A 9-year-old boy comes to the clinic for evaluation of a rash. The boy says that he began developing some blisters on his cheek the night prior. He says that over the past few days he has spent time outside with his friends "down by the creek." The rash appears to be a linear crop of vesicles beginning in front of his left ear and extending to the corner of his mouth. There is no erythema, and he describes them as quite pruritic. He has not had any fever, vomiting, or changes in his hearing
Along with good skin hygiene, which of the following is the best treatment plan for this child?
A. topical diphenhydramine for comfort
B. oral diphenhydramine for pruritus
C. topical and oral antibiotics which would cover Staphylococcus and Streptococcus
D. topical high-potency fluorinated steroid
E. oral acyclovir
Correct Answer: B Section: (none)
Explanation:
This represents an allergic contact dermatitis. The allergen is the oil on the leaf of certain plants (poison ivy). The reaction is a delayedtype hypersensitivity reaction (type 4) and may take up to 7296 hours after exposure to fully manifest. Limited allergic contact dermatitis will usually warrant limited therapy. Oral antihistamines, taken on an as-needed basis, can provide effective symptomatic relief. Topical antihistamines are usually not effective and, if added to oral antihistamines, can result in toxic effects. Steroids should be used sparingly on the face, and high-potency steroid should not be used at all on the face. Secondary infection is unlikely if good skin hygiene is used.
Question 402:
A 9-year-old boy comes to the clinic for evaluation of a rash. The boy says that he began developing some blisters on his cheek the night prior. He says that over the past few days he has spent time outside with his friends "down by the creek." The rash appears to be a linear crop of vesicles beginning in front of his left ear and extending to the corner of his mouth. There is no erythema, and he describes them as quite pruritic. He has not had any fever, vomiting, or changes in his hearing. What does this rash most likely represent?
A. HSV infection of the facial nerve (Ramsey-Hunt syndrome)
B. bullous impetigo
C. allergic contact dermatitis (Rhus dermatitis)
D. erythema chronica migrans
E. cutaneous larval migrans
Correct Answer: C Section: (none)
Explanation:
This represents an allergic contact dermatitis. The allergen is the oil on the leaf of certain plants (poison ivy). The reaction is a delayedtype hypersensitivity reaction (type 4) and may take up to 7296 hours after exposure to fully manifest. Limited allergic contact dermatitis will usually warrant limited therapy. Oral antihistamines, taken on an as-needed basis, can provide effective symptomatic relief. Topical antihistamines are usually not effective and, if added to oral antihistamines, can result in toxic effects. Steroids should be used sparingly on the face, and high-potency steroid should not be used at all on the face. Secondary infection is unlikely if good skin hygiene is used.
Question 403:
Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a "baby home" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given.
You place a purified protein derivative (PPD) and the parents come back in 48 hours to have it read. The response is 15 mm of induration. The boy does not have any respiratory symptoms at this time.
What is the most appropriate response to this information?
A. Collect three morning sputum and send for acid-fast stain and TB culture.
B. Give a repeat BCG vaccine.
C. Do nothing as the PPD is considered negative given the prior BCG vaccination.
D. Perform a CXR and begin isoniazid (INH) for 9 months if the x-ray is negative.
E. Perform a CXR and begin "triples" (INH, rifampin, pyrazinamide) even if the x-ray is negative.
Correct Answer: D Section: (none)
Explanation:
Repeating all serologies is important. The prior negative testing should be included in the medical record, but should not dissuade one from confirming the result. The collection of stool for ova and parasites (O + P) is an important evaluation but should not be the only testing performed. ACBC is not an adequate screen for infections.
The diagnosis of FAS includes findings of characteristic facies, growth retardation, and CNS impairment. The characteristic facies of FAS includes flat philtrum, thin upper vermilion border, short palpebral fissures, micrognathia, microphthalmos, and microcephaly.
BCG is a common vaccine administered in countries outside of the United States. The presence of a positive reaction to a PPD in a child who has had a prior BCG is still concerning. The presence of a 15-mm reaction is considered positive and warrants a CXR and initiation of anti TB treatment. The negative CXR would indicate TB exposure, and INH alone is recommended. Sputum collection is usually unwarranted in asymptomatic children.
Question 404:
Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a "baby home" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given.
The parents are concerned about fetal alcohol syndrome (FAS). Which physical feature is most consistent with FAS?
A. smooth philtrum
B. single palmar crease
C. hypertelorism
D. synophrys (confluent eye brows)
E. low set ears
Correct Answer: A Section: (none)
Explanation:
Repeating all serologies is important. The prior negative testing should be included in the medical record, but should not dissuade one from confirming the result. The collection of stool for ova and parasites (O + P) is an important evaluation but should not be the only testing performed. ACBC is not an adequate screen for infections.
The diagnosis of FAS includes findings of characteristic facies, growth retardation, and CNS impairment.
The characteristic facies of FAS includes flat philtrum, thin upper vermilion border, short palpebral fissures, micrognathia, microphthalmos, and microcephaly.
BCG is a common vaccine administered in countries outside of the United States. The presence of a positive reaction to a PPD in a child who has had a prior BCG is still concerning. The presence of a 15-mm reaction is considered positive and warrants a CXR and initiation of anti TB treatment. The negative CXR would indicate TB exposure, and INH alone is recommended. Sputum collection is usually unwarranted in asymptomatic children.
Question 405:
Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a "baby home" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given.
The parents are interested in having the boy tested for infections. What is the most appropriate evaluation at this time?
A. No need to repeat the serologies because they have been done within the past month.
B. Collect stool for ova and parasites only.
C. Repeat all serologies (HIV, hepatitis B, hepatitis C, RPR) now.
D. Perform a full sepsis workup (blood culture, urine culture, CSF culture).
E. Screen for infections using CBC.
Correct Answer: C Section: (none)
Explanation:
Repeating all serologies is important. The prior negative testing should be included in the medical record, but should not dissuade one from confirming the result. The collection of stool for ova and parasites (O + P) is an important evaluation but should not be the only testing performed. ACBC is not an adequate screen for infections.
The diagnosis of FAS includes findings of characteristic facies, growth retardation, and CNS impairment. The characteristic facies of FAS includes flat philtrum, thin upper vermilion border, short palpebral fissures, micrognathia, microphthalmos, and microcephaly.
BCG is a common vaccine administered in countries outside of the United States. The presence of a positive reaction to a PPD in a child who has had a prior BCG is still concerning. The presence of a 15-mm reaction is considered positive and warrants a CXR and initiation of anti TB treatment. The negative CXR would indicate TB exposure, and INH alone is recommended. Sputum collection is usually unwarranted in asymptomatic children.
Question 406:
A 41/2-year-old girl is brought to your office during summertime hours for ear pain. She has been swimming at camp for the past few days and now has copious cloudy discharge from her left external auditory canal with pain on movement of the pinna.
What is the best course of treatment for this patient?
A. amoxicillin PO
B. erythromoycin PO
C. erythromycin topical
D. cefuroxime PO
E. neomycin/polymyxin B/hydrocortisone topical
Correct Answer: E Section: (none)
Explanation:
The constellation of ear pain, pain with movement of the pinna, and cloudy discharge from the ear canal in a child who has been swimming frequently is most probably OE, also known as "swimmer's ear." Perforated TMs can occur, often as the result of an untreated otitis media, a foreign body inserted deep in the ear or from barotrauma. This can cause ear pain and may have a cloudy drainage if the perforation is the result of otitis media. Neither otitis media nor perforated TMs typically cause pain on movement of the pinna. Mastoiditis is a rare infection that usually results from extension of an untreated otitis media into the mastoid air cells. The common findings on examination would be an acute otitis media and tenderness over the mastoid area behind the ear. Temporomandibular joint dysfunction can cause ear pain, but the common finding is tenderness anterior to the ear, not pain with movement of the ear or drainage from the ear canal. It would also be uncommon in a child this age.
The most common cause of acute OE is Pseudomonas aeruginosa. Treatment for acute OE will involve topical antimicrobials which cover P. aeruginosa, often in combination with a topical steroid. A commonly used treatment consists of eardrops containing neomycin, polymyxin B, and hydrocortisone (Cortisporin Otic), four drops into the affected ear four times a day for 710 days. Alternative therapy consists of oflaxacin drops twice a day into the affected ear for 710 days. For chronic OE, yeast becomes a more important pathogen, and therapy should be directed as such.
Question 407:
A 41/2-year-old girl is brought to your office during summertime hours for ear pain. She has been swimming at camp for the past few days and now has copious cloudy discharge from her left external auditory canal with pain on movement of the pinna.
What organism is the most common cause of this infection?
A. methicillin-resistant Staphylococcus aureus (MRSA)
B. S. pneumoniae
C. Pseudomonas species
D. nontypable H. influenzae
E. GAS
Correct Answer: C Section: (none)
Explanation:
The constellation of ear pain, pain with movement of the pinna, and cloudy discharge from the ear canal in a child who has been swimming frequently is most probably OE, also known as "swimmer's ear." Perforated TMs can occur, often as the result of an untreated otitis media, a foreign body inserted deep in the ear or from barotrauma. This can cause ear pain and may have a cloudy drainage if the perforation is the result of otitis media. Neither otitis media nor perforated TMs typically cause pain on movement of the pinna. Mastoiditis is a rare infection that usually results from extension of an untreated otitis media into the mastoid air cells. The common findings on examination would be an acute otitis media and tenderness over the mastoid area behind the ear. Temporomandibular joint dysfunction can cause ear pain, but the common finding is tenderness anterior to the ear, not pain with movement of the ear or drainage from the ear canal. It would also be uncommon in a child this age.
The most common cause of acute OE is Pseudomonas aeruginosa. Treatment for acute OE will involve topical antimicrobials which cover P. aeruginosa, often in combination with a topical steroid. A commonly used treatment consists of eardrops containing neomycin, polymyxin B, and hydrocortisone (Cortisporin Otic), four drops into the affected ear four times a day for 710 days. Alternative therapy consists of oflaxacin drops twice a day into the affected ear for 710 days. For chronic OE, yeast becomes a more important pathogen, and therapy should be directed as such.
Question 408:
A 41/2-year-old girl is brought to your office during summertime hours for ear pain. She has been swimming at camp for the past few days and now has copious cloudy discharge from her left external auditory canal with pain on movement of the pinna.
What is the most likely diagnosis?
A. otitis media with perforation of the TM
B. mastoiditis
C. otitis externa (OE)
D. foreign body in the ear canal
E. tempero-mandibular joint dysfunction
Correct Answer: C Section: (none)
Explanation:
The constellation of ear pain, pain with movement of the pinna, and cloudy discharge from the ear canal in a child who has been swimming frequently is most probably OE, also known as "swimmer's ear." Perforated TMs can occur, often as the result of an untreated otitis media, a foreign body inserted deep in the ear or from barotrauma. This can cause ear pain and may have a cloudy drainage if the perforation is the result of otitis media. Neither otitis media nor perforated TMs typically cause pain on movement of the pinna. Mastoiditis is a rare infection that usually results from extension of an untreated otitis media into the mastoid air cells. The common findings on examination would be an acute otitis media and tenderness over the mastoid area behind the ear. Temporomandibular joint dysfunction can cause ear pain, but the common finding is tenderness anterior to the ear, not pain with movement of the ear or drainage from the ear canal. It would also be uncommon in a child this age.
The most common cause of acute OE is Pseudomonas aeruginosa. Treatment for acute OE will involve topical antimicrobials which cover P. aeruginosa, often in combination with a topical steroid. A commonly used treatment consists of eardrops containing neomycin, polymyxin B, and hydrocortisone (Cortisporin Otic), four drops into the affected ear four times a day for 710 days. Alternative therapy consists of oflaxacin drops twice a day into the affected ear for 710 days. For chronic OE, yeast becomes a more important pathogen, and therapy should be directed as such.
Question 409:
A 14-year-old boy is brought to the emergency department for evaluation of fever and headache. The mother relates that her son has had a worsening headache for 56 days. She says that she took him to a walk-in clinic, and he was put on amoxicillin for a sinus infection. His headaches have been getting worse and that he is now having fevers as high as 103.6°F . The mother says that he normally is very active and that he currently has a summer job at a local park clearing out underbrush. Since he has become ill, he has had such a decrease in energy that he cannot go to work. He has had a decrease in his appetite and has been sleeping more. He denies any sore throat, abdominal pain, chest pain, dysuria, vomiting, or diarrhea. On examination, he is an uncomfortable young man whose vital signs are: temp 101.9°F, RR 26, HR 124, and BP 79/56. is head, ear, eye, nose, and throat examination reveals normal TMs, a mildly erythematous hypopharynx, and some shotty cervical lymphadenopathy. His lungs are clear. His cardiac examination is normal. His liver edge is palpable just below the right costal margin and is mildly tender. His spleen is not palpable. His skin examination is normal with the exception of scattered petechiae around his ankles and wrists. A CBC reveals WBC 13,000 with 65% segs and 22% lymphs, hematocrit of 35, and platelet count of 95,000. His electrolytes reveal a Na 125, K 5.1, Cl 102, and bicarbonate 21. His BUN and Cr are normal.
What additional testing would be warranted at this point?
A. serum rickettsial titers
B. ESR
C. C-reactive protein (CRP)
D. enteroviral polymerase chain reaction (PCR) on cerebrospinal fluid (CSF)
E. head CT without contrast
Correct Answer: A Section: (none)
Explanation:
Typical symptoms include a summertime fever, headache, petechial rash, thrombocytopenia, and hyponatremia. This may be mistaken for a systemic enteroviral infection, or enteroviral encephalitis, but the presence of thrombocytopenia and hyponatremia would exclude this diagnosis. Still disease (systemiconset JRA) would have an elevation of acute-phase reactants, including the WBC and platelet count. Fourteen years old is an unlikely age for Kawasaki disease, and the acute phase reactants would likewise also be elevated.
RMSF is a very serious infectious illness. Appropriate antimicrobial therapy, usually doxycycline, needs to be started as soon as the diagnosis is seriously considered, as this can prevent some of the more severe sequelae. The use of systemic corticosteroids has no place in the management of RMSF. Confirmation of RMSF is serologic. Rising IgG titers or the presence of IgM titers to R. rickettsii is a confirmation of RMSF
Question 410:
A 14-year-old boy is brought to the emergency department for evaluation of fever and headache. The mother relates that her son has had a worsening headache for 56 days. She says that she took him to a walk-in clinic, and he was put on amoxicillin for a sinus infection. His headaches have been getting worse and that he is now having fevers as high as 103.6°F . The mother says that he normally is very active and that he currently has a summer job at a local park clearing out underbrush. Since he has become ill, he has had such a decrease in energy that he cannot go to work. He has had a decrease in his appetite and has been sleeping more. He denies any sore throat, abdominal pain, chest pain, dysuria, vomiting, or diarrhea. On examination, he is an uncomfortable young man whose vital signs are: temp 101.9°F, RR 26, HR 124, and BP 79/56. is head, ear, eye, nose, and throat examination reveals normal TMs, a mildly erythematous hypopharynx, and some shotty cervical lymphadenopathy. His lungs are clear. His cardiac examination is normal. His liver edge is palpable just below the right costal margin and is mildly tender. His spleen is not palpable. His skin examination is normal with the exception of scattered petechiae around his ankles and wrists. A CBC reveals WBC 13,000 with 65% segs and 22% lymphs, hematocrit of 35, and platelet count of 95,000. His electrolytes reveal a Na 125, K 5.1, Cl 102, and bicarbonate 21. His BUN and Cr are normal.
The best treatment course would include which of the following?
A. continue amoxicillin only
B. begin oral doxycycline
C. add acyclovir to the amoxicillin
D. begin oral corticosteroids E. stop all antimicrobials
Correct Answer: B Section: (none)
Explanation: Typical symptoms include a summertime fever, headache, petechial rash, thrombocytopenia, and hyponatremia. This may be mistaken for a systemic enteroviral infection, or enteroviral encephalitis, but the presence of thrombocytopenia and hyponatremia would exclude this diagnosis. Still disease (systemiconset JRA) would have an elevation of acute-phase reactants, including the WBC and platelet count. Fourteen years old is an unlikely age for Kawasaki disease, and the acute phase reactants would likewise also be elevated.
RMSF is a very serious infectious illness. Appropriate antimicrobial therapy, usually doxycycline, needs to be started as soon as the diagnosis is seriously considered, as this can prevent some of the more severe sequelae. The use of systemic corticosteroids has no place in the management of RMSF. Confirmation of RMSF is serologic. Rising IgG titers or the presence of IgM titers to R. rickettsii is a confirmation of RMSF
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