You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula.
What is the most likely cause of the blood in her stool?
A. Meckel diverticulum
B. group B streptococcal colitis
C. cow's milk protein intolerance
D. pseudomembranous colitis
E. lactose intolerance
Correct Answer: C Section: (none)
Explanation:
Most infant formulas are cow's milk based. The most common form of carbohydrate in these infant formulas is lactose. Soy formulas use corn syrup and/or sucrose as their source of carbohydrate. Casein is a form of protein. Human milk fortifier is a supplement added to breast milk for the premature infant and is a combination of protein and carbohydrate. GBS colitis is an uncommon disease in infants. Cow's milk protein intolerance is a common cause of blood-streaked stool in an infant on cow's milk based formulas. Lactose intolerance is very uncommon in an infant and usually causes chronic, nonbloody diarrhea. Pseudomembranous colitis would be a consideration in a child with diarrhea who recently had been on antibiotics
Question 422:
You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula.
What is the carbohydrate source in most infant formula?
A. casein
B. lactose
C. human milk fortifier
D. coconut oil
E. soy oil
Correct Answer: B Section: (none)
Explanation:
Most infant formulas are cow's milk based. The most common form of carbohydrate in these infant formulas is lactose. Soy formulas use corn syrup and/or sucrose as their source of carbohydrate. Casein is a form of protein. Human milk fortifier is a supplement added to breast milk for the premature infant and is a combination of protein and carbohydrate. GBS colitis is an uncommon disease in infants. Cow's milk protein intolerance is a common cause of blood-streaked stool in an infant on cow's milk based formulas. Lactose intolerance is very uncommon in an infant and usually causes chronic, nonbloody diarrhea. Pseudomembranous colitis would be a consideration in a child with diarrhea who recently had been on antibiotics.
Question 423:
You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.
What is the most worrisome complication of this disease?
A. encephalitis
B. coronary artery aneurysm
C. cardiac valve dysfunction
D. intracerebral hemorrhage
E. hemorrhagic stroke
Correct Answer: B Section: (none)
Explanation:
Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unclear etiology. The salient diagnostic features include fever for greater than 5 days, cervical lymph node greater than 1 cm, nonpurulent conjunctivitis, oral changes (cracking lips or "strawberry tongue"), polymorphous rash to the trunk, and changes to the hands and feet (peeling of the fingers or toes or edema of the hands or feet). This may be confused with group Abeta-hemolytic streptococcal pharyngitis, which usually is not associated with conjunctivitis. Coxsackie viral infection is commonly seen as the "hand-footmouth" disease, with shallow ulcers on the palms, soles, and in the mouth. There is nominal fever associated, and conjunctivitis is uncommon. Parvovirus B-19 (erythema infectiosum, "fifth disease") is commonly called "slapped cheek" disease because of the exanthem of bright red cheeks. Adenopathy and conjunctivitis are not features of this infection. Acute phase reactions are often elevated late in the course of Kawasaki disease. The most common blood test result would be a dramatically elevated platelet count. It is usually greater than 750,000 and can be greater than 1,000,000. An ESR is also likely to be elevated, not low. Apositive rapid strep test would lead one more toward acute GAS disease. The treatment of choice for Kawasaki disease is IVIG and aspirin. IVIG infusion is usually over 12 hours and will commonly result in rapid defervescence and clinical improvement. Treatment of Kawasaki disease is important as it will prevent long-term sequelae. A common side effect of IVIG is aseptic meningitis. Nearly a quarter of untreated children will develop coronary artery dilatation. This is most common cause of acquired heart disease in children younger than 5 years of age. The coronary artery dilatation can result in aneurysm formation and myocardial infarction.
Question 424:
You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.
What is the most appropriate treatment at thispoint?
A. no medicine is needed, only supportive care
B. an IM dose of long-acting penicillin (LA Bicillin)
C. oral acyclovir
D. IVIG
E. topical lidocaine gel 1%
Correct Answer: D Section: (none)
Explanation:
Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unclear etiology. The salient diagnostic features include fever for greater than 5 days, cervical lymph node greater than 1 cm, nonpurulent conjunctivitis, oral changes (cracking lips or "strawberry tongue"), polymorphous rash to the trunk, and changes to the hands and feet (peeling of the fingers or toes or edema of the hands or feet). This may be confused with group Abeta-hemolytic streptococcal pharyngitis, which usually is not associated with conjunctivitis. Coxsackie viral infection is commonly seen as the "hand-footmouth" disease, with shallow ulcers on the palms, soles, and in the mouth. There is nominal fever associated, and conjunctivitis is uncommon. Parvovirus B-19 (erythema infectiosum, "fifth disease") is commonly called "slapped cheek" disease because of the exanthem of bright red cheeks. Adenopathy and conjunctivitis are not features of this infection. Acute phase reactions are often elevated late in the course of Kawasaki disease. The most common blood test result would be a dramatically elevated platelet count. It is usually greater than 750,000 and can be greater than 1,000,000. An ESR is also likely to be elevated, not low. Apositive rapid strep test would lead one more toward acute GAS disease. The treatment of choice for Kawasaki disease is IVIG and aspirin. IVIG infusion is usually over 12 hours and will commonly result in rapid defervescence and clinical improvement. Treatment of Kawasaki disease is important as it will prevent long-term sequelae. A common side effect of IVIG is aseptic meningitis. Nearly a quarter of untreated children will develop coronary artery dilatation. This is most common cause of acquired heart disease in children younger than 5 years of age. The coronary artery dilatation can result in aneurysm formation and myocardial infarction.
Question 425:
You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.
Which laboratory result would be most consistent with the diagnosis?
A. an elevated platelet count
B. a positive rapid strep test
C. a low platelet count
D. elevated viral IgM titers
E. alowESR
Correct Answer: A Section: (none)
Explanation:
Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unclear etiology. The salient diagnostic features include fever for greater than 5 days, cervical lymph node greater than 1 cm, nonpurulent conjunctivitis, oral changes (cracking lips or "strawberry tongue"), polymorphous rash to the trunk, and changes to the hands and feet (peeling of the fingers or toes or edema of the hands or feet). This may be confused with group Abeta-hemolytic streptococcal pharyngitis, which usually is not associated with conjunctivitis. Coxsackie viral infection is commonly seen as the "hand-footmouth" disease, with shallow ulcers on the palms, soles, and in the mouth. There is nominal fever associated, and conjunctivitis is uncommon. Parvovirus B-19 (erythema infectiosum, "fifth disease") is commonly called "slapped cheek" disease because of the exanthem of bright red cheeks. Adenopathy and conjunctivitis are not features of this infection. Acute phase reactions are often elevated late in the course of Kawasaki disease. The most common blood test result would be a dramatically elevated platelet count. It is usually greater than 750,000 and can be greater than 1,000,000. An ESR is also likely to be elevated, not low. Apositive rapid strep test would lead one more toward acute GAS disease. The treatment of choice for Kawasaki disease is IVIG and aspirin. IVIG infusion is usually over 12 hours and will commonly result in rapid defervescence and clinical improvement. Treatment of Kawasaki disease is important as it will prevent long-term sequelae. A common side effect of IVIG is aseptic meningitis. Nearly a quarter of untreated children will develop coronary artery dilatation. This is most common cause of acquired heart disease in children younger than 5 years of age. The coronary artery dilatation can result in aneurysm formation and myocardial infarction.
Question 426:
You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers.
What is the most likely diagnosis?
A. group A beta-hemolytic streptococcal pharyngitis
B. hand-foot-mouth disease (Coxsackie viral infection)
C. Kawasaki disease
D. ITP
E. erythema infectiosum (parvovirus B-19 infection)
Correct Answer: C Section: (none)
Explanation: Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unclear etiology. The salient diagnostic features include fever for greater than 5 days, cervical lymph node greater than 1 cm, nonpurulent conjunctivitis, oral changes (cracking lips or "strawberry tongue"), polymorphous rash to the trunk, and changes to the hands and feet (peeling of the fingers or toes or edema of the hands or feet). This may be confused with group Abeta-hemolytic streptococcal pharyngitis, which usually is not associated with conjunctivitis. Coxsackie viral infection is commonly seen as the "hand-footmouth" disease, with shallow ulcers on the palms, soles, and in the mouth. There is nominal fever associated, and conjunctivitis is uncommon. Parvovirus B-19 (erythema infectiosum, "fifth disease") is commonly called "slapped cheek" disease because of the exanthem of bright red cheeks. Adenopathy and conjunctivitis are not features of this infection. Acute phase reactions are often elevated late in the course of Kawasaki disease. The most common blood test result would be a dramatically elevated platelet count. It is usually greater than 750,000 and can be greater than 1,000,000. An ESR is also likely to be elevated, not low. Apositive rapid strep test would lead one more toward acute GAS disease. The treatment of choice for Kawasaki disease is IVIG and aspirin. IVIG infusion is usually over 12 hours and will commonly result in rapid defervescence and clinical improvement. Treatment of Kawasaki disease is important as it will prevent long-term sequelae. A common side effect of IVIG is aseptic meningitis. Nearly a quarter of untreated children will develop coronary artery dilatation. This is most common cause of acquired heart disease in children younger than 5 years of age. The coronary artery dilatation can result in aneurysm formation and myocardial infarction.
Question 427:
A mother brings her 4-year-old son to your office, relating that he fell earlier that morning while at the playground. She says that the boy tripped over another child and landed on his outstretched hands. On examination, the boy has some mild swelling around his left wrist, and he says that it hurts when you palpate it. What is the most appropriate next step?
A. Call the department of Children's Protective Services to investigate the accident.
B. Attempt a nursemaid's elbow reduction.
C. Perform anterior-posterior (AP) and lateral x-rays of the left wrist and elbow.
D. Wrap the wrist in an Ace wrap, and put the arm in a sling.
E. Order a magnetic resonance imaging (MRI) of the wrist looking for a growth plate injury.
Correct Answer: C Section: (none)
Explanation:
Falling on outstretched arms is one of the most common injuries among school-aged children. This can result in a buckle, or torus, fracture of the distal radius and/or ulna. This is a common accidental mechanism and should not, by itself, raise suspicions for an inflicted injury. AP and lateral x-rays of the wrist and elbow would be diagnostic of this type of injury. Nursemaid's elbows occur from a pulling or twisting mechanism to the upper extremity and are not the result of falls. An MRI of this injury would be overkill.
Question 428:
A mother brings her baby girl for a 9-month wellchild visit. You have been following her since birth. Her growth chart is shown in Figure. Her vital signs and examination are otherwise normal. The growth pattern is most consistent with which of the following?
A. congenital growth hormone (GH) deficiency
B. constitutional short stature
C. constitutional growth delay
D. familial short stature
E. nutritional failure to thrive (FTT)
Correct Answer: E Section: (none)
Explanation:
This infant's growth pattern is most consistent with nutritional FTT. This is often termed "nonorganic" FTT. This term is used for conditions in which the child, usually an infant, begins to fall off of the standardized growth curves. The growth curve in this vignette shows that this infant's weight has trailed off while her length has remained stable. Causes of poor growth that are hormonal in nature will tend to have blunted growth velocity (decreased linear growth) that results in infants and children with short stature and normal weight. Short stature refers to deceased linear growth (i.e., length or height). The infant in this vignette does not have short stature, as her linear growth is normal. Achild with GH deficiency would be expected to have a decreased linear growth velocity (height) with a weight that remains relatively stable. The next best step in the evaluation of this infant would hinge on understanding the total calories that this infant is consuming. A measure of the appropriate caloric intake is related in terms of calories per kilogram per day. This will give a metric to measure whether infants are getting appropriate nutritional intake. Obtaining a serum GH level is an unreliable way to look at an infant's growth due to its pulsatile nature. While a serum somatomedin-C (ILGF-1) may be a more accurate measure of GH activity, in this child a level will likely not reveal much useful information. In children with malnutrition or caloric deprivation, a somatomedin-C level may be depressed due to decreased body mass. If there were a family history of short stature, that would be manifested with poor linear growth, which is not the case in this vignette. While a malabsorption may be a cause of FTT, an UGI series would not be the modality to evaluate for it.
Question 429:
A term infant male is born after an uncomplicated vaginal delivery. The mother's prenatal labs were negative with the exception of being GBS positive at 36 weeks' gestation. The mother received two doses of ampicillin prior to delivery and did not have a fever. The infant had APGAR scores of 9 at 1 minute and 9 at 5 minutes. The infant was brought to the newborn nursery and appears well
The father tells you that he has hemophilia. His wife neither has hemophilia nor is a carrier. What does this mean for the baby?
A. The baby has a 50% chance of having hemophilia.
B. The baby neither has hemophilia nor is a carrier of the hemophilia gene.
C. The baby is a carrier of the hemophilia gene but does not have the disease.
D. The baby has a 25% chance of being a carrier for hemophilia.
E. The baby has a 50% chance of being a carrier for hemophilia.
Correct Answer: B Section: (none)
Explanation:
The most common bacterial infection in the newborn period is GBS. GBS is commonly cultured in the adult vaginal tract, and its vertical transmission can be interrupted with maternal antimicrobial treatment prior to delivery of the infant. Mothers are commonly treated in labor with penicillin, ampicillin, clindamycin, or azithromycin in an attempt to interrupt transmission to the infant while passing through the birth canal. If antimicrobial prophylaxis is initiated greater than 4 hours prior to delivery, the rate of early-onset GBS disease is dramatically decreased. The current recommendation for term infants of GBS-positive women who have received antibiotics in labor (at least two doses or =4 hours prior to delivery) is observation without testing or antibiotics. (American Academy of Pediatrics, 2003, pp. 584591) Classic hemophilia is an X-linked recessive bleeding diathesis. Hemophilia is inherited on the maternal lineage from carrier (or affected) mothers. This infant, being a male, would receive his X chromosome from his mother. He is, therefore, not at risk for having hemophilia. Further, being an X-linked trait, there cannot be a male "carrier" state.
Question 430:
A term infant male is born after an uncomplicated vaginal delivery. The mother's prenatal labs were negative with the exception of being GBS positive at 36 weeks' gestation. The mother received two doses of ampicillin prior to delivery and did not have a fever. The infant had APGAR scores of 9 at 1 minute and 9 at 5 minutes. The infant was brought to the newborn nursery and appears well.
The most appropriate management of the infant would be which of the following?
A. Draw a CBC and blood culture, but do not start empiric antibiotics.
B. Give the baby a prophylactic dose of ampicillin.
C. Routine care.
D. Cultures of blood, urine, and spinal fluid and wait for culture results before starting antibiotics.
E. Cultures of blood, urine, and spinal fluid and begin empiric antibiotics before getting culture results.
Correct Answer: C Section: (none)
Explanation:
The most common bacterial infection in the newborn period is GBS. GBS is commonly cultured in the adult vaginal tract, and its vertical transmission can be interrupted with maternal antimicrobial treatment prior to delivery of the infant. Mothers are commonly treated in labor with penicillin, ampicillin, clindamycin, or azithromycin in an attempt to interrupt transmission to the infant while passing through the birth canal. If antimicrobial prophylaxis is initiated greater than 4 hours prior to delivery, the rate of early-onset GBS disease is dramatically decreased. The current recommendation for term infants of GBS-positive women who have received antibiotics in labor (at least two doses or =4 hours prior to delivery) is observation without testing or antibiotics. (American Academy of Pediatrics, 2003, pp. 584591) Classic hemophilia is an X-linked recessive bleeding diathesis. Hemophilia is inherited on the maternal lineage from carrier (or affected) mothers. This infant, being a male, would receive his X chromosome from his mother. He is, therefore, not at risk for having hemophilia. Further, being an X-linked trait, there cannot be a male "carrier" state.
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