Pediatric Examination and Board Review (236 page)

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CASE 137: AN 8-YEAR-OLD BOY WITH DIFFICULTY IN SCHOOL

An 8-year-old boy is referred to your clinic for evaluation of a learning disability. His mother states that her son was born at full term and met all of the developmental milestones at the appropriate ages. A week ago, she attended a meeting with his school teacher who expressed concerns about his grades and inability to pay attention in class. When asked about his behavior at home, she describes her son as very active. She admits it is probably beyond what most would consider “normal boy behavior.” For example, he recently took a set of markers and scribbled all over the kitchen walls. She states that she has to keep an eye on him every minute of the day to ensure he doesn’t get into any mischief. He has a hard time sitting still and jumps from task to task. As a result, very few of the neighborhood children will play with him because he never seems to complete any of the games and is very disruptive. When she tries to talk to him, he doesn’t seem to want to listen.

During the examination, the child has a hard time sitting still. He empties all the equipment from the drawers, despite his mother’s objections. When asked to write the alphabet, he gets to the letter “E” before running out the door. His mother has an exasperated look on her face as she chases him into the waiting room. While she is gone, his father states that he had similar problems in school. On the child returning to the examination room, you manage to complete the physical examination with difficulty and find it is within normal limits.

SELECT THE ONE BEST ANSWER

1.
To make a diagnosis and begin therapy, you will need which of the following pieces of information?

(A) a letter from the school teacher delineating some of the observed behaviors and academic difficulties

(B) an MRI of the brain looking for frontal lobe injury

(C) completion of behavior rating scales by the parents and school teachers

(D) psychiatric evaluation

(E) A and C

2.
You obtain the appropriate information and it confirms your initial hypothesis. The most likely diagnosis in this patient is which of the following?

(A) conduct disorder

(B) ADHD

(C) mental retardation

(D) bipolar disorder

(E) oppositional defiant disorder

3.
His father asks if he could have passed on these symptoms to his son. In fact, he has wondered about treatment for himself. Which of the following is the most appropriate response?

(A) “the likelihood is small because ADHD is probably not a genetic disorder”

(B) “probably not, because ADHD is an X-linked disorder”

(C) “possibly, however, environmental factors, such as upbringing and maternal drug use, are much more important”

(D) “ADHD is probably a genetic disorder; a child born to a parent with ADHD has a greater than 50% risk of developing symptoms”

(E) “not much is known about the genetics of ADHD because concordance for monozygotic twins is low”

4.
Which of the following is not a
DSM-IV
diagnostic criteria for ADHD?

(A) symptoms of hyperactivity and/or inattention are present for at least 6 months

(B) impairment from the symptoms occurs in 2 or more settings

(C) hyperactive or inattentive symptoms must be present after the age of 7 years

(D) the patient must have at least 6 symptoms of either inattention or hyperactivity-impulsivity to be considered for that specific type of ADHD or 6 from each category to be considered for the combined type

(E) the symptoms cannot be due to another condition, such as pervasive developmental delay or a psychotic disorder

5.
You decide to start the patient on therapy. Which of the following treatment options could be considered in patients with ADHD?

(A) behavioral therapy

(B) dextroamphetamine

(C) methylphenidate

(D) A, B, and C

(E) only B and C are correct

6.
You decide to start the patient on a stimulant. You inform his parents that you will need to see him in the clinic every 1-3 months to assess for which of the following?

(A) growth progress

(B) academic progress

(C) cardiovascular side effects

(D) psychological well-being

(E) all of the above

7.
Although the patient demonstrates significant improvement following initiation of therapy, he continues to have some academic difficulty despite several medication adjustments. At this point, the most appropriate action would be which of the following choices?

(A) a second opinion

(B) request for a child psychiatry consultation

(C) neuropsychologic or psychoeducational testing

(D) an EEG

(E) treatment with nonstimulant medications, such as bupropion or tricyclic antidepressants

8.
Which of the following medications used in the treatment of ADHD is associated with chemical hepatitis and, rarely, fulminant liver failure?

(A) methylphenidate

(B) dextroamphetamine

(C) pemoline

(D) clonidine

(E) bupropion

9.
Which of the following is the most frequently observed learning disorder?

(A) mathematics disorder

(B) disorder of written expression

(C) reading disorder

(D) atypical learning disorder

(E) none of the above

10.
A child in the third grade presents to your clinic for evaluation of a learning disorder. His mother states that although he has a good memory and does well with rote learning, he has problems with comprehension, organization of information, and concept formation. He initially did well in math but now struggles to finish his homework, despite a significant amount of effort. She states that he doesn’t seem to have good reasoning skills. Which of the following learning disorders is most likely in this child?

(A) dyslexia

(B) mental retardation

(C) mathematics disorder

(D) nonverbal learning disability

(E) disorder of written expression

11.
A 7-year-old girl comes to your clinic with a letter from her teacher. The letter states that the child is having problems with reading, especially with phonologic processing. In particular, she has a problem identifying phonemes. Her father states that he had reading difficulties as a child. You ask the child to read a short paragraph and she has a hard time associating sounds with letters and often mispronounces words. When asked to write the alphabet, she demonstrates a tendency to reverse certain letters. She has a hard time spelling simple words. Her physical examination is unremarkable. This patient most likely has which of the following diagnoses?

(A) mental retardation

(B) reading disorder

(C) ADHD

(D) disorder of written expression

(E) nonverbal learning disability

12.
In terms of evaluating the patient from question 11 further, which of the following would be helpful in making the diagnosis?

(A) chromosome karyotyping

(B) MRI of the brain pre- and postcontrast

(C) EEG

(D) behavior rating scales

(E) no further studies

13.
In the
DSM
-
IV
, the category “Pervasive Developmental Disorders” has 5 subgroups. Which of the following is not a subgroup of this category?

(A) autistic disorder

(B) Asperger syndrome

(C) childhood disintegrative disorder

(D) Angelman syndrome

(E) Rett syndrome

14.
A 3-year-old girl presents to your clinic for an evaluation of profound language delay. Although the child is capable of vocalizing, mostly in the form of screaming, she has no words and cannot communicate her needs. Her mother states that her verbal development has never been normal. She does not make eye contact and seems oblivious to your presence. Her mother states that she is not very affectionate and has been unable to make friends with the child next door who is the same age. During the examination, the child repetitively opens and closes a drawer containing medical supplies without removing them. A hearing test was reportedly normal. You try to perform your physical examination, but the child cries and furiously flaps her arms. Her head circumference has been stable at the 97th percentile for the last year. The most likely diagnosis is which of the following?

(A) childhood disintegrative disorder

(B) autism

(C) Rett syndrome

(D) Asperger syndrome

(E) Landau-Kleffner syndrome

15.
Which of the following statements is (are) true regarding the association of autism and seizures?

(A) approximately a third of patients with autism develop epilepsy by adulthood

(B) studies have suggested that up to 80% of patients with autism can have abnormal EEGs

(C) a family history of seizures is a risk factor for the development of seizures in a patient with autism

(D) patients with autism and seizures are more likely to have complex partial seizures, although all seizure types can occur

(E) all of the above statements are true