Pediatric Board Review Part Dos Mark Heller, MD Department of Emergency Medicine Mount Sinai School...

Pediatric Board ReviewPart Dos

Mark Heller, MD

Department of Emergency Medicine

Mount Sinai School of Medicine

Question 1

Which of the following statements regarding ingested foreign bodies is correct?

a) All children with suspected foreign body ingestion should undergo x-ray.

b) Ipecac can be used safely to dislodge a button battery in the esophagus.

c) Meat tenderizer can be used safely to dissolve an impacted meat bolus.d) Most common site of esophageal foreign body entrapment in pediatric

patients is the thoracic inlet.e) Objects longer than 5cm and wider than 2cm should be removed before

they pass through the stomach.

Q 1 Answer

Which of the following statements regarding ingested foreign bodies is correct?

a) All children with suspected foreign body ingestion should undergo x-ray.

b) Ipecac can be used safely to dislodge a button battery in the esophagus.

c) Meat tenderizer can be used safely to dissolve an impacted meat bolus.d) Most common site of esophageal foreign body entrapment in pediatric

patients is the thoracic inlet.e) Objects longer than 5cm and wider than 2cm should be removed before

they pass through the stomach.

PEER VII Q20

Swallowed Foreign Bodies

Swallowed Foreign Bodies

• Most pass spontaneously

• Exceptions are objects longer than 5cm and wider than 2cm– Rarely pass the pylorus

• Lodging in the esophagus– Children – Cricopharyngeal narrowing at level

C6 (Upper Esophagus)– Adults – Lower Esophagus

Swallowed Foreign Bodies (continued)

• Need to be removed– Extremely pointed edges– Safety pins– Razor blades– Button Batteries– 15-35% will cause intestinal perforation

• Need for X-ray– Highly debated topic– No difference in 5-day morbidity rates between x-ray

and no x-ray

Question 2

Which of the following organisms is most likely to cause a rash with the characteristic “slapped-cheek” appearance?

a. Coxsackievirus A16b. Group A beta-hemolytic streptococcic. Human herpesvirus Cd. Parvovirus B19e. Varicella-zoster virus

Q 2 Answer

Which of the following organisms is most likely to cause a rash with the characteristic “slapped-cheek” appearance?

a. Coxsackievirus A16b. Group A beta-hemolytic streptococcic. Human herpesvirus Cd. Parvovirus B19e. Varicella-zoster virus

PEER VII Q309

Parvovirus B19

• Erythema Infectiosum– Fifth Disease– Slapped Cheek

• Viral Illness– Begins with Fever, Cold, HA– Symptoms Resolve– Slapped Cheek Rash Appears– Spreads to Trunk/Arms/Legs– Treatment is symptomatic

Coxsackievirus A16

• Hand-Foot-and-Mouth Disease – Mouth Sores– Blisters on Hand– Fever– Sore Throat– Abdominal Pain

Varicella-Zoster Virus

• Multiple states of rash on same body part

• Low-grade fever, malaise, and headache

• Treatment is symptomatic– Varicella-zoster immune globulin and

acyclovir for immunocompromised children

Question 3

A mother brings her 14 month old son into the ED. For the past 4 to 5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct?

a) Affects girls more than boysb) Is associated with cystic fibrosis and malnutritionc) Requires excision of the lesion in the emergency departmentd) Requires proctasigmoidoscopye) Requires referral for surgical correction

Q 3 Answer

A mother brings her 14 month old son into the ED. For the past 4 to 5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct?

a) Affects girls more than boysb) Is associated with cystic fibrosis and malnutritionc) Requires excision of the lesion in the emergency departmentd) Requires proctasigmoidoscopye) Requires referral for surgical correction

PEER VII Q334

Rectal Prolapse

• Affects very young and very old• Loose connection of mucosa to

submucosa• Laxity of anal sphincter• Mucus or Blood-stained mucus in diaper• Protruding mass after bowel movement• Associated with cystic fibrosis• Reducible in ED with sedation as needed

Question 4

For previously healthy children with community-acquired pneumonia, which of the following statement is correct?

a. Age is the most important factor in selecting empiric antibiotic therapyb. Concurrent presence of watery diarrhea reliably identifies a viral etiologyc. Localized chest pain is the most commonly associated with viral

pneumoniad. Viral and bacterial pneumonias can reliably be differentiated in infantse. Wheezing in preschool-aged children is pathognomonic for viral

pneumonia

Q 4 Answer

For previously healthy children with community-acquired pneumonia, which of the following statement is correct?

a. Age is the most important factor in selecting empiric antibiotic therapyb. Concurrent presence of watery diarrhea reliably identifies a viral etiologyc. Localized chest pain is the most commonly associated with viral

pneumoniad. Viral and bacterial pneumonias can reliably be differentiated in infantse. Wheezing in preschool-aged children is pathognomonic for viral

pneumonia

PEER VII Q343

Pneumonia in Children

• Etiologic agents have seasonal variations– Parainfluenze Virus = Fall– RSV & Bacteria = Winter– Influenza = Spring

• Clinical Features– Variable and Dependent on Age– Neonates and Young Infants

• Can present w/ Sepsis Syndrome• Fever, apnea, tachypnea, poor feeding, V/D, lethargy, shock

– Older Children• Fever, abnormal lung exam, cough, pleuritic chest pain

Pneumonia in Children

• Abbreviated Reference:• Neonates (<28 days)

– Group B Strep, E.Coli, Klebsiella– Ampicillin and Cefotaxime

• 1-24 months– RSV, Parainfluenza, Strep– Erythromycin, Cefuroxime, Ampicillin

• 2-5 years– Influenza A and B, Strep– Amoxicillin

• 6-18 years– Mycoplasma pneumoniae, S. Pneumoniae– Azithromycin

Name That Saturday Morning Cartoon Character


Astro


Betty


Brainy Smurf

Question 5

For a previously healthy toddler with mild croup, the administration of oral dexamethasone:

a) Is indicated only for moderate-to-sever croup, because mild croup is self-limited.b) Is indicated only if the parents are unable to provide cool mist at homec) Is precluded by an unacceptably high rate of uncontrollable vomiting after

administrationd) Leads to mild hyperactivity that interferes with normal sleep patternse) Leads to quicker resolution of symptoms when compared with observation

Q 5 Answer

For a previously healthy toddler with mild croup, the administration of oral dexamethasone:

a) Is indicated only for moderate-to-sever croup, because mild croup is self-limited.b) Is indicated only if the parents are unable to provide cool mist at homec) Is precluded by an unacceptably high rate of uncontrollable vomiting after

administrationd) Leads to mild hyperactivity that interferes with normal sleep patternse) Leads to quicker resolution of symptoms when compared with observation

PEER VII Q347

Croup

• Inflammation of the Upper Airway• Epidemiology

– Parainfluenza, RSV, Influenza• Clinical Features

– 6 months to 3 years old– Late Fall to Early Winter– Bark-Like Cough– Biphasic Stridor

• Treatment– Humidified Air– Dexamethasone in Mild to Moderate Croup– Nebulized Epinephrine (racemic epi) for moderate to severe– Intubate if necessary

Question 6

For a child with stridor, which of the following best differentiates croup from bacterial tracheitis?

a. Drooling and feverb. Normal chest x-rayc. Productive coughd. Rhinorrhea prodromee. Stridor at rest

Q 6 Answer

For a child with stridor, which of the following best differentiates croup from bacterial tracheitis?

a. Drooling and feverb. Normal chest x-rayc. Productive coughd. Rhinorrhea prodromee. Stridor at rest

PEER VII Q368

Bacterial Tracheitis• Clinical Features

– More severe form of croup– Bacterial superinfection– 3 months to 13 years old– S. aureus, S. pneumoniae– More respiratory distress than croup– Appear septic– Inspiratory and expiratory stridor– Thick sputum production– Raspy hoarse voice

• Diagnosis– Radiograph of lateral neck and chest– Subglottic narrowing of the trachea

• Treatment– Similar to epiglottitis– 85% require intubation– Vanc and Ceftriaxone

Question 7

A 9 month old boy presents with hypotonia and constipation. His mother says he has recently started eating “table food.” Which of the following is the most likely diagnosis?

a. Botulismb. Ciguaterac. Listeriosisd. Scombroid poisoninge. Typhoid

Q 7 Answer

A 9 month old boy presents with hypotonia and constipation. His mother says he has recently started eating “table food.” Which of the following is the most likely diagnosis?

a) Botulismb) Ciguaterac) Listeriosisd) Scombroid poisoninge) Typhoid

PEER VII Q349

Botulism

• Toxin Produced by Clostridium botulinum• Blocks acetylcholine release at synapse causing

flaccid paralysis• Onset 1 to 4 days post intake• Symptoms

– Constipation– Difficulty sucking– Difficulty swallowing– Hypotonia

• Care is symptomatic• Antitoxin should be given

Question 8

Which of the following statements regarding intussusception is correct?

a) If the stool is negative for occult blood, the diagnosis is excluded.b) Most patients show profound dehydration at the time of diagnosisc) Mucus-laden, bloody, “currant jelly” stools are seen in most casesd) Postreduction recurrence is best predicted by patient age and sexe) Ultrasonography is an accepted diagnostic test

Q 8 Answer

Which of the following statements regarding intussusception is correct?

a) If the stool is negative for occult blood, the diagnosis is excluded.b) Most patients show profound dehydration at the time of diagnosisc) Mucus-laden, bloody, “currant jelly” stools are seen in most casesd) Postreduction recurrence is best predicted by patient age and sexe) Ultrasonography is an accepted diagnostic test

PEER VII Q354

Intussusception

• Telescoping of one portion of the intestine into another– Most commonly occurs between the ileum and colon

• Most prevalent 3 months to 6 years old• Presentation

– Sudden abdominal pain– Pain-free intervals– Sausage-shaped mass on R

• Diagnosis– US used for diagnosis

• Treatment– Barium or Air enema diagnostic

and therapeutic– Possible Surgical Correction

Question 9

For young infants who are vomiting, which of the following is most likely to differentiate acute malrotation with midgut volvulus from pyloric stenosis?

a) Abdominal examinationb) Color of the vomitusc) History of constipationd) Presence of high fevere) Resting tachycardia

Q 9 Answer

For young infants who are vomiting, which of the following is most likely to differentiate acute malrotation with midgut volvulus from pyloric stenosis?

a. Abdominal examinationb. Color of the vomitusc. History of constipationd. Presence of high fevere. Resting tachycardia

PEER VII Q357

Pyloric Stenosis

• Clinical Presentation– Nonbilious Projectile Vomiting– Just after feeding– Seen in 2nd or 3rd week

• Diagnosis– Palpation of pyloric

mass in LUQ– US

Malrotation

• Clinical Presentation– Bilious Vomiting– Abdominal Distention– Streaks of Blood in Stool– Most present within

first month of life

• Diagnose– Abdominal Radiograph


Skeletor


Patrick Star

(SpongeBob’s Friend)


Snorks

Question 10

Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children?

a) Anal fissuresb) Infectious diarrheac) Juvenile polypsd) Milk-protein allergye) Vitamin K deficiency

Q 10 Answer

Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children?

a) Anal fissuresb) Infectious diarrheac) Juvenile polypsd) Milk-protein allergye) Vitamin K deficiency

PEER VII Q358

Infectious Diarrhea

• Etiology– Campylobacter– E. coli– Salmonella– Shigella– Most common cause of bloody diarrhea in school-

aged children

• Treatment– Treat for Dehydration– No role for antiemetics / antidiarrhea medications– No antibiotics

Question 11

A 14 year old girl is brought to the emergency department because she has difficulty walking. She has been noted to have some weakness in her legs over the past 36 hours. There is no history of trauma, and she is afebrile. On examination she has normal mental status and normal strength and sensation in her arms. In her lower extremities, she ahs flaccid paralysis, absent reflexes, and no sensation. Which of the following should be done next in the ED?

a. Administer an intravenous cephalosporinb. Immediately strap her down to long boardc. Initiate fluid resuscitation with 2 L normal salined. Order MRI of the spinee. Perform lumbar puncture and administer intravenous acyclovir

Q 11 Answer

A 14 year old girl is brought to the emergency department because she has difficulty walking. She has been noted to have some weakness in her legs over the past 36 hours. There is no history of trauma, and she is afebrile. On examination she has normal mental status and normal strength and sensation in her arms. In her lower extremities, she ahs flaccid paralysis, absent reflexes, and no sensation. Which of the following should be done next in the ED?

a. Administer an intravenous cephalosporinb. Immediately strap her down to long boardc. Initiate fluid resuscitation with 2 L normal salined. Order MRI of the spinee. Perform lumbar puncture and administer intravenous acyclovir

PEER VII Q373

Acute Spinal Cord Dysfunction

• Etiology– Transverse Myelitis– Guillain-Barre– Spinal Cord Tumors

• Diagnosing– MRI Spine

• Treatment– Supportive– Respiratory Support– Admission to Neurology

Question 12

Which of the following is most commonly seen in infants with congestive heart failure?

a. Bilateral pedal edemab. Bounding femoral pulsesc. Excessive weight gaind. Jugular venous distentione. Sweating with eating

Q 12 Answer

Which of the following is most commonly seen in infants with congestive heart failure?

a. Bilateral pedal edemab. Bounding femoral pulsesc. Excessive weight gaind. Jugular venous distentione. Sweating with eating

PEER VII Q376

Congestive Heart Failure

• Clinical Features– Poor feeding– Diaphoresis– Irritability or Lethargy with Feeding

• Diagnosis– Cardiomegaly on CXR– EKG w/ ST changes, dysrhythmias or ectopy

• Treatment– Oxygen– Lasix– Inotropic Agents (Dopamine or Dobutamine)– Admission


Mr. Owl


Dora


Bill

Question 13

A 4 day old boy presents in shock. According to the mother, he seemed to be doing well until 2 hours prior to presentation. He is cyanotic with mottled skin, has poor tone, and cries weakly. Initial pulse oximetry reading is 78%. After successful intubation and the administration of high-flow oxygen, the pulse oximetry reading remains between 78-82%. Of the following, what is the most appropriate next step?

a. Administer intravenous antibiotics and acyclovirb. Call child protective services, and order xraysc. Extubate, suction the airway, and intubate againd. Insert a nasogastric tube to decompress the stomache. Promptly administer intravenous prostaglandin E1

Q 13 Answer

A 4 day old boy presents in shock. According to the mother, he seemed to be doing well until 2 hours prior to presentation. He is cyanotic with mottled skin, has poor tone, and cries weakly. Initial pulse oximetry reading is 78%. After successful intubation and the administration of high-flow oxygen, the pulse oximetry reading remains between 78-82%. Of the following, what is the most appropriate next step?

a. Administer intravenous antibiotics and acyclovirb. Call child protective services, and order xraysc. Extubate, suction the airway, and intubate againd. Insert a nasogastric tube to decompress the stomache. Promptly administer intravenous prostaglandin E1

PEER VII Q382

Ductal-Dependent Lesions

• Ductus arteriosus closes in first 2 weeks of life• Babies with congenital heart conditions can depend on a

patent ductus arteriosus to perfuse the body will rapidly deteriorate.

• Babies remain hypoxic despite high flow oxygen

• Treatment– Prostaglandin E1– Sepsis workup as well

Question 14Which of the following fracture patterns is most likely to be caused by nonaccidental trauma (child abuse) in a 2 year old boy?

a. Linear nondepressed parietal skull fracture after falling out of a shopping cartb. Metaphysial corner fracture of the distal tibia after falling out of bedc. minimally displaced supracondylar humerus fracture after falling backwards off a

piece of playground equipmentd. Torus fracture of the distal radius after falling down three stairse. Transverse fracture of the middle phalanx of the index finger after the finger was

closed in a door by an older sibling

Q 14 AnswerWhich of the following fracture patterns is most likely to be caused by nonaccidental trauma (child abuse) in a 2 year old boy?

a. Linear nondepressed parietal skull fracture after falling out of a shopping cartb. Metaphysial corner fracture of the distal tibia after falling out of bedc. minimally displaced supracondylar humerus fracture after falling backwards off a

piece of playground equipmentd. Torus fracture of the distal radius after falling down three stairse. Transverse fracture of the middle phalanx of the index finger after the finger was

closed in a door by an older sibling

PEER VI Q59

Child Abuse - Fractures

• Metaphyseal “corner” and Triangular “bucket-handle”– Caused by joints being pulled apart forcefully and joint

surfaces crushed together and moved back and forth• Any fracture can be a sign of child abuse

Question 15A 7 year old boy is brought in for evaluation of fever and headache. Examination reveals an acutely ill child with a temperature of 39C (102.2F). A maculopapular rash is present on the wrists, palms, and lower legs. The patient has complained of myalgias, particularly in the lower extremities. Which of the following intravenous agents is most appropriate?

a. Acyclovirb. Ampicillin/Sulbactamc. Azithromycind. Chloramphenicole. Levofloxacin

Q 15 AnswerA 7 year old boy is brought in for evaluation of fever and headache. Examination reveals an acutely ill child with a temperature of 39C (102.2F). A maculopapular rash is present on the wrists, palms, and lower legs. The patient has complained of myalgias, particularly in the lower extremities. Which of the following intravenous agents is most appropriate?

a. Acyclovirb. Ampicillin/Sulbactamc. Azithromycind. Chloramphenicole. Levofloxacin

PEER VI Q134

Rocky Mountain Spotted Fever

• Etiology– Rickettsia rickettsii

• Transmitted by ticks

• Clinical Features– Rash– Headache– Myalgias– Fever

• Treatment– Tetracycline– Doxycycline– Chloramphenicol

No Mas

Pediatric Board Review Part Dos Mark Heller, MD Department of Emergency Medicine Mount Sinai School...

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