Wards
Subspecialty
Clinic
NBN
FYI
100
A 3-year-old girl is seen in the emergency department 30 minutes after ingesting a large amount of her father’s propranolol that was prescribed for the treatment of hypertension. You are working with a group of medical students who ask you what symptoms the patient may exhibit. Of the following, the MOST likely symptom that would be seen is A. hyperglycemia B. hypertension C. seizures D. tachycardia E. tachypnea
C ß-blocker overdose can produce changes in mental status, including coma, delirium, and seizures. ß-blocker overdose can cause hypotension, sinus bradycardia, heart block, increased airway resistance, respiratory depression, hypoglycemia, and hyperkalemia. Symptoms of ß-blocker overdose are almost always seen by 6 hours unless the drug is a sustained-release formulation.
100
A 9-year-old girl presents to your office for her annual health supervision visit. She has no significant medical history or complaints and is growing normally. Her physical examination, including vital signs, is unremarkable. Her mother was recently diagnosed with systemic lupus erythematous (SLE). Per the mother’s request, an antinuclear antibody test was performed on the child, resulting in a low-positive titer. Of the following, the BEST information you can provide the mother is that her daughter A. has a confirmed diagnosis of SLE B. has a high likelihood of developing autoimmune diseases C. has an infection D. most likely does not have SLE E. will develop lupus later in life
B
100
You have just diagnosed a 9-year-old boy with attention-deficit/hyperactivity disorder, following your usual data-gathering steps from both school and home that helped characterize the problem. After discussing the treatment options, the parents have elected to initiate methylphenidate and plan a follow-up appointment with you in 4 weeks. Of the following adverse effects, the MOST likely to occur in this patient is A. dysphoria B. hallucinations C. headaches D. hypertension E. tics
C. Stimulant medications are very well known for causing appetite suppression and weight loss (for which regular monitoring of the growth curve is very helpful) and difficulty with initiating sleep. In addition to these risks, more than 10% of children using stimulants will also experience headaches, stomach aches, dry mouth, and nausea. Two percent to 10% of children using stimulants will experience irritability, dysphoria, cognitive dulling, obsessiveness, anxiety, tics, dizziness, or blood pressure and pulse changes. Less than 2% of children using stimulants could have a notable, but rare reaction of hallucinations (usually visual or tactile rather than auditory) or manic symptoms; these are typically risks that appear when using stimulants at high doses.
100
At birth, a full-term neonate is noted to have a L4 to L5 myelomeningocele. The neonate was born to a 28-year-old mother with inconsistent prenatal care. The baby is transferred to your neonatal intensive care unit. On physical examination, he has visible head enlargement with a bulging fontanelle. He has severe foot deformities and bilateral hip dislocation. Head ultrasonography confirms hydrocephalus, and neurosurgery is consulted. The mother is concerned about any other systemic abnormalities that may be present. Of the following, the MOST appropriate next step in evaluation should be A. chromosome analysis B. electroencephalogram C. hearing screen D. ophthalmologic evaluation E. urologic evaluation
E
100
The first stethoscope was made of:
wood It was described by Laennec in 1819 and was designed for use by one ear. By 1852 it had been modified to a two-ear instrument with rubber tubing similar to those used today.
200
A 3-week-old full-term newborn, with fever and decreased oral intake over the past 24 hours, is admitted to a teaching hospital where you are the supervising pediatrician. Her plan of care includes obtaining blood, urine, and cerebrospinal fluid cultures, and initiating empiric intravenous antibiotic therapy. As you discuss this plan with the admitting resident, you ask how she will manage the newborn’s procedure-related pain. The resident replies that she generally does not use any pain management modality when performing procedures in newborns, as they are much less affected by these procedures than older children. Of the following, the MOST accurate statement about pain management for patients of this age is that A. a single modality should be used to manage procedure-related pain B. their level of procedure-related pain is overestimated by parents and health care providers C. they do not have the cognitive ability to remember painful experiences D. they typically display a less pronounced physiologic response to pain than older children E. undergoing painful procedures may result in long-term changes in pain response
E. Recent studies suggest that newborns may actually have an increased sensitivity to pain, which may be attributable to the fact that although their ascending nerve pathways can transmit painful stimuli to the brain, descending inhibitory pathways are not yet established. Data demonstrate that neonates display a more pronounced physiologic response to pain and require higher serum concentrations of analgesics to modulate pain compared with older children. Studies also indicate that repeated exposure to painful stimuli in the neonatal period can increase sensitivity to subsequent painful stimuli as well as routine handling. In addition, infants who experience painful procedures may develop altered responses to future painful episodes, even those that occur well beyond infancy. Pain may even be a contributing factor in the occurrence of intraventricular hemorrhage in preterm infants.
200
An 18-month-old boy presents to your clinic for a routine well-child visit. There is no history of serious illnesses or infections. His weight and height are at the 50th percentile for age. In the office, he is afebrile with normal vital signs. He is alert and in no apparent distress. On physical examination, you palpate a large nontender, right upper quadrant abdominal mass. The remainder of the physical examination is unremarkable. Ultrasonography is performed and shows a large mass suggestive of a malignancy in the liver. Of the following, the laboratory findings MOST likely to be seen in this patient would be A. anemia, elevated titers for hepatitis C, and elevated carcinoembryonic antigen B. anemia, thrombocytosis, and elevated a-fetoprotein C. elevated d-dimers, thrombocytopenia, and decreased fibrinogen D. elevated ferritin, elevated catecholamines, elevated lactate dehydrogenase E. leukocytosis, thrombocytopenia, and elevated ß-human choriogonadotropin
B
200
A 4-day-old newborn presents for his newborn check. His mother, who has not breastfed before, reports that she is having a lot of pain with breastfeeding despite assistance from a lactation consultant. She has heard that tongue-tie can cause breastfeeding problems and wonders whether the baby needs to have his frenulum clipped. Of the following, the MOST appropriate information to provide this mother is that A. ankyloglossia is common, affecting about one-quarter of all babies B. frenulotomy may be useful in improving maternal nipple pain during breastfeeding C. strong evidence exists that newborn frenulotomy improves the baby’s long term speech outcome D. there are reliable tools for determining which infants may benefit from frenulotomy E. there is clear evidence that frenulotomy is not helpful in supporting breastfeeding
Correct Answer: B Ankyloglossia, also known as tongue-tie, has long been considered a possible cause of breastfeeding, speech, oral hygiene, and psychological difficulties for either mother or infant. Unfortunately, there is limited objective data as to how often or severe these effects are or whether division of tongue-tie resolves these problems. A literature review concluded that frenulotomy can facilitate breastfeeding, improve milk transfer, and decrease maternal nipple pain for many affected infants and mothers. In one study, there was no statistically significant difference in speech articulation between controls and children with ankyloglossia who did or did not have a frenulotomy during infancy.
200
You are called to evaluate a 10-hour-old full-term neonate with poor feeding. The chart documents a normal pregnancy, labor, and delivery. The mother did not take any medications during pregnancy and did not receive any medications during delivery. Physical examination of the neonate reveals a high forehead with narrowing at the temples and a thin upper lip. With crying, the facial movements are symmetric, and the palate and tongue are normal. The neonate’s limbs move symmetrically when he is stimulated, but at rest, there is very low tone in the limbs and trunk. Deep tendon reflexes are present, but diminished. The remainder of the physical examination is unremarkable. Of the following, the MOST likely diagnosis is A. Angelman syndrome B. Duchenne muscular dystrophy C. infant botulism D. Prader-Willi syndrome E. spinal muscular atrophy
D presents in the neonatal period with hypotonia, poor suck, and characteristic facial features that include bitemporal narrowing of the head, almond-shaped eyes, elongated face, and thin upper lip.
200
In the years following World War II, poliomyelitis, more commonly called polio, was one of the most feared communicable diseases in the United States. It is now a rare disease in most western countries because of a vaccine developed by what famous scientist?
Jonas Salk
300
A 19-month-old boy is seen in your office for follow-up after a diagnosis of anemia. One month ago, iron supplementation was initiated for treatment. At that time, his hemoglobin was 9.1 g/dL (91 g/L), hematocrit was 28% (0.28), and the mean corpuscular volume was 67 fL. Today, his hemoglobin is 11.0 g/dL (110 g/L), hematocrit is 33% (0.33), and the mean corpuscular volume is 71 fL. He eats a varied diet and continues to breastfeed well. His growth is normal. Of the following, the BEST plan for management today is to A. continue iron supplementation for 3 months B. encourage more meat in the child’s diet C. have the mother take a multivitamin with iron tablet daily D. offer reassurance and discontinue the iron supplementation E. suggest weaning the child from breastfeeding
A Presumptive iron deficiency anemia may be treated with oral (elemental) iron at a dose of 3 to 6 mg/kg per day for 4 weeks. If improvement in the hemoglobin concentration and hematocrit occurs after 4 weeks of treatment with supplemental iron, iron deficiency is confirmed as the cause of anemia. Iron supplementation should continue for at least 2 months after the anemia has corrected to replenish the iron stores.
300
A medical student is working with you in clinic. He is preparing to see a 2-month-old infant whose older sister has sickle cell disease. The infant’s medical record has the results of the state newborn screen, which shows the hemoglobin fractionation to be an F, A, S pattern. Of the following, the MOST appropriate counseling for the family of this patient is that the infant A. has a less severe phenotype of sickle cell disease B. has the most common form of sickle cell disease C. has sickle cell trait D. must be referred to a hematologist immediately E. start monthly transfusions
C
300
At a health supervision visit, the parents of a 13-month-old boy express concern that their son’s legs are very bowed. After reviewing the child’s history and performing a physical examination, you diagnose physiologic genu varum. Of the following, the feature MOST likely to be associated with this diagnosis is A. bilateral, symmetric bowing B. bowing that appears most pronounced at 3 years of age C. breech presentation at birth D. walking at an early age E. weight greater than the 95th percentile for his age
A. Physiologic genu varum (bowing of the legs) generally resolves by age 2 years. Asymmetric bowing, and bowing that persists at age 3 years, should prompt evaluation for idiopathic tibia vara.Infantile tibia vara, sometimes referred to as infantile Blount disease, results from depression of the medial tibial physis. Risk factors include walking at an early age and obesityOther causes of nonphysiologic genu varum include skeletal dysplasias, such as achondroplasia, and trauma-induced growth plate injuries, which lead to asymmetric bone growth resulting in unilateral genu valgum or genu varum, depending on the location of injury. Breech presentation is a risk factor for hip dysplasia but not for genu varum.
300
You are asked to speak to a group of new mothers about the importance of breastfeeding. You want to highlight that there are only a few absolute medical contraindications to breastfeeding. In the case of the rare maternal infection that requires temporary discontinuation of breastfeeding, expressed breast milk from the mother may be offered until feeding at the breast can be resumed. Of the following, an example of this situation would include a mother who A. develops varicella 4 days before delivery B. is human T-lymphotropic virus-1 seropositive and lives in the United States C. is recently diagnosed with brucellosis and has not been treated D. is seropositive for cytomegalovirus and her infant is born at 40 weeks of gestation E. receives the live attenuated rubella virus vaccine immediately after delivery
A Feeding at the breast should be temporarily interrupted and expressed breast milk offered in cases of perinatal maternal infection with varicella, untreated active infectious tuberculosis, or active herpes simplex lesions on the breast. Mothers with untreated brucellosis should not breastfeed or feed their infant expressed breast milk. In the industrialized world, mothers with HIV, HTLV 1, or HTLV 2 should not breastfeed or feed their infant expressed breast milk.
300
Who invented the electrocardiogram?
Willem Einthoven
400
A 10-year-old boy presents to your office with the chief complaint of having cola-colored urine for one day. His review of systems is significant only for a mild sore throat without fever 4 weeks ago. On physical examination, the boy has normal growth parameters. He has a respiratory rate of 18 breaths/min, heart rate of 94 beats/min, and blood pressure of 138/90 mm Hg. The remainder of the physical examination findings is normal. A urine test strip analysis demonstrates a specific gravity of 1.015, pH of 5.5, 3+ blood, 2+ leukocyte esterase, and no protein or nitrites. Of the following, the test MOST likely to offer both diagnostic and prognostic information about this boy’s condition is A. antistreptolysin O titer B. C3 measurement C. renal ultrasonography D. urine culture E. urine microscopy
B Acute glomerulonephritis is characterized by the triad of cola-colored urine, hypertension, and azotemia on serum chemistry. These patients may or may not have proteinuria with or without hypoalbuminemia. Hypocomplementemia usually resolves within 8 weeks in postinfectious GN (PIGN). Persistently low C3 level is associated with an increased risk for membranoproliferative GN and possibly a poorer prognosis. Postinfectious GN is characterized by an immune-complex–mediated nephritis after an infectious process. Poststreptococcal GN (PSGN) exclusively relates to a group A, β-hemolytic streptococcal infection. Therefore ASO titers will be elevated only when PIGN associated with strep infection. However, in PIGN secondary to nonstreptococcal infections, ASO titers will be normal. Initial urine microscopy shows hematuria, pyuria (glomerular inflammation), and RBC casts. Subsequent urine microscopy in patients with classic PIGN may show persistent microscopic hematuria (which may persist for up to 1 to 3 years in some cases). This has not been associated with worse prognosis in the patients.
400
A 15-year-old boy is seen for a health supervision visit. The patient is healthy with normal growth parameters and development. He has no significant past medical or past surgical history. Physical examination and vital signs are unremarkable. His urine analysis in the office reveals a specific gravity of 1.010, a pH of 6.0, 4+ protein, and no blood, leukocyte esterase, or nitrites. His parents recall that their son had protein in his urine during a sports physical last year. Of the following, the BEST next step in management is A. evaluation by a nephrologist B. evaluation of a first morning urine sample C. quantitative urine protein estimation in a 24-hour urine sample D. recheck at the next health supervision visit E. urine micro-albumin estimation in a 24-hour urine sample
B A first-morning urine sample is necessary to evaluate for othostatic proteinuria. Persistent dipstick-positive proteinuria or a urine protein-creatinine ratio higher than 0.2 indicates renal pathology, which requires evaluation by a pediatric nephrologist. It is not usually necessary to obtain timed/24-hour urine collections for evaluating. Microalbuminuria testing should be restricted and used for early detection of renal injury secondary to chronic conditions.
400
You are evaluating a 2-month-old infant who was born at 28 weeks of gestation and went home from the neonatal intensive care unit 3 days ago. The baby’s birth weight was 990 g and her current weight is 1,900 g. The formula-fed infant was discharged on a diet of 22 cal/oz premature formula. The parents have had difficulty finding the formula and ask if the baby could be fed a different type of milk while still maintaining the benefits of premature formula. Of the following, the MOST accurate statement about feeding options for this infant is A. banked human milk supplies sufficient minerals and calories to support growth and prevent metabolic bone disease in low birth weight infants B. compared to formula made for term infants, premature formulas contain higher levels of calcium and phosphorus C. formula made for term infants would provide iron in excess of this infant’s needs D. the primary cause of decreased bone mineral concentration in premature infants is low vitamin D intake E. this infant should receive supplementation with 200 IU/day of vitamin D
B. Most mineral accumulation occurs during the third trimester, therefore premature newborns are at risk for developing deficiencies of calcium, phosphorus, iron, copper, and zinc. The primary cause of decreased bone mineral density in premature infants is low levels of calcium and phosphorus caused by either low intake or low absorption. Fortified human breast milk is the preferred energy source for preterm infants and supplies adequate minerals for their growth needs. Formula made for preterm infants also supplies adequate calcium and phosphorus.
400
A term male newborn is born to a 35-year-old woman known to have hepatitis C. The mother is anxious to know if her newborn has acquired the infection. Of the following, the test that would BEST identify early infection in the newborn is A. polymerase chain reaction at birth B. polymerase chain reaction at 4 months of age C. polymerase chain reaction at 18 months of age D. serology at 4 months of age E. serology at 18 months of age
B. Neonates born to hepatitis C virus (HCV)-infected mothers are expected to be antibody-positive, given transplacental transfer of maternal anti-HCV antibodies. Polymerase chain reaction assays that can detect viremia are preferred over serology for early diagnoses of vertically transmitted HCV infection and should be performed between 2 and 6 months of age.Serology could be performed at 18 months of age, when maternal IgG would be expected to be undetectable; however, this option would not best identify infection early
400
Which human organ was successfully transplanted first?
Kidney
500
A 6-week-old infant is being discharged after a hospitalization for an apparent life-threatening event (ALTE). He was born at term and had no medical problems before this event. During the hospitalization, no underlying cause for the ALTE was found, and he remained well, had a normal physical examination, and had no further events. His parents ask about home apnea monitoring. Of the following, the MOST accurate information to give these parents is A. the benefits of home monitoring to the infant outweigh the negative psychosocial effects on parents B. the psychosocial changes the parents will experience are likely to remain constant during the entire time the infant is monitored C. the parents are likely to experience early increases in depression and hostility once home monitoring is instituted D. the parents are likely to experience increases in depression starting about 6 months after home monitoring is instituted E. the parents are likely to report feeling that home monitoring of their infant is not helpful
C There is no evidence that home apnea monitors are effective in decreasing mortality or preventing sudden infant death syndrome. Use of apnea monitors in the home may increase parental anxiety, mood disturbance, and social isolation, especially immediately after hospital discharge. Parents often describe home apnea monitors as helpful and a source of comfort.
500
An intern you are supervising requests your assistance interpreting the results of spirometry performed on one of her patients who has persistent asthma. The intern would like to learn about the lung function parameters measured during spirometry that aid in the diagnosis of asthma. You review the interpretation of the spirometry results (ie, forced expiratory volume in 1 second [FEV1] to forced vital capacity [FVC] ratio, FEV1, and postbronchodilator reversibility) with the intern. Of the following, the findings MOST consistent with this diagnosis are A. FEV1 to FVC ratio < 85% and FEV1 <80%; postbronchodilator reversibility of 12% B. FEV1 to FVC ratio < 85% and FVC < 80%; postbronchodilator reversibility of 12% C. FEV1 to FVC ratio > 85% and FVC < 80%; postbronchodilator reversibility of 20% D. FEV1 to FVC ratio > 85% and FEV1 < 80%; postbronchodilator reversibility of 12% E. FEV1 to FVC ratio > 85% and FEV1 < 80%; postbronchodilator reversibility of 20%
A An FEV1/FVC ratio less than 85% in children suggests the presence of airway obstruction. FEV1 can be an indicator of current obstruction and predict risk for future exacerbations. Reversibility is determined either by an increase in FEV1 of at least 12% from baseline or by an increase of at least 10% of predicted FEV1 after inhalation of a short-acting bronchodilator. In obstructive diseases FEV1 is diminished because of increased airway resistance to expiratory flow. In some cases, the FVC may be decreased as well, owing to the premature closure of airway in expiration, but the FEV1 is typically disproportionately affected. In restrictive diseases the FEV1 and FVC are both reduced proportionally and the ratio may be normal or even increased as a result of decreased lung compliance.
500
Search Nutrition and Nutritional Disorders Question View: [ Other Specialty ] Mode: Learning Exam 2 of 9 (260 total)Print Add Bookmark ASSESSMENT PROGRESS:Total Questions: 260 Questions Answered: 16 Correct Answers: 8 Question 7 During a routine health supervision visit, the mother of a 10-week-old infant tells you that her baby has been experiencing bloating and flatulence for the past week. His diet consists of 5 oz to 6 oz of a cow milk–based formula given 5 times per 24 hours. Because of frequent episodes of emesis after feedings, rice cereal was added to each bottle at 2 months of age. The baby has 4 to 5 loose to seedy stools per day. On physical examination, the baby is alert and vigorous. His length and weight are tracking between the 50th and 75th percentiles. The infant’s mother asks you whether switching to a soy protein–based formula will help her baby’s “gassiness.” Of the following, the MOST likely cause of this infant’s symptoms is A. cow-milk protein allergy B. excessive energy intake C. incomplete starch digestion D. lactose malabsorption E. sucrase–isomaltase deficiency
C Symptoms of colic, including flatulence and bloating, are often the result of bacterial hydrolysis of unabsorbed carbohydrate. In infants younger than 4 months of age, dietary starches may be hydrolyzed incompletely. Lactase deficiency is extremely rare during the first year after birth, unless it occurs as the consequence of intestinal mucosal injury.
500
You are called by the nursery staff to inform you of a newborn admitted to your service. The mother presented in labor at 36 3/7 weeks of gestation after receiving good prenatal care that was complicated only by unknown group B Streptococcus screening status. She received 1 dose of cefazolin 4 hours prior to delivery. Spontaneous rupture of the membranes occurred 8 hours prior to delivery and the mother remained afebrile. The newborn appears clinically well 1 hour after delivery, with a glucose value of 51 mg/dL (2.8 mmol/L). The mother is requesting discharge 24 hours after delivery. Of the following, the MOST appropriate initial management is to A. observe for 24 hours with no additional evaluation B. observe for 48 hours with no additional evaluation C. obtain a blood culture and complete blood cell count with differential and observe for 24 hours D. obtain a blood culture and complete blood cell count with differential and observe for 48 hours E. obtain a blood culture and complete blood cell count with differential and treat with antibiotics
B Mothers who are admitted in labor before 37 weeks and 0 days with unknown group B streptococcal (GBS) status should receive antibiotic prophylaxis. Late preterm newborns who appear well at birth may simply be observed for 48 hours or more in the hospital if their mother received adequate antibiotic therapy starting at 4 or more hours before delivery, had ruptured membranes less than 18 hours, and did not develop chorioamnionitis.
500
When taking the Hippocratic Oath, by which Greek god does the oath taker swear?
Apollo
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