4 clinical mastery series peds questions

[vincentannie]

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1. previously health 11yo boy, 14-day history of fever, headache, yellow-green nasal discharge, and Nocturnal cough. His 8yo sister has cold. 39C, pulse 100, respiration 18, SaO2 96%. Posterior pharyngeal wall is erythematous and covered with thin gray mucus. CXR no abnormalities.

a) bacterial tracheitis

b)bronciolitis

c)laryngotracheobronchitis(wrong)

d)sinusitis

maybe d?

2. previously healthy 2yo boy is brought to ED because of 5day history of 40C. 39C, pulse 130, BP 90/60. 3/6 systolic murmur @ LSB. No history of murmur. Spleen tip 4cm below left costal margin. In addition to echo, which confirm diagnosis ?

a) ANA assay

b)ESR

c) measure cardiac enzyme(wrong. Someone posted this before saying that her answer to C was wrong)

d)blood culture

e)ECG (WRONG)

3. previously healthy 3 yo girl comes to physician b/c 3wk history of fever, pallor, decreased appetite. She’s been taking acetaminophen. Over the past week, her mother also noticed bruises on her leg. 38.5C, pulse 120, R 24. P/E pallor and scattered ecchymoses over lower extremities. Several ulcerations of oral cavity. No lymphadenopathy. No hepatosplenomegaly.

Hb 4.5, leukocyte 300, segmented neutrophils 1%, lymphocytes 99%, platelet 2000. Diagnosis?

a) aplastic anemia

b) chedia-higashi

c) child abuse

d) CML

e) Congenital agranulocytosis

f) Cyclic neutropenia

g) Drug induced neutropenia

h) Leukocyte adhesion deficiency

i) Viral mediated neutropenia

4. 8yo boy comes to physician b/c 9mo history of nonproductive cough worse at night and SOB during physical activity. His mother says he has not had an unusual number of colds for his age, but she is concerned because the colds seem to go to his chest and linger. He is 75% height and weight. Cardiopulmonary exam show no abnormalities. CXR show mild hyperinflation. Next step in diagnosis?

a)sweat chloride test

b)measure IgA

c)measure IgE

d)allergy testing

e)spirometry

 

[Distant]

1) D, Because of the Yellow Green Nasal Discharge.
2) B, Must be Rheumatic Fever [New murmur in a child following a fever]
3) G, I have absolutely no idea, But this is my best guess
4) A...Edit. the answer is E

 

[CaliAtenza]

1) D, Because of the Yellow Green Nasal Discharge.
2) B, Must be Rheumatic Fever [New murmur in a child following a fever]
3) G, I have absolutely no idea, But this is my best guess
4) A, I think you should rule out CF, non of the other choices help Diagnose Asthma anyway.

For #4, can't spirometry help to diagnose Asthma?

 

[Distant]

For #4, can't spirometry help to diagnose Asthma?

Hmm, you're right, so you're saying it's E?

 

[CaliAtenza]

Hmm, you're right, so you're saying it's E?

I'm thinking its that, because there really isn't anything there to suggest that it could be Cystic Fibrosis, unless the whole question wasn't posted. Non productive cough; worse at night, and SOB during physical activity sure sounds like Asthma to me. Also, the weight seems to be on track as well, which would kind of rule out CF.

 

[Distant]

I agree with you, Choice E it is.

Thanks

 

[reverieinvictus]

1- D
2- D (new murmur + fever = endocarditis. You want a blood culture to confirm the diagnosis)
3- A (anemia + leukopenia + thrombocytopenia = aplastic anemia)
4- E (spirometry to diagnose asthma)

 

[reverieinvictus]

1) D, Because of the Yellow Green Nasal Discharge.
2) B, Must be Rheumatic Fever [New murmur in a child following a fever]
3) G, I have absolutely no idea, But this is my best guess
4) A...Edit. the answer is E

Rheumatic fever generally needs a history of pharyngitis. Plus, he doesn't meet the required number of Jones criteria to make that diagnosis

 

[Distant]

1- D
2- D (new murmur + fever = endocarditis. You want a blood culture to confirm the diagnosis)
3- A (anemia + leukopenia + thrombocytopenia = aplastic anemia)
4- E (spirometry to diagnose asthma)

I Agree, Thank for sharing. 👍👍

 

[Dhenki]

Have another one for you guys...

A 12 mo. old AA girl with Sickle cell disease is brought to the ER because of sudden onset high fever, irritability, and tachypnea for 6 hrs. Her diet consists of iron-fortified formula and pureed fruits and veggies. Mom says she's occasionally missed a dose of her penicillin prophylaxis. 102.2F, 180/min., RR is 48/ min. Conjunctival pallor with a 2/6 systolic murmur. Hct is 23%, leukocyte count is 23,000, and platelets are 250,000. Next step?

A) oral penicillin.
B) IV cefotaxime.
C) IV corticosteroids.
D) IV Ig.
E) IV nafcillin.
F) IV penicillin.

I'd appreciate the help! 🙂

 

[Distant]

Have another one for you guys...

A 12 mo. old AA girl with Sickle cell disease is brought to the ER because of sudden onset high fever, irritability, and tachypnea for 6 hrs. Her diet consists of iron-fortified formula and pureed fruits and veggies. Mom says she's occasionally missed a dose of her penicillin prophylaxis. 102.2F, 180/min., RR is 48/ min. Conjunctival pallor with a 2/6 systolic murmur. Hct is 23%, leukocyte count is 23,000, and platelets are 250,000. Next step?

A) oral penicillin.
B) IV cefotaxime.
C) IV corticosteroids.
D) IV Ig.
E) IV nafcillin.
F) IV penicillin.

I'd appreciate the help! 🙂

I vote for (B) IV cefotaxime, You need an empiric coverage since **** hit the fan.

 

[Dhenki]

I vote for (B) IV cefotaxime, You need an empiric coverage since **** hit the fan.

Thank you! After reading up on it, I agree too.

 

[Dhenki]

Have another one...

16 yo boy comes with a 3 day hx of pain and pressure over the left cheek. Hx of strep pneumonia at 6 and 10 yr. and 2 episodes of sinusitis over the past 2 yrs. 100.5F, 88 bp, RR is 20.min., and bp is 120/60. PE shows bilateral tender maxillary sinuses and boggy turbinates. Sputum culture shows H. influenzae. What is the cause of the recurrent infections?

A) Combined Immunodeficiency.
B) Complement Deficiency.
C) Impaired cell-mediated Immunity.
D) Impaired Chemotaxis.
E) Impaired Humoral Immunity.

Thank you!

 

[Distant]

16 yo boy comes with a 3 day hx of pain and pressure over the left cheek. Hx of strep pneumonia at 6 and 10 yr. and 2 episodes of sinusitis over the past 2 yrs. 100.5F, 88 bp, RR is 20.min., and bp is 120/60. PE shows bilateral tender maxillary sinuses and boggy turbinates. Sputum culture shows H. influenzae. What is the cause of the recurrent infections?

A) Combined Immunodeficiency. Presents in adolescents (this pt had symptoms since childhood)
B) Complement Deficiency. Niesseria infection if C5-C9 Def., or Hereditary Angioedema if C1H is Def.
C) Impaired cell-mediated Immunity. Presents with PCP pneumonia and Candida infections
D) Impaired Chemotaxis.Hx of non-separation of the Umbilical Cord and High Neutrophilic Leukocytosis
E) Impaired Humoral Immunity. [Correct], Infection with encapsulated organisms

 

[Dhenki]

16 yo boy comes with a 3 day hx of pain and pressure over the left cheek. Hx of strep pneumonia at 6 and 10 yr. and 2 episodes of sinusitis over the past 2 yrs. 100.5F, 88 bp, RR is 20.min., and bp is 120/60. PE shows bilateral tender maxillary sinuses and boggy turbinates. Sputum culture shows H. influenzae. What is the cause of the recurrent infections?

A) Combined Immunodeficiency. Presents in adolescents (this pt had symptoms since childhood)
B) Complement Deficiency. Niesseria infection if C5-C9 Def., or Hereditary Angioedema if C1H is Def.
C) Impaired cell-mediated Immunity. Presents with PCP pneumonia and Candida infections
D) Impaired Chemotaxis.Hx of non-separation of the Umbilical Cord and High Neutrophilic Leukocytosis
E) Impaired Humoral Immunity. [Correct], Infection with encapsulated organisms

Thank you so much! These immunodeficiencies are always a struggle for me. :/

 

[Dhenki]

I'm having a hard time coming up with a diagnosis on this one, let alone the most appropriate next step.

18 mo. brought to ER 4 hr. after onset of lethargy. He has intermittent abdominal pain for past 24 hrs. No N/V or diarrhea. Soft, non-tender abdomen, mass palpated in RLQ. Stool is red and occult blood positive. x-ray shows no air in the ascending or transverse colon. Next step?

A) Air-contrasted enema.
B) Upper GI series.
C) Meckel Scan.
D) Upper endoscopy.
E) Laparotomy.

 

[Distant]

This is an NBME 6 Question.
A) Air Contrasted enema, a case of intussuseption. [Bloody Stool, Palpable Mass, signs of obstruction]
if the pt had a hx of chronic GI Bleeding or other signs of Meckel, then this would be intussuseption complicating Meckle and a Laparotomy would be indicated after confirming the Diagnosis. if Air Contrast Management failed.

But as far as I know, Meckle does not present with a palpable mass.

 

[Dhenki]

I didn't know this was a NBME 6 question. Lol. I got it from CMS Peds form 2. But I think you're right. I jumped the gun and picked laparotomy, which was wrong. I didn't think it was Meckel's and intussusception, after reading up on it, does present with a "sausage like" mass on abdominal exam. You would do an air enema.

Thank you for your help!

 

[jane123]

Have another one for you guys...

A 12 mo. old AA girl with Sickle cell disease is brought to the ER because of sudden onset high fever, irritability, and tachypnea for 6 hrs. Her diet consists of iron-fortified formula and pureed fruits and veggies. Mom says she's occasionally missed a dose of her penicillin prophylaxis. 102.2F, 180/min., RR is 48/ min. Conjunctival pallor with a 2/6 systolic murmur. Hct is 23%, leukocyte count is 23,000, and platelets are 250,000. Next step?

A) oral penicillin (this is actually the correct answer)
B) IV cefotaxime.
C) IV corticosteroids.
D) IV Ig.
E) IV nafcillin.
F) IV penicillin.

I'd appreciate the help! 🙂

 

[Haider868]

Why not VIRAL induced Neutropenia because Lympho's are 99%

 

[brown-bear]

Why not VIRAL induced Neutropenia because Lympho's are 99%

b/c that doesnt account for the anemia, lymphopenia, or thrombocytopenia