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

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Presentation on theme: "Pediatric Board Review Part Dos Mark Heller, MD Department of Emergency Medicine Mount Sinai School of Medicine."— Presentation transcript:

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

2 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.

3 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

4 Swallowed Foreign Bodies

5 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

6 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

7 Question 2 Which of the following organisms is most likely to cause a rash with the characteristic “slapped-cheek” appearance? a. Coxsackievirus A16 b. Group A beta-hemolytic streptococci c. Human herpesvirus C d. Parvovirus B19 e. Varicella-zoster virus

8 Q 2 Answer Which of the following organisms is most likely to cause a rash with the characteristic “slapped-cheek” appearance? a. Coxsackievirus A16 b. Group A beta-hemolytic streptococci c. Human herpesvirus C d. Parvovirus B19 e. Varicella-zoster virus PEER VII Q309

9 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

10 Coxsackievirus A16 Hand-Foot-and-Mouth Disease –Mouth Sores –Blisters on Hand –Fever –Sore Throat –Abdominal Pain

11 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

12 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 boys b)Is associated with cystic fibrosis and malnutrition c)Requires excision of the lesion in the emergency department d)Requires proctasigmoidoscopy e)Requires referral for surgical correction

13 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 boys b)Is associated with cystic fibrosis and malnutrition c)Requires excision of the lesion in the emergency department d)Requires proctasigmoidoscopy e)Requires referral for surgical correction PEER VII Q334

14 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

15 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 therapy b. Concurrent presence of watery diarrhea reliably identifies a viral etiology c. Localized chest pain is the most commonly associated with viral pneumonia d. Viral and bacterial pneumonias can reliably be differentiated in infants e. Wheezing in preschool-aged children is pathognomonic for viral pneumonia

16 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 therapy b. Concurrent presence of watery diarrhea reliably identifies a viral etiology c. Localized chest pain is the most commonly associated with viral pneumonia d. Viral and bacterial pneumonias can reliably be differentiated in infants e. Wheezing in preschool-aged children is pathognomonic for viral pneumonia PEER VII Q343

17 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

18 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

19 Name That Saturday Morning Cartoon Character

20 Astro

21 Name That Saturday Morning Cartoon Character

22 Betty

23 Name That Saturday Morning Cartoon Character

24 Brainy Smurf

25 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 home c)Is precluded by an unacceptably high rate of uncontrollable vomiting after administration d)Leads to mild hyperactivity that interferes with normal sleep patterns e)Leads to quicker resolution of symptoms when compared with observation

26 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 home c)Is precluded by an unacceptably high rate of uncontrollable vomiting after administration d)Leads to mild hyperactivity that interferes with normal sleep patterns e)Leads to quicker resolution of symptoms when compared with observation PEER VII Q347

27 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

28 Question 6 For a child with stridor, which of the following best differentiates croup from bacterial tracheitis? a. Drooling and fever b. Normal chest x-ray c. Productive cough d. Rhinorrhea prodrome e. Stridor at rest

29 Q 6 Answer For a child with stridor, which of the following best differentiates croup from bacterial tracheitis? a. Drooling and fever b. Normal chest x-ray c. Productive cough d. Rhinorrhea prodrome e. Stridor at rest PEER VII Q368

30 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

31 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. Botulism b. Ciguatera c. Listeriosis d. Scombroid poisoning e. Typhoid

32 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)Botulism b)Ciguatera c)Listeriosis d)Scombroid poisoning e)Typhoid PEER VII Q349

33 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

34 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 diagnosis c)Mucus-laden, bloody, “currant jelly” stools are seen in most cases d)Postreduction recurrence is best predicted by patient age and sex e)Ultrasonography is an accepted diagnostic test

35 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 diagnosis c)Mucus-laden, bloody, “currant jelly” stools are seen in most cases d)Postreduction recurrence is best predicted by patient age and sex e)Ultrasonography is an accepted diagnostic test PEER VII Q354

36 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

37 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 examination b)Color of the vomitus c)History of constipation d)Presence of high fever e)Resting tachycardia

38 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 examination b. Color of the vomitus c. History of constipation d. Presence of high fever e. Resting tachycardia PEER VII Q357

39 Pyloric Stenosis Clinical Presentation –Nonbilious Projectile Vomiting –Just after feeding –Seen in 2 nd or 3 rd week Diagnosis –Palpation of pyloric mass in LUQ –US

40 Malrotation Clinical Presentation –Bilious Vomiting –Abdominal Distention –Streaks of Blood in Stool –Most present within first month of life Diagnose –Abdominal Radiograph

41 Name That Saturday Morning Cartoon Character

42 Skeletor

43 Name That Saturday Morning Cartoon Character

44 Patrick Star (SpongeBob’s Friend)

45 Name That Saturday Morning Cartoon Character

46 Snorks

47 Question 10 Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children? a)Anal fissures b)Infectious diarrhea c)Juvenile polyps d)Milk-protein allergy e)Vitamin K deficiency

48 Q 10 Answer Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children? a)Anal fissures b)Infectious diarrhea c)Juvenile polyps d)Milk-protein allergy e)Vitamin K deficiency PEER VII Q358

49 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

50 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 cephalosporin b. Immediately strap her down to long board c. Initiate fluid resuscitation with 2 L normal saline d. Order MRI of the spine e. Perform lumbar puncture and administer intravenous acyclovir

51 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 cephalosporin b. Immediately strap her down to long board c. Initiate fluid resuscitation with 2 L normal saline d. Order MRI of the spine e. Perform lumbar puncture and administer intravenous acyclovir PEER VII Q373

52 Acute Spinal Cord Dysfunction Etiology –Transverse Myelitis –Guillain-Barre –Spinal Cord Tumors Diagnosing –MRI Spine Treatment –Supportive –Respiratory Support –Admission to Neurology

53 Question 12 Which of the following is most commonly seen in infants with congestive heart failure? a. Bilateral pedal edema b. Bounding femoral pulses c. Excessive weight gain d. Jugular venous distention e. Sweating with eating

54 Q 12 Answer Which of the following is most commonly seen in infants with congestive heart failure? a. Bilateral pedal edema b. Bounding femoral pulses c. Excessive weight gain d. Jugular venous distention e. Sweating with eating PEER VII Q376

55 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

56 Name That Saturday Morning Cartoon Character

57 Mr. Owl

58 Name That Saturday Morning Cartoon Character

59 Dora

60 Name That Saturday Morning Cartoon Character

61 Bill

62 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 acyclovir b. Call child protective services, and order xrays c. Extubate, suction the airway, and intubate again d. Insert a nasogastric tube to decompress the stomach e. Promptly administer intravenous prostaglandin E1

63 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 acyclovir b. Call child protective services, and order xrays c. Extubate, suction the airway, and intubate again d. Insert a nasogastric tube to decompress the stomach e. Promptly administer intravenous prostaglandin E1 PEER VII Q382

64 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

65 Question 14 Which 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 cart b. Metaphysial corner fracture of the distal tibia after falling out of bed c. minimally displaced supracondylar humerus fracture after falling backwards off a piece of playground equipment d. Torus fracture of the distal radius after falling down three stairs e. Transverse fracture of the middle phalanx of the index finger after the finger was closed in a door by an older sibling

66 Q 14 Answer Which 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 cart b. Metaphysial corner fracture of the distal tibia after falling out of bed c. minimally displaced supracondylar humerus fracture after falling backwards off a piece of playground equipment d. Torus fracture of the distal radius after falling down three stairs e. 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

67 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

68 Question 15 A 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. Acyclovir b. Ampicillin/Sulbactam c. Azithromycin d. Chloramphenicol e. Levofloxacin

69 Q 15 Answer A 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. Acyclovir b. Ampicillin/Sulbactam c. Azithromycin d. Chloramphenicol e. Levofloxacin PEER VI Q134

70 Rocky Mountain Spotted Fever Etiology –Rickettsia rickettsii Transmitted by ticks Clinical Features –Rash –Headache –Myalgias –Fever Treatment –Tetracycline –Doxycycline –Chloramphenicol

71 No Mas


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