Show:
Development
Sleep
Nutrition and growth
Health supervision
Musculoskeletal
100
at what age is separation anxiety usually first noticeable and when is it especially prominent?
6 months; 9-18 months it begins to lessen by 3 years of age
100
Do nightmares occur during REM or non –REM sleep?
REM sleep Nightmares occur during REM sleep. Nightmares tend to occur during the last 1/3 of the night and do not typically cause a child to get out of bed. Parental reassurance is the best response.
100
1- A mother of a 6-week-old infant tells you that her child has been crying for approximately 4 to 5 hours nearly every day of the week. This has been occurring for at least 4 weeks, and the crying has impacted on the mother’s sleep patterns. The mother tells you that she hears the crying mostly in the late evening hours, and it does not appear to correlate with her formula feedings. The crying dissipates when the child is gently rocked but reoccurs once the rocking motion ceases. You believe that the child may have colic. Given this suspicion, what would you first recommend for the treatment of colic?
effective swaddling Colic is defined as an otherwise healthy infant who cries for more than 3 hours per day, more than 3 days per week, and for more than 3 weeks in duration. most often in the late afternoon and evening. Colic begins during 2nd week of life, peaks at 6 weeks, and resolves between 12 and 16 weeks. It is equally common in both breast- and bottle-fed infants. A diagnosis of colic is made by history and is a diagnosis of exclusion. An organic cause can be found in fewer than 5% and may include constipation, gastroesophageal reflux disease, infections, feeding disorders, and, less commonly, acute abdominal pain, occult fracture, and maternal drug effects. First-line therapy includes parental reassurance and behavioral interventions. These interventions can take many forms, including effective swaddling, gentle rocking, and decreased stimulation of the infant. White noise, vibration, and motion can soothe some infants. Simethicone, considered by many as a mainstay of colic treatment, is a safe but relatively ineffective remedy.
100
1- 1-month old infant seems to have difficulty feeding and becomes diaphoretic with feeding. Also, he cries excessively. What is the most likely diagnosis?
Congenital heart disease Suspect some form of congenital heart disease since it is uncommon for infants to become diaphoretic. You may suspect anomalous left coronary artery of they give you a “colic-sounding” infant.
100
A 15-year-old obese African American boy presents with a limp. He complains of pain in his left hip and knee. Plain x-ray show the epiphysis has removed when compared to the metaphysis. What is the most likely diagnosis?
Slipped capital femoral epiphysis (SCFE). SCFE is the slipping of the epiphysis off the metaphysis causing a limp and impaired internal rotation. It most commonly occurs in obese, aunchoid adolescents and is more common in African Americans. Get an AP and frog-leg view. 1 joint above and below the area of pain. Treatment is surgery.
200
A 9-year-old boy include genitals in a drawing of his family. What should you consider as a possibility?
Sexual abuse It is unusual for older, grade-school- aged children to draw genitals on figures. Sexual abuse must be strongly considered and thoroughly investigated.
200
1- A 6-year-old boy who is obese presents to you with his mother because he snores loudly at night with observed apnea events on a nightly basis. His mother reports that he has appeared more inattentive in school. She is concerned that he may have attention-deficit/hyperactivity disorder. No other developmental delays are reported. His physical examination is notable for obesity and enlarged tonsils. What would you recommend at this time?
nocturnal polysomnogram The disorder is characterized by intermittent complete or partial obstruction of the upper airway that leads to obstructive apnea or hypopnea, disrupting normal ventilation during sleep, and may be associated with hypoventilation and oxyhemoglobin desaturation. OSA must be distinguished from primary snoring, which is snoring without associated obstructive events or gas-exchange abnormalities. The prevalence: 2% to 4% in healthy children. most common in the preschool-age group (2-6 years) and adolescents. In prepubertal children, the disease equally occurs in boys and girls. A higher prevalence has been reported in African American children. OSA appears to run in families. Early diagnosis and treatment of OSA is important because the untreated condition has been associated with cor pulmonale, pulmonary hypertension, systemic hypertension, poor learning, behavioral problems, and attention-deficit/hyperactivity disorder.
200
Which mineral deficiency has been associated with late- onset trichotillomania (hair pulling)?
Iron defiecincy
200
An infant girl is born at home and is examined by her pediatrician within 48 hours. At what age the hearing screening is recommended?
All infants should be screened by 1 month of age Every newborn should receive a hearing screen by 1 month of age. Fail referral to an audiologist and otolaryngologist by the age of 3 months. Early intervention services should be in place by 6 months. NICU infants are considered high risk and should be referred to an audiologist for rescreening if they fail the first hearing test. They should also undergo repeat hearing testing if they experience a condition associated with potential hearing loss such as hyperbilirubinemia or sepsis. Some infants require repeat hearing screens at a later date to screen for signs of delayed-onset hearing loss due to infection, trauma, or neurodegenerative conditions.
200
7-year-old boy presents with: Pain in his left hip and knee He has been limping for several days Plain x-ray of the hip shows a ratty appearance of the left femoral head. What is the most likely diagnosis?
Legg-Calve-Perthes Disease It is a partial or complete idiopathic avascular necrosis of the femoral head. It is most common in boys between 3 and 12 years of age with a peak incidence at 5-7 years. Make the child non weight bearing and refer to an orthopedics. Generally, it resolves with time, and doesn’t require specific therapy.
300
Which endocrine abnormality is more common in children with ADHD?
Thyroid abnormalities Not to screen with TSH, but you should look for signs and symptoms, if they occur, then you should pursue a possible thyroid disorder. Know that thyroid abnormalities are more common in children with ADHD than in the unaffected population.
300
What is the best way to manage a sleep problem in a toddler (e.g., waking up in the middle of the night, having trouble staying in a bed)?
Begin with a daily routine. It is important to begin each night the same way with a standard routine. It may be to read a book, take a bath, etc. the key is consistency and sticking with it. Verbal reassurance to the child and parents should be provided. encourage the parents to put the child to a bed while a drowsy but not asleep
300
A 12-month-old infant is admitted for chronic enteritis, failure to thrive, and eczematous lesions over the perioral and perianal regions (see figure). What is the diagnosis and treatment?
acrodermatitis enteropathica; Treatment with high-dose zinc and close monitoring of levels is indicated. Acrodermatitis enteropathica is inherited in an autosomal recessive pattern. which is the reason for this child’s failure to thrive. Treatment involves zinc replacement.
300
A mother presents to you with her young son for his annual well-child visit prior to him starting kindergarten. Which screening tests should be performed at this visit?
vision, hearing, blood pressure - Vision screening: annually at physical examinations for children 3 to 6 years of age and less frequently thereafter. - Hearing screening: annually at physical examinations for children 4 to 6 years of age and less frequently thereafter. - A blood pressure measurement: annual physical examination for all healthy children starting at 3 years of age.
300
During a routine health supervision visit, a 13-year-old boy reports a 3-week history of left anterior knee pain that began during basketball practice and without any specific traumatic event. The patient reports localized swelling but denies any bruising, redness, catching, or locking. On physical examination, you note swelling and point tenderness over the tibial tuberosity. He does not have bruising, warmth, or erythema. He has full range of motion of the knee but reports mild pain when he actively extends the knee. The boy would like to continue his participation in basketball, but his parents are concerned this may cause longstanding problems with his knee. the BEST next step for management is:
home exercise program and physical activities as tolerated Osgood-Schlatter disease (OSD), an irritation of the tibial tubercle apophysis. The quadriceps tendon attaches to the top of the patella and the patellar tendon connects the inferior patella to the tibial tubercle. Thus, quadriceps muscle contraction puts tension on the tibial tubercle apophysis. typically occurs in girls between the ages of 10 and 13 years and in boys between the ages of 12 and 15 years. A prevalence of 10% to 20% Quadriceps stretching may also relieve symptoms by decreasing the tension on the tibial tubercle. Ice and nonsteroidal anti-inflammatory drugs can also contribute to symptom relief.
400
3- Some children with obsessive- compulsive disorder (OCD) can have worse symptoms with group A streptococcal infection. What is the name of this syndrome?
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococci (PANDAS). PANDAS is thought to be due to antibodies directed toward group A beta-hemolytic streptococci that somehow cross-react with the basal ganglia and result in worsening symptoms.
400
A 5-year-old boy presents with his mother for evaluation of sleep-related issues at night. The child is waking up screaming only a few hours after going to bed. He is found sitting up in bed and unresponsive. When awakened, the child appears to be confused and disoriented. The child does not remember the episodes the following morning. What is the most likely diagnosis?
night terrors Parasomnias are undesirable physical events that occur during entry into sleep, within sleep, or during arousal from sleep. Night terrors (pavor nocturnus) are arousals from deep (slow wave) sleep, usually in the first one-third of the night. Tremendous autonomic system discharge occurs with tachycardia, tachypnea, flushing of the skin, diaphoresis, and increased muscle tone. The child may be found sitting up in bed and unresponsive and, if awakened, the child might be confused and disoriented. Vocalization occurs frequently. Amnesia for the episodes is usually the case when the child is questioned the next morning. Management of night terrors is focused primarily on parental reassurance and education. Most children stop having them after the onset of puberty due to the dramatic decrease in slow-wave sleep.Short-acting benzodiazepines may be considered in rare cases, when a child has frequent severe episodes that are excessively violent and place him or her at high risk of injury. Treatment can be considered for 3 to 6 months, until the episodes cease completely. Benzodiazepines should be slowly tapered because abrupt discontinuation results in slow-wave sleep rebound and a return of the nocturnal episodes.
400
A 2-year-old male with no prior health problems presents with history of “head banging”. Most commonly it occurs at bedtime and occasionally in the middle of the night. What is the EEG pattern seen in these children?
Normal Head banging occurs in 5-15 % of normal children and typically begins at ~ 8-9 months of age. Do not order EEG or imaging study to evaluate these children. Reassurance is the best. This is different from the child with an intellectual disability or autism who has head banging as part of their condition. In this case, helmet or medications may be required to prevent/lessen the banging.
400
A child presents to you with his mother for his annual physical examination. His mother is concerned that he may develop high cholesterol. She wants to know when the blood work will be scheduled for such a check. He is a healthy boy of average weight and height without a significant family medical history. What is the age recommendation from the American Academy of Pediatrics for universal dyslipidemia screening in healthy children?
9-11 years The American Academy of Pediatrics recommends initial screening for dyslipidemia between the ages of 9 and 11 years. Risk assessments should be performed at well-child visits prior to this age to identify children at high risk for high cholesterol due to medical issues or family history. Such children should have blood work done at earlier ages.
400
A 7-year-old with Down syndrome presents for evaluation of an abnormal gait. The child just participated in the Special Olympics. On physical examination, the child's hips are not painful and there is full range of motion. What should be the next step?
Plain cervical x-ray in the neutral position Down syndrome puts children at increased risk of atlantoaxial instability. Until they reach 3 years of age, children with Down syndrome do not have adequate epiphyseal development and vertebral mineralization to obtain reliable results on X-ray of the cervical spine. However, because this child has reached 7 years of age and has symptoms of atlantoaxial instability, a plain cervical X-ray in the neutral position is appropriate. Results on plain X-rays may not accurately discern which children are at increased risk of developing spine problems, so routinely obtaining X-rays of the cervical spine in children without any symptoms is not recommended. If significant abnormalities are present on X-ray, then no additional radiographic examination is necessary. Instead, the patient should receive a consultation with a pediatric orthopedic surgeon or neurosurgeon who has experience with cases of atlantoaxial instability.
500
3- What is the most common obsessive-compulsive disorder (OCD) ritual in children?
Repetitive cleaning and washing The most common OCD ritual in childhood is repetitive cleaning and washing. This includes showering, hand washing, and tooth brushing. Other common OCD rituals include going n and out of doors, rereading, rechecking that solve and appliances are off., rechecking the alarm clock and counting, ordering and arranging objects.
500
In infants, what type of sleep initiate sleep?
REM sleep In infants, REM sleep occurs at the onset of sleep. In older children, non-REM sleep begins before REM sleep. Infants have a higher proportion of REM sleep but older children have nearly 75% non-REM sleep
500
Are low-birth weight newborns farsighted, nearsighted or have normal vision?
Nearsighted The normal eye at birth, due to its size and shape, is farsighted (hyperopic). As the visual system mature, the eye becomes longer in shape and less farsighted. Although most full-term infants are mildly physiologically hyperopic at birth, premature and low birth weight infants tend to be either less hyperopic or myopic (near sighted) and often have some degree of astigmatism. Approximately 45% of premature infants are myopic compared to 20% of full term infants.
500
You perform a cross-cover (or unilateral cover) test on a 2-year-old boy during a routine physical examination. The test involves covering one's eye and looking for movement of the uncovered eye while trying to fixate on a distant object. What ophthalmic condition does this screen for?
Strabismus Eye evaluation in the pediatric population should include external inspection, tests for ocular and eye muscle motility, an ophthalmoscopic examination (when possible), and a vision risk assessment or screening. - The cross (or unilateral) cover test: strabismus or ocular misalignment. - The red reflex: cataracts or corneal opacities. - vision testing: Poor vision due to astigmatism or hyperopia
500
A mother presents with her 13-year-old daughter who has had a fever and diarrhea. During discharge, the mother asks if her daughter may participate in soccer practice this afternoon. Her team is preparing for a tournament and her daughter wishes to participate. What is the best recommendation?
She should not participate. Both fever and diarrhea are contraindications for involvement in sports. An elevated core temperature may be indicative of an infection or disease that is often associated with increased resting metabolism and heart rate. Accordingly, during the usual exercise regimen of an athlete, the presence of fever can result in decreased heat tolerance, increased risk of heat illness, increased cardiopulmonary effort, reduced maximal exercise capacity, and increased risk of hypotension because of altered vascular tone and dehydration. On rare occasions, fever may accompany myocarditis or other conditions that may make usual exercise dangerous. Unless the diarrhea is mild and the athlete is fully hydrated, no participation can be permitted because diarrhea may increase the risk of dehydration and heat illness. Therefore, all of the other choices are not appropriate. Fever and anything but mild diarrhea are medical conditions that exclude sports participation.