Afather and son come to your office because of persistent diarrhea. They relate the presence of watery diarrhea for over 2 weeks. They noted that the diarrhea began after returning from a Boy Scout camping trip in the Rocky Mountains. The diarrhea has waxed and waned for 2 weeks. It is nonbloody and foul smelling. They have had increased flatulence and mild abdominal cramping.
What is the most likely etiology of their diarrhea?
A. enterotoxigenic Escherichia coli
B. Giardia lamblia
C. Rickettsia rickettsii (Rocky Mountain spotted fever [RMSF])
D. rotavirus
E. Norwalk virus
Correct Answer: B Section: (none)
Explanation:
G. lamblia is a common protozoan which can be acquired by ingesting unfiltered water. It is seen frequently in people who drink fresh stream water. It is a cause of chronic, nonbloody diarrhea. There is typically a large amount of gas and cramping associated with Giardia infections. RMSF does not typically cause a gastroenteritis. Children with RMSF will commonly have fevers, headaches, and a petechial rash. Rotavirus and Norwalk viruses typically cause acute, self-limited gastroenteritis. The diarrhea is nonbloody, nonmucousy, and typically lasts a few days. The most appropriate treatment for giardiasis is oral metronidazole. Oral rehydration is an important mainstay in the treatment of diarrhea of any cause but is not a specific treatment for giardiasis. Ciprofloxacin is commonly used for traveler's diarrhea caused by E. coli.
Question 462:
You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome.
If you were to perform an abdominal x-ray, what is the most likely finding that would be seen?
A. "double-bubble" sign
B. scimitar sign
C. normal gas patterns
D. free fluid in the abdomen
E. pneumatosis intestinalis
Correct Answer: A Section: (none)
Explanation:
The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Café au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome. Ambiguous genitalia are commonly seen in CAH.
Children with Down syndrome are at an increased risk for hypothyroidism. It may be hard to detect without routine laboratory screening as they will commonly have mental retardation and developmental delay as part of their syndrome. Hypothyroidism may not be present in the immediate newborn period and requires, at a minimum, annual testing throughout the child's life. The other findings listed are not specifically associated with Down syndrome. Lens dislocation is commonly found with Marfan syndrome or homocysteinuria. Children with Down syndrome have an increased prevalence of duodenal atresia. Pyloric stenosis is uncommon to see in the newborn period. It tends to present with nonbilious vomiting usually after 24 weeks of age. Hirschsprung disease (aganglionosis coli) presents with constipation and failure to pass stool. Infants with Hirschsprung disease commonly will not pass stool in the first days of life. Biliary atresia is a progressive cause of jaundice in an infant. It is the most common cause of a cholestatic jaundice in the newborn period. Emesis is not typically associated with biliary atresia. Milk protein allergy is a common cause of bloody stools in the first few months of life, but does not have bilious emesis associated with it.
Question 463:
You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome.
What is the most common central nervous system (CNS) complication of Down syndrome?
A. seizures
B. hydrocephalus
C. microcalcifications
D. berry aneurysms
E. mental retardation
Correct Answer: E Section: (none)
Explanation:
The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Café au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome. Ambiguous genitalia are commonly seen in CAH.
Children with Down syndrome are at an increased risk for hypothyroidism. It may be hard to detect without routine laboratory screening as they will commonly have mental retardation and developmental delay as part of their syndrome. Hypothyroidism may not be present in the immediate newborn period and requires, at a minimum, annual testing throughout the child's life. The other findings listed are not specifically associated with Down syndrome. Lens dislocation is commonly found with Marfan syndrome or homocysteinuria.
Children with Down syndrome have an increased prevalence of duodenal atresia. Pyloric stenosis is uncommon to see in the newborn period. It tends to present with nonbilious vomiting usually after 24 weeks of age. Hirschsprung disease (aganglionosis coli) presents with constipation and failure to pass stool. Infants with Hirschsprung disease commonly will not pass stool in the first days of life. Biliary atresia is a progressive cause of jaundice in an infant. It is the most common cause of a cholestatic jaundice in the newborn period. Emesis is not typically associated with biliary atresia. Milk protein allergy is a common cause of bloody stools in the first few months of life, but does not have bilious emesis associated with it.
Question 464:
You are called to see a newborn in the nursery because the nurse is concerned that the baby may have
Down syndrome.
The infant begins to have progressively large amounts of bilious emesis. The infant feeds well and has only
a small amount of abdominal distention.
What is the most likely diagnosis?
A. pyloric stenosis
B. Hirschsprung disease
C. biliary atresia
D. duodenal atresia
E. milk protein allergy
Correct Answer: D Section: (none)
Explanation:
The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Café au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome. Ambiguous genitalia are commonly seen in CAH.
Children with Down syndrome are at an increased risk for hypothyroidism. It may be hard to detect without routine laboratory screening as they will commonly have mental retardation and developmental delay as part of their syndrome. Hypothyroidism may not be present in the immediate newborn period and requires, at a minimum, annual testing throughout the child's life. The other findings listed are not specifically associated with Down syndrome. Lens dislocation is commonly found with Marfan syndrome or homocysteinuria.
Children with Down syndrome have an increased prevalence of duodenal atresia. Pyloric stenosis is uncommon to see in the newborn period. It tends to present with nonbilious vomiting usually after 24 weeks of age. Hirschsprung disease (aganglionosis coli) presents with constipation and failure to pass stool. Infants with Hirschsprung disease commonly will not pass stool in the first days of life. Biliary atresia is a progressive cause of jaundice in an infant. It is the most common cause of a cholestatic jaundice in the newborn period. Emesis is not typically associated with biliary atresia. Milk protein allergy is a common cause of bloody stools in the first few months of life, but does not have bilious emesis associated with it.
Question 465:
You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome.
After confirming that the child does indeed have Down syndrome, the parents ask you what problems their baby may have in the future. With which of the following is the infant most likely to have problems?
A. renal failure
B. hypothyroidism
C. osteoporosis
D. hemophilia
E. lens dislocation
Correct Answer: B Section: (none)
Explanation:
The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Café au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome.
Ambiguous genitalia are commonly seen in CAH.
Children with Down syndrome are at an increased risk for hypothyroidism. It may be hard to detect without routine laboratory screening as they will commonly have mental retardation and developmental delay as part of their syndrome. Hypothyroidism may not be present in the immediate newborn period and requires, at a minimum, annual testing throughout the child's life. The other findings listed are not specifically associated with Down syndrome. Lens dislocation is commonly found with Marfan syndrome or homocysteinuria.
Children with Down syndrome have an increased prevalence of duodenal atresia. Pyloric stenosis is uncommon to see in the newborn period. It tends to present with nonbilious vomiting usually after 24 weeks of age. Hirschsprung disease (aganglionosis coli) presents with constipation and failure to pass stool. Infants with Hirschsprung disease commonly will not pass stool in the first days of life. Biliary atresia is a progressive cause of jaundice in an infant. It is the most common cause of a cholestatic jaundice in the newborn period. Emesis is not typically associated with biliary atresia. Milk protein allergy is a common cause of bloody stools in the first few months of life, but does not have bilious emesis associated with it.
Question 466:
You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome.
Which of the following signs is associated with Down syndrome?
A. café au lait spots
B. high arched palate
C. ambiguous genitalia
D. hypotonia
E. club feet
Correct Answer: D Section: (none)
Explanation:
The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Café au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome. Ambiguous genitalia are commonly seen in CAH.
Children with Down syndrome are at an increased risk for hypothyroidism. It may be hard to detect without routine laboratory screening as they will commonly have mental retardation and developmental delay as part of their syndrome. Hypothyroidism may not be present in the immediate newborn period and requires, at a minimum, annual testing throughout the child's life. The other findings listed are not specifically associated with Down syndrome. Lens dislocation is commonly found with Marfan syndrome or homocysteinuria.
Children with Down syndrome have an increased prevalence of duodenal atresia. Pyloric stenosis is uncommon to see in the newborn period. It tends to present with nonbilious vomiting usually after 24 weeks of age. Hirschsprung disease (aganglionosis coli) presents with constipation and failure to pass stool. Infants with Hirschsprung disease commonly will not pass stool in the first days of life. Biliary atresia is a progressive cause of jaundice in an infant. It is the most common cause of a cholestatic jaundice in the newborn period. Emesis is not typically associated with biliary atresia. Milk protein allergy is a common cause of bloody stools in the first few months of life, but does not have bilious emesis associated with it.
Question 467:
An 8-month-old boy is brought to the clinic by his mother because he has been lethargic, fussy, and not feeding well over the past several days. The mother has been working two jobs so the baby has been cared for by her boyfriend for the past month. She is very worried because he has not been smiling and vocalizing as much as he normally does and he has not been able to lift his head.
Which of the following findings on physical examination is suggestive of child abuse?
A. superficial abrasions on the shins of a 5 year old
B. retinal hemorrhages visualized on funduscopy in a 4 month old
C. a laceration on the forehead of a 6 year old
D. a partial dislocation of the elbow in a 3 year old
E. a linear skull fracture in a 9-year-old boy
Correct Answer: B Section: (none)
Explanation:
There are nearly 900,000 victims of child abuse in the United States each year. An inflicted injury is the most common cause of injury in the first year of life. As a child becomes more mobile, falls and motor vehicle accidents become increasingly more common. Other children are a very rare cause of serious injury in childhood. (Department of Health and Human Services, 2002) Brain injury that results from violent shaking of the infant is known as Shaken baby syndrome. These infants can present with seizures, a bulging fontanelle, or irritability presenting a clinical picture similar to that of a septic infant. Intracranial injury is evident on CT or MRI and with a funduscopic examination revealing retinal hemorrhages. Accidental bruises are usually found over bony areas such as shins, knees, elbows, and forehead. Linear fractures of the skull can result from low-energy blunt trauma over a wide surface area of the skull. Nursemaid's elbow is a common condition in young children and generally affects children under 5. It occurs when a child is pulled up too hard by the hand or wrist resulting a in a partial dislocation of the elbow.
Question 468:
A 16-year-old sexually active woman is being seen in the emergency department. She is complaining of vaginal discharge. She has a temperature of 99.5°F, but is otherwise well. On pelvic examination, you see a mucopurulent cervical discharge with scant blood. Samples of the discharge are sent to the laboratory for culture. There are no cervical ulcers noted. She does not have any medical allergies.
For this patient, what is the most appropriate regimen for initial therapy?
A. azithromycin (Zithromax) 1 g orally once and ceftriaxone (Rocephin) 125 mg intramuscular (IM) once
B. amoxicillin/clavulanic acid (Augmentin) 500 mg orally twice a day for 7 days and ceftriaxone 125 mg IM once
C. metronidazole (Flagyl) 500 mg orally twice a day for 7 days and amoxicillin/clavulanic acid 500 mg orally twice a day for 7 days
D. ceftriaxone 125 mg IM once
E. azithromycin 1 g orally once and metronidazole 500 mg orally for 7 days
Correct Answer: A Section: (none)
Explanation:
This young woman has cervicitis, but without evidence of pelvic inflammatory disease (PID). Chlamydia is the most common bacterial cause of sexually transmitted diseases in the United States and the most likely etiology of this patient's infection. Gonorrhea would be the next most likely cause and, frequently, there will be coinfection with the two pathogens. The simplest outpatient treatment for these two would be a single 1g oral dose of azithromycin and a 125-mg IM dose of ceftriaxone. This regimen will ensure complete compliance, which is crucial. Treatment of her sexual partners would also be recommended. Another cause of cervicitis is trichomoniasis, for which metronidazole, either for 1 week of 500 mg bid or a single 2g oral dose, would be recommended therapy. Of the suggested answers, option Ais the only one which would cover the two most common infectious agents.
Question 469:
An 8-month-old boy is brought to the clinic by his mother because he has been lethargic, fussy, and not feeding well over the past several days. The mother has been working two jobs so the baby has been cared for by her boyfriend for the past month. She is very worried because he has not been smiling and vocalizing as much as he normally does and he has not been able to lift his head.
What is the most common cause of injury in the first year of life?
A. falls down stairs
B. child abuse
C. motor vehicle collisions
D. dog bites
E. other children
Correct Answer: B Section: (none)
Explanation:
There are nearly 900,000 victims of child abuse in the United States each year. An inflicted injury is the most common cause of injury in the first year of life. As a child becomes more mobile, falls and motor vehicle accidents become increasingly more common. Other children are a very rare cause of serious injury in childhood. (Department of Health and Human Services, 2002) Brain injury that results from violent shaking of the infant is known as Shaken baby syndrome. These infants can present with seizures, a bulging fontanelle, or irritability presenting a clinical picture similar to that of a septic infant. Intracranial injury is evident on CT or MRI and with a funduscopic examination revealing retinal hemorrhages. Accidental bruises are usually found over bony areas such as shins, knees, elbows, and forehead. Linear fractures of the skull can result from low-energy blunt trauma over a wide surface area of the skull. Nursemaid's elbow is a common condition in young children and generally affects children under 5. It occurs when a child is pulled up too hard by the hand or wrist resulting a in a partial dislocation of the elbow.
Question 470:
A 16-year-old sexually active woman is being seen in the emergency department. She is complaining of vaginal discharge. She has a temperature of 99.5°F, but is otherwise well. On pelvic examination, you see a mucopurulent cervical discharge with scant blood. Samples of the discharge are sent to the laboratory for culture. There are no cervical ulcers noted. She does not have any medical allergies.
Which of the following is the most common sexually transmitted infection in adolescents?
A. herpes simplex virus (HSV)
B. chlamydia
C. gonorrhea
D. human immunodeficiency virus (HIV)
E. syphilis
Correct Answer: B Section: (none)
Explanation:
This young woman has cervicitis, but without evidence of pelvic inflammatory disease (PID). Chlamydia is the most common bacterial cause of sexually transmitted diseases in the United States and the most likely etiology of this patient's infection. Gonorrhea would be the next most likely cause and, frequently, there will be coinfection with the two pathogens. The simplest outpatient treatment for these two would be a single 1g oral dose of azithromycin and a 125-mg IM dose of ceftriaxone. This regimen will ensure complete compliance, which is crucial. Treatment of her sexual partners would also be recommended. Another cause of cervicitis is trichomoniasis, for which metronidazole, either for 1 week of 500 mg bid or a single 2g oral dose, would be recommended therapy. Of the suggested answers, option Ais the only one which would cover the two most common infectious agents.
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