Pediatric Examination and Board Review (197 page)

On physical examination the child is well nourished with stable vital signs. She is quiet yet willing to answer questions. The head and neck, respiratory, and cardiovascular examinations are normal. Her abdomen is soft and nontender. You order a urinalysis and urine culture; the urinalysis shows 10-15 white blood cells/HPF and 5-10 red blood cells/HPF. You culture the urine.

SELECT THE ONE BEST ANSWER

1.
Which is an appropriate next step toward evaluating this patient?

(A) presumptive treatment with oral antibiotics until the culture results are confirmed

(B) advise baths without bubble bath and reassure that the discharge is a response to irritation from harsh soap

(C) provide the child with a topical steroid and instruct application to any areas of vaginal redness

(D) interview the mother and child with regard to concerns for sexual abuse

(E) refer the child to an advocacy center or contact the child welfare system to evaluate for suspected abuse

2.
The differential diagnosis for vaginal bleeding in this age group includes all but the following

(A) vulvovaginitis

(B) precocious puberty

(C) foreign body

(D) trauma

(E) labial adhesions

3.
Which is a true statement regarding genital examinations in prepubertal females?

(A) insufficient labial traction to visualize the hymenal margins and vestibule adequately is a common examination error

(B) examination in the frog leg position with feet together is optimal to visualize the posterior hymenal area

(C) sedation is often required to examine prepubertal girls

(D) examination should be performed without a caretaker, allowing the child an opportunity to make a disclosure or reduce embarrassment

(E) speculum examination is indicated if there is concern for a foreign body

4.
You interview the child and mother separately. The mother has noticed that the child has been quieter lately and not complaining of any vaginal or abdominal pain; she has no concerns about the father sexually abusing her child. You interview the child and she makes no disclosure regarding sexual abuse. A true statement regarding the presentation of child sexual abuse is

(A) specific signs and symptoms of sexual abuse include rectal or genital bleeding, developmentally unusual sexual behavior, and the presence of a sexually transmitted disease (STD)

(B) an STD in this child is diagnostic of child sexual abuse

(C) sexual abuse represents 25% of all confirmed cases of child maltreatment

(D) penetration defines child sexual abuse

(E) sexual play is determined by the parents’ standards of behavior

5.
Which is a correct statement regarding findings indicative of child sexual abuse on examination?

(A) a fimbriated hymen is suspicious for child abuse

(B) children who have experienced penetration will not have a finding on genital examination in most cases

(C) hymenal diameter is a sensitive measure for child sexual abuse

(D) hymenal tears are frequently seen in straddle injuries

(E) an intact hymen rules out child abuse

6.
A normal description of the prepubertal hymen can include all of the following except

(A) crescentic

(B) fimbriated

(C) annular

(D) septate

(E) congenital absence of the hymen

7.
On examination of your 6-year-old patient you find she is not cooperative enough to perform a thorough genital examination. You note that she has a malodorous discharge and some dried blood on her labia. At this point what would be the best management?

(A) the examination is consistent with a straddle injury; reassure the mother that this is a normal injury for her child’s age

(B) obtain vaginal cultures for gonorrhea and chlamydia. Presumptively treat for an STD and contact the regional child welfare system

(C) arrange for an examination under anesthesia

(D) reassure mother this is a hygiene issue and schedule an appointment in 2 weeks

(E) attempt reexamination with support staff who can hold the child in place

8.
You are now examining a different 6-year-old with a chief complaint of finding drops of blood on her underwear. There have been no complaints of dysuria, history of trauma, fevers, or discharge. On genital examination you note a purplish doughnutshaped mass that obscures the vaginal opening. Which of the following is true?

(A) this condition is mostly seen in white children

(B) sudden or recurrent increases of intra-abdominal pressure are felt to be precursors for this condition

(C) the child should immediately be referred to an oncologist

(D) this is a prolapsed hymen and warrants immediate treatment by a gynecologist

(E) surgery is required to correct this problem

9.
A 6-year-old is seen in your clinic for recurring abdominal pain. This pain is described as lasting for 4 months, intermittent, and periumbilical. She has had no history of fever, vomiting, mouth sores, weight loss, joint pain, or rashes, although she has intermittent diarrhea. The pain does not interfere with her activity. Examination reveals a normally developing 6-year-old. The most correct choice is

(A) obtaining erythrocyte sedimentation rate (ESR), CBC, stool for occult blood, culture, ova and parasites, and urinalysis

(B) referral to a regional child abuse advocacy center because of suspicion of child sexual abuse

(C) empiric administration of an antireflux medication

(D) order an upper GI series to rule out juvenile peptic ulcer disease

(E) referral to a psychiatrist for antidepressants

10.
In your clinic you have a 15-year-old girl who presents with a 4-day history of nausea, vomiting, and diffuse lower abdominal pain. She has had fever, no diarrhea, and denies dysuria. She has a history of irritable bowel syndrome, which has been under control per her mother. She denies sexual activity when her mother is in the room. Her menstrual cycles have been regular and she just started her menses about 1 week before this visit. On examination her neck is supple, she has no oral lesions, but she does have right upper quadrant pain and lower abdominal tenderness. You interview the patient alone and she admits to sexual activity. You perform a pelvic examination and she is tender on cervical and adnexal examination. You obtain cultures. The most likely diagnosis is

(A) chronic pelvic inflammatory disease (PID) because of chlamydia infection

(B) gonococcal cervicitis

(C) appendicitis

(D) mesenteric adenitis

(E) Fitz-Hugh and Curtis syndrome

11.
Which of the following is false statement regarding the Fitz-Hugh and Curtis syndrome?

(A) perihepatitis or Fitz-Hugh and Curtis syndrome develops in 5-20% of women with acute salpingitis

(B) liver function tests are usually abnormal in Fitz-Hugh and Curtis syndrome

(C) causative agents include
Chlamydia trachomatis
,
Neisseria gonorrhoeae
, anaerobes, and Mycoplasma

(D) complaints of upper right quadrant pain because of Fitz-Hugh and Curtis may continue for weeks after the lower abdominal pain has resolved

(E) the risk of ectopic pregnancy because of tubal closure may be a sequela of PID

12.
A 5-year-old girl is brought to your office with a complaint of vaginal discharge that can be seen on her underwear for 1 week. She has no fever, has had no rashes, but does complain that it hurts when she urinates, although she has no frequency or urgency. A true statement about vulvovaginitis in prepubertal girls is

(A) nonspecific vulvovaginitis accounts for most vulvovaginitis in prepubertal girls and often is related to poor hygiene

(B)
Candida
spp. is a common cause of prepubertal vulvovaginitis

(C) specific pathogens that cause vulvovaginitis are mostly a result of STDs

(D) estrogenization produces vaginal discharge seen in infants and prepubertal girls

(E) immune evaluation should be considered in prepubertal girls who have a specific respiratory and enteric pathogen causing vulvovaginitis

13.
All of the following are diagnostic of child sexual abuse except

(A) culture-positive gonorrhea infection

(B) nonperinatally transmitted (or transfusionacquired) HIV or syphilis

(C) disclosure by the child of sexual abuse

(D) condyloma acuminata (anogenital warts)

(E) documented presence of semen or sperm

14.
Which is a true statement about straddle injuries to children?

(A) straddle injuries are seen in nonambulatory children

(B) penetration in most cases is associated with hymenal injury

(C) bruising or laceration near or between the labia majora and minora can occur

(D) straddle injuries often involve the posterior hymenal area

(E) boys with straddle injuries often have anal tears

15.
A mother brings her 8-month-old female infant in to see you because she noted on examination of her daughter’s vagina that she “does not look right down there.” She is worried the baby was possibly sexually abused. You examine the child’s genital area and note she has labial adhesions. A true statement regarding labial adhesions is

(A) the urethral opening is always obscured in the presence of a labial adhesion

(B) if there is no urinary obstruction, topical estrogen is an optional treatment

(C) the child needs immediate referral to a urologist due to the relationship of labial adhesions and urinary tract anomalies

(D) labial adhesions in this age group are most often a result of sexual abuse

(E) the first line treatment for labial adhesions is surgical

16.
A 9-year-old boy presents with a history of anal pain for 3 days. He has complained of a painful perianal rash and pain with defecation. His mother noted blood on his stool last night. Your history reveals that his 6-year-old sister just recovered from a sore throat, and your interview with mother reveals no concerns for a traumatic injury or sexual abuse. On examination, the child is cooperative. The eyes, ears, throat, lung, and skin examination are all normal. Examination of his anal region reveals a very erythematous perianal rash without ulcers. You also note 1 or 2 superficial rectal fissures. Which of the following is true?

(A) streptococcal infection in the anogenital region is very suspicious of child sexual abuse, and a report to a child welfare agency is indicated

(B) topical treatment with a steroid cream is indicated

(C) a rectal swab used to detect enteric pathogens will also detect streptococcal infection