Infectious
Disease
Disease
A 2-year-old male is brought to your office in October with a 2-day history of low-grade fever, runny nose, and a barking cough. He has a rectal temperature of 38.9°C (102.0°F) and does not appear toxic. He has a respiratory rate of 35/min and you hear occasional stridor but he is not wheezing. His oxygen saturation is 95% on room air.
Which one of the following has the strongest evidence of benefit in this situation?
A. Supplemental oxygen
B. Treatment with nebulized racemic epinephrine
C. Oral glucocorticoids
D. Oral amoxicillin
C. Oral glucocorticoids
Croup, or inflammation of the larynx and trachea, is common in children. It is a viral infection that causes hoarseness, a barking cough, and noisy breathing. Croup is usually self-limited, but children who are hypoxic or have stridor at rest should be hospitalized.
Corticosteroids should be administered to children with croup, regardless of the severity of disease (SOR A). A Cochrane review of randomized, controlled trials has shown that glucocorticoids can improve croup within 6 hours and that the effect lasts for 12 hours, decreasing the need for other interventions and/or hospitalization (SOR A).
A 6-year-old child sustained a dog bite on his left hand about 24 hours ago. The bite was provoked, and the dog is his family’s pet and is up to date on its immunizations. The child has received all indicated well care, including immunizations, and has no known drug allergies.
An examination reveals two tender, erythematous puncture wounds on the dorsal aspect of the hand. There is some regional lymphangitis.
Which one of the following is considered first-line treatment for this patient?
A. Augmentin
B. High dose amoxicillin
C. Clindamycin plus ciprofloxacin
D. Doxycycline
A. Augmentin
Only 15%–20% of dog bite wounds become infected, with crush injuries, puncture wounds, and hand wounds more likely to do so than scratches or tears. Most infected wounds contain multiple organisms, with Pasteurella multocida and Staphylococcus aureus being the most common. Other pathogens include Streptococcus species, Corynebacterium species, Eikenella corrodens, and Capnocytophaga canimorsus. Anaerobic organisms, including Bacteroides fragilis, Fusobacterium species, and Veillonella parvula, have also been implicated.
Prophylactic antibiotics should be prescribed for any high-risk bite wound, which includes those on the extremities or hand, crush injuries, puncture wounds, and wounds with delayed presentation (SOR B).
An 18-month-old female is brought to your office because of a chronic red, dry, itchy rash over her neck and cheeks. The mother has been cleaning the affected area with alcohol but she thinks this has only made the rash worse.
Which one of the following is true regarding the management of this condition?
A. Effective skin hydration is the most important component of managing this condition
B. Lotions with higher water content are more effective than thick creams or ointments with low water content
C. Assessment and management of food allergies is important for children with this condition
D. Systemic treatments are more effective than topical treatments
A. Effective skin hydration is the most important component of managing this condition
Effective skin hydration is the major focus of management of atopic dermatitis in children. Returning moisture to the skin will allow it to heal and will reduce redness, itching, and scaling (SOR C). Thick creams with a low water content such as Cetaphil or Eucerin, or ointments such as petroleum jelly or Aquaphor that have zero water content, provide better protection against dry skin. Emollients should be applied liberally at least once a day and immediately after bathing or hand washing. A randomized, controlled trial of infants with moderate to severe atopic dermatitis demonstrated that regular emollient use resulted in improved symptoms and reduced the need for topical corticosteroid use.
A 17-year-old female comes to your office accompanied by her mother. The patient tells you that she had unprotected intercourse the night before. She describes this as a one-time, consensual encounter and says that she is not in an established relationship. She is requesting emergency contraception only and does not wish to start long-term contraception.
Which one of the following would be most appropriate?
A. Order single or split dose of levonorgestrel
B. Tell the patient she will need to return for an evaluation if she needs emergency contraception in the future
C. Explain that she will need to have a pelvic examination at this visit prior to receiving the prescription
D. Order a pregnancy test
A. Order the single or split dose of levonorgestrel
The majority of adolescents begin sexual activity during their teenage years. Provision of emergency contraception before it is needed has been demonstrated to increase the rate and timeliness of use in adolescents, with 2–7 times greater use among those who had received an advanced supply. The use of emergency contraceptives by adolescents does not result in higher rates of STDs or unprotected intercourse and does not change patterns of routine contraceptive use (SOR C). However, the rates of pregnancy in patients receiving an advanced supply have not seemed to decline despite timely use.
A 7-year-old male is brought to your office by his parents because of his poor performance in school. His teacher reports that he often does not pay attention to details, has difficulty concentrating on tasks, does not seem to listen when spoken to, is forgetful, loses school supplies, and is easily distracted. His developmental and medical histories are unremarkable. A physical examination is normal. You suspect that he has attention-deficit/hyperactivity disorder (ADHD).
Which one of the following is true regarding the evaluation of this problem?
A. A direct report of symptoms from the parents alone is sufficient to make the diagnosis
B. ADHD-specific instruments, such as the Conners Parent Rating scale or the Vanderbilt scales, are reliable for establishing the diagnosis
C. Global teacher rating scales are reliable instruments for establishing the diagnosis
D. Children suspected of having ADHD should undergo a routine laboratory workup
B. ADHD-specific instruments, such as the Conners Parent Rating scale or the Vanderbilt scales, are reliable for establishing the diagnosis
A 7-year-old male presents with a rapid onset of a red, swollen right shin. He is on a youth football team, and two teammates recently had boils on their legs that were culture-positive for methicillin-resistant Staphylococcus aureus (MRSA). The boy has a hot, tender, 5×5-cm area of erythema on the right lateral shin where his football pants rub the skin.
Which one of the following would be the most appropriate treatment?
A. Augmentin
B. Keflex
C. Bactrim
D. Levofloxacin
E. Vancomycin
C. Bactrim
This child has a cellulitis that is most likely due to methicillin-resistant Staphylococcus aureus (MRSA). Cephalexin and amoxicillin/clavulanate are ineffective against MRSA. Vancomycin must be given intravenously and is not cost effective in this situation. Levofloxacin is contraindicated in persons under the age of 19 years because of the risk of joint malformation. The best antibiotic for this patient is trimethoprim/sulfamethoxazole. It is bactericidal and there is clinical data to support its use (SOR A).
A 6-week-old male is brought to your office with a 3-day history of projectile, non-bilious vomiting at every feeding. He appears healthy and an abdominal examination is normal. A CBC and electrolyte panel are normal.
Which one of the following should be ordered initially?
A. A plain film of the abdomen
B. An upper GI series
C. Abdominal ultrasound
D. CT of the abdomen
E. Nuclear scintigraphy
C. Abdominal ultrasound
Ultrasonography has become the standard test for hypertrophic pyloric stenosis, with muscle thickness measurements of 4 mm considered positive (SOR C). Measurements of 3–4 mm are indeterminate and require further evaluation. A pyloric length ≥2 cm is also considered diagnostic. An experienced ultrasonographer is needed to ensure accurate measurements.
A 5-month-old male born at term has a 4-month history of random, nonprojectile vomiting 2–4 times daily. Because of his mother’s work schedule the child breastfeeds only twice a day and ingests appropriate amounts of bottled breast milk or formula for other feedings. He also eats 2 small jars of baby food every day. His development has been appropriate and he is growing well and smiles or giggles frequently. A physical examination is normal, including the abdominal and neurologic examinations.
To reduce these vomiting episodes you advise the parents to
A. Elevate his head when he sleeps
B. Place him in a prone position for sleep
C. Start him on metoclopramide (reglan)
D. Thicken his feedings with rice cereal
E. Give him a dose of antacid following each meal
D. Thicken his feedings with rice cereal
Numerous studies have documented the benefits of formula thickening (SOR A). Rice cereal has been shown to be an adequate food thickener and is likely to help in this case.
Which one of the following should receive further evaluation for developmental problems, assuming they are persistent?
A. A 10 month old who cannot make a mark on a piece of paper with a crayon
B. A 15 month old who does not point to an object he wants
C. A 24 month old who cannot thread a shoelace into the eyelet of a shoe or into a bead
D. A 30 month old who cannot balance on 1 foot for 1 second
E. A 36 month old who cannot throw a ball overhand while standing
B. A 15 month old who does not point to an object he wants
A 10-month-old infant should be able to hold a crayon but would not be expected to make a mark on a piece of paper until 15 months of age. A 15-month-old child who does not point to an object he wants clearly is behind in abilities and needs to be evaluated further. This failure may be a cardinal sign of a difficulty such as pervasive developmental delay or autism, especially when accompanied by other suggestive findings.
The mother of a 6-year-old male has recently noticed fecal soiling evident in the child’s underwear once or twice weekly. When she asks her son about this problem he quickly changes the subject to avoid the discussion. She fears that this sudden change might indicate a serious physical or psychological problem, which concerns her because the child’s father was recently diagnosed with bipolar disorder. She is married to the father but they are currently separated.
The child started first grade 4 months ago and appears to be doing well in school. His teacher reports no behavioral problems. Specifically, she said she has not noticed any behavior or odor that might suggest fecal soiling during the school day.
The mother had a normal prenatal course and delivery, and the child’s infancy and early childhood have been unremarkable. Developmental milestones were met in a timely fashion. He was exclusively breastfed until 6 months of age and continued partial breastfeeding until 18 months of age. He was fully toilet trained at 2½ years of age. There has been no recent change in his diet.
Which one of the following is true regarding this problem?
A. A referral for a psychological assessment and counseling should be made at this visit
B. The most effective treatment plan includes both dietary and behavioral components
C. A low-residue diet has been shown to reduce the frequency and amount of stool leakage
D. Biofeedback bowel training has been shown to reduce the frequency of fecal soiling in children over the age of 5 years
B. The most effective treatment plan includes both dietary and behavioral components
After the age of 5 years, encopresis is three times as common in males as in females (SOR A). Although psychological causes are possible and parents often fear this is the case, fecal soiling is the result of functional constipation over 80% of the time (SOR B). Functional fecal incontinence, the most common cause of fecal soiling, tends to resolve spontaneously by adolescence, but treatment should not be deferred for this reason (SOR C).
A 5-year-old female has a 12-day history of nighttime and daytime cough, low-grade fever, and nasal drainage that has substantially increased in amount and gradually changed from yellow to greenish. Her growth and development have been appropriate, and she has no chronic illnesses.
Which one of the following would be most helpful for making a diagnosis?
A. The increase in amount of nasal drainage
B. The change in color of the nasal drainage
C. Symptom duration of >10 days w/o improvement
D. Presence of mucosal thickening in a paranasal sinus on radiograph
C. Symptom duration of >10 days w/o improvement
In most children with uncomplicated upper respiratory infections (URIs), improvement is seen in 10 days or less. A child with persistence of any one of the typical URI symptoms for more than 10 days with no improvement makes the likelihood of sinusitis >90% (SOR C). The quantity, quality, and color of nasal discharge are not helpful in differentiating acute bacterial sinusitis from other upper respiratory illnesses such as the common cold or allergic rhinitis (SOR B, C).
A 5-year-old female is brought to your office with a 36-hour history of vomiting and nonbloody diarrhea. Her temperature has been around 101°F, she has had 7 watery stools daily, and she has not had a cough or nasal congestion. The mother has given her oral rehydration solution but she has not been able to keep it down consistently. The child has urinated twice today.
On examination the patient is alert and fussy but is easily calmed by her mother. She is thirsty and eager to drink but vomits after attempting to do so. Her axillary temperature is 37.7°C (99.9°F), and her pulse rate, respiratory rate, and blood pressure are appropriate for her age. Her mouth is dry and her skinfold recoil is less than 2 seconds.
Which one of the following would be most appropriate at this time?
A. Advising the mother to offer a flat soft drink as desired
B. Bismuth subsalicylate
C. A serum electrolyte panel
D. Ondansetron
D. Ondansetron
There is ample high-quality evidence that oral rehydration is essentially as effective as intravenous rehydration for dehydrated children (SOR B). This is supported by evidence-based guidelines endorsed by the CDC and the American Academy of Pediatrics. The most-studied solution for oral rehydration is the World Health Organization Oral Rehydration Solution (WHO ORS). WHO now recommends rehydration with a reduced osmolarity ORS. The official WHO ORS or a solution composed of ½ teaspoon salt and 6 teaspoons sugar per 1 L water may be used. While other preparations resemble WHO ORS, they are not exactly the same.
The mother of a 1-year-old African-American male is concerned that her child’s umbilical hernia has not decreased in size after she treated it by taping a half-dollar coin over it, as suggested by the child’s grandmother. The hernia measures approximately 1.5–2.0 cm at the abdominal muscle layer. She asks your opinion about surgical correction of the hernia.
With regard to surgery, you advise her that it should be
A. Performed as soon as possible
B. Deferred until the age of 2
C. Deferred until 3-5 years of age
D. Deferred until puberty
C. Deferred until 3-5 years of age
Asymptomatic children with an umbilical ring that is progressively closing typically can be observed without concerns about incarceration, regardless of their age. Closure of the umbilical ring is complete in almost all children by 5 years of age, although the frequency of closure may be lower in African-American children. Surgery should not be considered until at least 3–5 years of age (SOR C). Conditions that increase the likelihood of surgery include a fascial opening that is greater than ≥1.5 cm, a significant amount of protruding skin, an older child, or an underlying predisposing condition that makes spontaneous closure less likely.
A healthy 5-year-old male is brought to your office by his mother for a well child visit. His birth history and past medical history are unremarkable and his immunizations are up to date. The mother has no specific concerns.
For a patient such as this one, the U.S. Preventive Services Task Force recommends routine screening for
A. Developmental dysplasia of the hip
B. Visual disturbance
C. Hearing loss
D. Proteinuria
B. Visual disturbance
Although there is no direct evidence demonstrating that vision screening in children leads to an improvement in ultimate visual acuity, various screening tests are known to be effective in detecting common childhood visual problems, including strabismus, amblyopia, and refractive errors. Addressing these problems does improve vision. Therefore, the U.S. Preventive Services Task Force (USPSTF) recommends that age-appropriate screening be offered at least once in all children 3–5 years of age to detect amblyopia or its risk factors (B recommendation). Age-appropriate screening tools, such as the Snellen, Lea Symbols, and HOTV charts, may be used in children older than 3 years of age. Additional tests that can be considered in the primary care office include the red reflex test, the cover-uncover test for strabismus, and the corneal light reflex test.
A 13-year-old female is brought to your office by her parents. They tell you that since she started seventh grade 2 months ago she has not been sleeping well, and they often find her awake at 2 a.m. or later using social media on her phone. They also report that her teachers have been concerned because her behavior at school has been somewhat erratic. The mother, who has bipolar disorder, worries that her daughter might have the same diagnosis.
Which one of the following is most accurate with regard to assessing this patient for bipolar disorder?
A. Given the family history, there is sufficient information provided at this visit to make a diagnosis of bipolar disorder
B. The symptom complex of irritability, reckless behaviors, and increased energy has a high specificity for making a diagnosis of bipolar disorder
C. Genetic testing will help to establish a diagnosis of bipolar disorder
D. DSM-5 criteria should be followed when making a diagnosis of mania or hypomania in children and adolescents
D. DSM-5 criteria should be followed when making a diagnosis of mania or hypomania in children and adolescents
Assessment of symptoms for mania, hypomania, or depression in adolescents requires a series of observations. DSM-5 criteria should be followed when making a diagnosis of mania or hypomania in children and adolescents (SOR C). The assessment should incorporate both current and past history, noting the frequency, intensity, and duration of symptoms, as well as looking for specific findings that cluster together, including symptoms, treatment response, psychosocial stressors, and family psychiatric history.
A 5-year-old female is brought to an emergency department in Oregon with a 3-day history of intermittent fever, headache, mild nausea, and a sore throat. There is no history of recent travel. On examination the child has a fever of 40.6°C (105.1°F), appears uncomfortable, and has a maculopapular rash on her legs and the soles of her feet.
Which one of the following would be most appropriate at this point?
A. Order titers for lyme disease
B. Give ceftriaxone in the office
C. Order CBC to look for leukocytosis
D. Begin treatment with doxycyline now
D. Begin treatment with doxycyline now
Rocky Mountain spotted fever (RMSF) is most common in the south central and south Atlantic states, although cases have been reported from all contiguous 48 states and the District of Columbia. Doxycycline, not ceftriaxone, is the effective treatment. It remains the drug of choice for all tickborne diseases, regardless of the patient’s age. For children, the recommended dosage is 2.2 mg/kg twice daily, with oral therapy being effective for those who can be treated as outpatients. The risk of tooth staining is not high after only one course of treatment for RMSF (SOR A).
A 9-month-old previously healthy male is brought to the emergency department by his mother. She tells you that approximately 5 hours ago the child suddenly began to cry inconsolably. Since then he has experienced paroxysms of screaming in apparent pain and pulls his legs up to his abdomen. These episodes are interspersed with periods of lethargy. He has had vomiting and diarrhea, and in the past hour has passed stool with dark blood in it. On examination you feel a cylindrical mass in the right lower quadrant.
Which one of the following tests would be most appropriate at this point?
A. Order a CT-abdomen
B. Hydrostatic or air enema
C. Rigid sigmoidoscopy
D. Flexible sigmoidoscopy
E. Surgery
B. Hydrostatic or air enema
Intussusception is the most common abdominal emergency in early childhood, typically presenting between 6 and 36 months of age. In the majority of cases the cause is unknown. However, viruses, tumors, cystic fibrosis, Henoch-Schönlein purpura, Meckel’s diverticulum, and parasites have all been associated with this condition. Pneumatic reduction in experienced hands is likely to be more successful in reducing the intussusception. If the diagnosis is uncertain, ultrasonography or plain films may be useful if readily available.
Over the past 3 months a 5-year-old male has had three episodes of muteness accompanied by drooling and what he describes as a “funny taste” in his mouth. The episodes all occurred when he first woke up in the morning, lasted 3–5 minutes, and were not associated with a loss of consciousness or postictal state. His father had similar episodes when he was a child.
The most likely diagnosis is
A. Benign focal epilepsy
B. Complex partial epilepsy
C. Febrile seizures
D. Juvenile myoclonic epilepsy
E. Video game-relate epilepsy
A. Benign focal epilepsy
Benign focal epilepsy of childhood has its onset between 3 and 13 years of age and is one of the most common focal epilepsies in children. It is genetically inherited as an autosomal dominant trait with an age-dependent penetrance. The typical focal seizure lasts seconds to minutes, and manifestations include sensory symptoms or focal twitching involving the mouth, possibly accompanied by a sudden inability to speak and/or drooling. There is no loss or alteration of consciousness, and no postictal phase. The child may not mention these episodes to parents. A single bedtime dose of carbamazepine may be all that is needed to control recurrences (SOR C). The seizures generally stop by about 14–16 years of age.
A healthy, 3350-g (7 lb 6 oz) female is born at a birthing center at 8:00 p.m. Because of the family’s financial circumstances and at the parents’ insistence, the baby is discharged with the mother the following morning at about 12 hours of life. A blood sample for mandated screening for genetic and metabolic disorders is collected before discharge.
Testing for which one of the following should be repeated in 1–2 weeks?
A. Congenital Adrenal Hyperplasia
B. Congenital Hypothyroidism
C. Galactosemia
D. Phenylketonuria
E. Sickle Cell Anemia
D. Phenylketonuria
A normal result from a PKU sample taken at or before 12 hours of age does not rule out PKU. This is because the child has not yet ingested enough dietary phenylalanine to raise the PKU level. Because some cases of PKU can be missed when the test is performed too early, the recommendation is that a repeat specimen be taken 1–2 weeks later in infants whose initial test was performed within the first 24 hours of life.
A 5-year-old female has recently been wetting the bed 3–4 nights weekly. Before this she had wet the bed 2–3 nights weekly and she has never been dry through the night for a long period of time. She has no recent history of daytime enuresis. Her mother asks if you can prescribe something to treat the enuresis because she expects there will be sleepover invitations once the child begins school.
Further history reveals that the mother has recently remarried, and that her husband has two children of his own. The mother reports that her daughter seems to be generally adjusting well to her new family but is a bit more clingy than in the past. A review of systems is otherwise unremarkable. The child’s growth and development are appropriate for her age.
Which one of the following is true regarding the management of this problem?
A. The bed wetting will eventually resolve without treatment
B. The local child protective agency should be contacted to report presumptive sexual abuse
C. TCA's are first line treatment of enuresis
D. Enuresis alarms are no more effective than placebo
A. The bed wetting will eventually resolve without treatment
Enuresis in children is most commonly primary, or mono-symptomatic, which is defined as never having achieved 6 months of continuously dry nights. Secondary, or non mono-symptomatic, enuresis refers to enuresis in children who have previously achieved 6 months or more of dry nights and have a recurrence of nighttime bedwetting. Studies have shown that up to 20% of 5-year-old children, and 5%–10% of all 7-year-olds experience some degree of nocturnal enuresis (SOR C). Spontaneous resolution of primary enuresis is common, occurring at an annual rate of approximately 15%. Less than 2% of the population experiences nocturnal enuresis by the age of 15 years (SOR A).
A 9-year-old male presents with a 1-week history of fever, anorexia, malaise, and axillary and supraclavicular adenopathy. He had previously been well and thriving. No one else in his home is sick. He brought home a stray cat about 6 weeks ago but recalls no scratches or skin sores. The cat was noted to have fleas. An examination confirms the presenting symptoms. He has no skin lesions, there is no hepatosplenomegaly, and a neurologic examination is within normal limits.
Which one of the following would be most appropriate at this point?
A. An erythrocyte sedimentation rate
B. Tuberculin testing
C. An indirect immunofluorescent antibody assay
D. A lymph node biopsy
C. An indirect immunofluorescent antibody assay
Immunofluorescent antibody testing to antigens of Bartonella species is useful for making the diagnosis (SOR A). However, a negative serologic test should not rule out CSD if there is a high clinical suspicion for disease. A lymph node biopsy generally is not indicated in typical cases of CSD, given the invasiveness and expense (SOR C). It should be considered only when the diagnosis is in doubt.
A 6-year-old female is brought to your office by her father for follow-up of an urgent care visit 2 days ago for uncontrolled epistaxis after minor trauma to her nose. She has not had another nosebleed since the urgent care visit but her mother has noted some bleeding of the child’s gums after she brushes her teeth. A review of her chart reveals that she has been healthy, apart from occasional childhood infections and mild allergies. Her growth and development have been normal. Her family history is benign except for Hashimoto’s thyroiditis in her mother. You saw the child 10 days ago for a febrile upper respiratory infection that resolved without complications.
On examination today the only significant finding is petechiae around her eyes. A CBC shows a WBC count of 7200/mm3 (N 4500–11,000), a hemoglobin level of 14.0 g/dL (N 12.0–16.0), a hematocrit of 40.7% (N 36.0–46.0), and a platelet count of 32,000/mm3 (N 150,000–300,000).
Which one of the following is true regarding this case?
A. She has likely had thrombocytopenia for a long time
B. The test of choice in this situation is serum antiplatelet antibodies
C. The test of choice is a bone marrow biopsy
D. The recent infection is the most likely cause of these findings
E. Child abuse is the most likely cause of these findings
D. The recent infection is the most likely cause of these findings
Childhood immune thrombocytopenia (ITP) typically presents with the sudden appearance of a petechial rash, bruising, and/or bleeding in an otherwise healthy-appearing child. Most children with ITP have a history of a preceding viral illness. ITP may also infrequently occur following administration of MMR vaccine. ITP can present at any age, but the peak incidence in childhood is between 2 and 5 years of age.
A 4-year-old male is brought to your office for a well child evaluation. His family recently moved across town, so you are seeing him for the first time. He has a history of mild lower limb weakness beginning at age 3, which has been increasing over the past 6 months. During that time he has developed shortness of breath and difficulty with daily activities such as climbing stairs. The parents note that he is easily fatigued.
His last visit with his previous physician was 6 months ago and did not reveal any cause for his problems. Since that time he has lost 1 kg (2 lb) and developed a chronic nonproductive cough that is now accompanied by occasional nausea and vomiting, and he has also developed orthopnea. His bowel movements are regular.
On examination his blood pressure is 95/60 mm Hg, his pulse rate is 100 beats/min, and his respiratory rate is 20/min. He is not cyanotic. His lungs are clear to auscultation and no murmur or arrhythmia is evident. His muscle strength is reduced to 4/5 diffusely and he has hyporeflexia in his lower extremities. When he stands up he pushes his hands against his thighs and has a lordotic posture. His calf muscles are proportionately hypertrophied in relation to his thighs.
The recent escalation of this patient’s symptoms is most likely a consequence of which one of the following?
A. Cardiomyopathy
B. Gastroenteropathy
C. Peripheral neuropathy
D. Renal Failure
E. Reversible airway disease
A. Cardiomyopathy
This presentation is typical of Duchenne’s muscular dystrophy (DMD), which causes cardiomyopathy in 50%–70% of affected boys. Weight loss, cough, nausea, vomiting, orthopnea, and fatigue are common symptoms of heart failure in childhood. In patients with DMD, these symptoms are particularly associated with cardiomyopathy, which does not always correlate with the severity of the musculoskeletal symptoms. In addition to a careful history and physical examination, noninvasive imaging with either echocardiography or cardiac MRI is recommended, based on the child’s age and ability to cooperate. More recent studies have shown that cardiac MRI is superior to echocardiography for diagnosing DMD-related ventricular dysfunction because it is less affected by body habitus and has lower rates of suboptimal imaging. Consultation with a cardiologist is important for ongoing surveillance.
A 9-year-old female is brought to the office for a well child visit. Her mother mentions that a family friend is being treated for scoliosis and she wants to have her daughter screened for this condition.
Which one of the following is true regarding this condition?
A. The USPSTF recommends screening adolescents for idiopathic scoliosis
B. Screening for scoliosis is most important in females who have reached skeletal maturity
C. Using a scoliometer in the school setting improves detection of clinically significant scoliosis
D. Idiopathic scoliosis is most commonly seen in females between the ages of 10 and 13
E. Approximately 3% of patients with idiopathic scoliosis will eventually require treatment
D. Idiopathic scoliosis is most commonly seen in females between the ages of 10 and 13
The U.S. Preventive Services Task Force’s 2018 update on screening for idiopathic scoliosis in adolescents gives it an I recommendation, indicating that current evidence is insufficient to assess the balance of benefits and harms of screening. This is based on its findings that although there is adequate evidence that currently available screening tests can accurately detect adolescent idiopathic scoliosis, there is no direct evidence regarding the effect of screening for adolescent idiopathic scoliosis on patient-centered health outcomes, and no studies on the direct harms of screening, such as psychological harms or harms associated with confirmatory radiography.
Scoliosis is most commonly seen in females between the ages of 10 and 13 years and progresses most severely during the growth phase before the patient has reached skeletal maturity. Ninety percent of cases are idiopathic, and the prevalence of scoliosis that eventually requires treatment is very small (<0.5%). This means that there is much unnecessary testing and referral. Use of a scoliometer does not increase the rate of discovery of clinically significant scoliosis, which usually comes to light without the aid of screening tests.
A 14-year-old male presents with low mood and difficulty concentrating for the past 4 months. His mother says that he is more withdrawn and that his symptoms seem to be worsening. During the visit the patient says he does not have any suicidal ideation. His Patient Health Questionnaire-9 (PHQ-9) score is 17.
Which one of the following statements is most accurate regarding treatment of this condition?
A. Clinical trials have shown an increase in completed suicides among children and adolescents treated for depression with SSRIs
B. Fluoxetine (Prozac) is an approved first-line treatment
C. Cognitive-behavioral therapy alone has been shown to be equally effective in achieving remission or recovery, compared to SSRIs alone or combined therapy
D. All SSRIs have been shown to be equally effective
B. Fluoxetine (Prozac) is an approved first-line treatment
Fluoxetine and escitalopram are the only two antidepressants that are FDA-approved for pediatric patients. While either can be used as first-line therapy, three systematic reviews of randomized, controlled trials have concluded that fluoxetine has the highest efficacy for treatment of depression in children and adolescents. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and other SRRIs have not been demonstrated to be effective in this population.