement includes educating the parents about potential lead expo- sures in the environment as well as in the diet. A repeat level should be performed in three months. Chelation therapy is currently advised for patients with a blood lead level of 45 μg/dL and above. Environmental investigation is recommended in patients with a blood lead level of 20 μg/dL and above, or if levels remain elevated despite educational efforts. Long bone radiographs are not recom- mended at any blood lead level.

Front 14

While evaluating the family in the previous question, you discovered a three-year-old sibling with a lead level of 50 μg/dL. You reported the case to the local authorities and initiated chelation therapy. All lead sources in the home have since been removed (verified by dust wipe samples), and the parents do not work in occupations prone to lead exposure. After a course of outpatient chelation therapy, the three- year-old’s lead level dropped to 5 μg/dL. Today, however, the child’s three month followup blood lead level is 15 μg/dL. At this point, appropriate management includes which of the following actions?

A. Initiate a course of inpatient parenteral chelation therapy.
B. Perform long bone radiographs.
C. Reassure the parents and repeat a blood lead level in three months.
D. Recommend the family move to another home.
E. Repeat a course of outpatient chelation therapy.

Back 14

C. In this case, reassurance is appropriate. Lead deposits in bone, and chelation does not remove all lead from the body. After chelation is complete, lead levels tend to rise again; the source is thought to be the redistribution of lead stored in bone. Repeat chelation is only recommended if the blood lead level rebounds to 45 μg/dL or higher. Moving to another home is not necessary, assuming the health department successfully remediated their current home. Long bone radiographs are not recommended at any blood lead level.

Front 15

A term newborn infant is admitted to the Neonatal ICU after having a seizure in the Well Baby Nursery. Your examination reveals a micro- cephalic infant with low birth weight who does not respond to sound. In your discussions with the family, you discover this is the parents’ first child. They recount odd symptoms that have developed in the both of them in the last few months, including fine tremors in their upper extremities and blurry vision. They also note that they both can no longer smell their food and that it “tastes funny.” The mother notes that she has had trouble walking straight in the last few weeks, but she attributes that to her pregnancy. Which of the following environmen- tal toxins is most likely to have caused these findings?

A. Inorganic arsenic salts
B. Lead
C. Methyl mercury
D. Orellanine
E. Polychlorinated biphenyls

Back 15

C. Infants exposed in utero to methyl mercury may display low birth- weight, microcephaly, and seizures. They also display significant developmental delay and can have vision and hearing impairments. Symptoms in children and adults include ataxia, tremor, dysarthria, memory loss, altered sensorium (including vision, hearing, smell, and taste), dementia, and ultimately death. Acute ingestion of arsenic causes severe gastrointestinal symptoms; chronic exposure causes skin lesions and can cause peripheral neuropathy and encephalopa- thy. Orellanine is a toxin found in the Cortinarius species of mush- room that causes nausea, vomiting, and diarrhea; renal toxicity may occur several days later. Polychlorinated biphenyls (PCBs) cross the placenta and accumulate in breast milk; exposure in utero is thought to cause behavioral problems in later life.

Front 16

A previously healthy two-year-old boy is brought to the emergency department by ambulance after having a generalized tonic-clonic seizure at home. The mother reports that she put him to bed early the night before because she was having some friends over for a Bunco party. This afternoon when she awoke she found him wandering around the house, seemingly off balance, and he was “not acting right.” She called EMS as soon as he had his seizure. The responding paramedic reported that the child’s initial blood glucose was 15 mg/dL; after administration of lorazepam and a bolus of D10W he stopped seizing. Upon examination you find a heart rate of 110 beats per minute, a respiratory rate of 20 breaths per minute, a temperature of 37°C (98.6°F), and a blood pressure of 89/43 mm Hg. His pupils are reactive, and his funduscopic examination is normal. The rest of his examination is benign. Which of the following is the most likely cause of the seizure?

A. 3,4-methylenedioxymethamphetamine (MDMA; ‘Ecstasy’) ingestion
B. Braintumor
C. Ethanol ingestion
D. Exogenous insulin administration
E. Head trauma

Back 16

C. While all of the answers are situations or conditions that can be associated with seizure, ethanol ingestion is the most likely based on the history of a toddler with hypoglycemia poorly supervised with presumed access to alcohol after an adult party. An ingestion of MDMA can certainly cause seizure in a toddler but is usually associ- ated with hypertension, dilated pupils, and hyperthermia. There was no evidence of trauma on exam, and the funduscopic exam did not suggest increased intracranial pressure. If insulin was in the home and Munchausen by Proxy was suspected, simultaneous evaluation of serum insulin level and C peptide during an episode of hypoglycemia may help make the diagnosis.