Pediatric Examination and Board Review (42 page)

(E) strabismus

7.
At 12 months of age, motor delay continues. Sarah cannot get to sit or consistently roll both ways. There is hip abduction to 40 degrees. At what initial routine examination age would difficulty with sitting first reflect a delay?

(A) 4 months

(B) 5 months

(C) 6 months

(D) 9 months

(E) 12 months

8.
At 12 months of age, there is intermittent fisting, right greater than left. What fine motor skills are most likely to be observed?

(A) transferring objects between hands

(B) batting at objects

(C) finger feeding

(D) pincer grasping

(E) releasing blocks

9.
An audiogram, hip radiograph, cranial magnetic resonance imaging (MRI), and Bayley Developmental Scales are obtained. If the audiogram reveals a hearing loss of more than 60 db, what might you discover?

(A) delays in cooing

(B) difficulty localizing a fire siren directly

(C) previous exposure to high levels of aminoglycosides

(D) parents reporting she does not smile when they call her name

(E) she was too young to test hearing

10.
What potential abnormalities that may explain this child’s motor disability are least likely to be found on cranial MRI?

(A) central nervous system (CNS) calcification

(B) craniosynostoses

(C) periventricular leukomalacia

(D) ventriculomegaly

(E) all of the above are likely to be found

11.
Sarah’s developmental skills on the Bayley Scales reveal a mental development index (MDI) of 70 and a psychomotor development index (PDI) of less than 50. The normal range is 100 plus or minus 15. What do these scores most likely predict?

(A) transient motor delays

(B) delays that qualify her for Early Intervention

(C) delays that do not qualify her for supplemental security income (SSI) defined in the Welfare Reform Act

(D) delays that will make it difficult to learn any skills beyond these possessed by a normal 1-year-old

(E) none of the above

12.
At 15 months of age, Sarah was assessed on the Battelle Developmental Scales. Her gross motor and fine motor skills are at a 6-month developmental age, her receptive language skills are at 12 months, her expressive language skills are at 9 months, and her social and emotional skills are at 15 months. Sarah would be expected to do all of the following except

(A) roll

(B) maintain sitting in tripod

(C) have head control

(D) crawl

(E) roll front to back

13.
If Sarah’s fine motor skills are at a 6-month level, which skill should be most challenging for her?

(A) batting at objects

(B) picking up a block

(C) demonstrating a mature pincer when offered a pellet

(D) holding a bottle

(E) none of the above skills should be difficult for her

14.
If her social and emotional skills are at a 15-month level, what would be most difficult for Sarah?

(A) physically separating from her mother

(B) recognizing her mother

(C) recognizing her father

(D) sharing toys with her younger cousin

(E) playing peek-a-boo

15.
At 18 months of age, Sarah has anterior props and can be placed sitting in her playpen. She fully extends both arms during the parachute maneuver. There is no fisting. She can combat crawl. Her lower extremities adopt a scissoring posture when you check her ability to bear weight. Sarah’s type of CP is best characterized as

(A) hemiplegic

(B) diplegic

(C) triplegic

(D) quadriplegic

(E) none of the above

16.
At the age of 2 years, Sarah can say a few words (“Mommy, cookie”), point at five pictures, point at body parts, maintain sitting balance, pull to a stand, finger-feed, drink from a sippy cup, remove socks, and use a spoon. Which skill will be most difficult for Sarah to learn in her preschool years?

(A) communicating in sentences

(B) using the toilet

(C) walking with the assistance of braces and rollator

(D) running as fast as peers

(E) pedaling a tricycle

ANSWERS

1.
(C)
Wessel has listed criteria for colic as crying for more than 3 hours per day, for 3 days or more a week, and for more than 3 weeks. Colic typically begins at 41 to 42 weeks’ gestational age even in preterm infants. Thus a 34-week infant who comes for a checkup at 8 weeks is at the peak age for beginning colic. There are two clinical patterns: (1) paroxysmal fussing, which typically occurs between 5 and 8 pm with the infant seeming content at other times; (2) hyperirritability, which occurs at all hours in response to either external or internal stimuli that are hard for adults to decipher.

2.
(B)
The key to colic is history and careful physical examination. Any problem that causes pain can also cause irritability but rarely paroxysmal irritability.

3.
(D)
Major management tools are to empathize, give parents permission to describe the impact of crying on the family’s sense of well-being, and support for feelings of anxiety, guilt, isolation, and fear. In trying various management options, such as formula changes, it is important to emphasize to a parent that this will be a clinical trial that might not work and does not mean the child has an ongoing illness.

4.
(C)
Both being SGA and of moderately low birthweight status increase the risks for spastic diplegia. Children with SGA can have a range of colic and temperament differences as well as gastroesophageal (GE) reflux and growth delays.

5.
(D)
Associated factors with CP include congenital cytomegalovirus (CMV), placental abnormalities, or CNS abnormalities originating at 24 to 32 weeks. Ultrasound findings associated with CP can include intraventricular hemorrhage (IVH) 3, IVH 4, and periventricular leukomalacia.

6.
(C)
Sarah is demonstrating increased tone; thus bringing her foot to her ear is difficult.

7.
(D)
Piper and colleagues demonstrated that 1% of infants are not sitting by 8 months; thus not sitting at 9 months reflects a delay.

8.
(B)
As children develop more mature motor skills, their hands become more relaxed and unfisted. They begin to have controlled movements of fingers that allow for higher-level manipulative skills. Persistent hand openness is required for transferring objects between hands, finger feeding, pincer grasping, and releasing blocks. Batting at objects does not require controlled coordination of fingers.

9.
(C)
Children with 60-db hearing loss can respond to sirens (>100-db sound source). They also smile and coo. In an era of transient otoacoustic emissions and automated auditory brainstem response, no child is too young to be tested. Children who receive aminoglycosides may experience auditory nerve toxicity. However, both genetic testing for common causes of nonsyndromic sensorineural hearing loss and evaluation for genetic vulnerabilities to ototoxicity need to be considered.

10.
(B)
Craniosynostosis is not associated with CP. Both periventricular leukomalacia and ventriculomegaly reflect white matter injury that contributes to spastic motor disability. Children with CNS calcifications secondary to CMV, toxoplasmosis, or rubella have multiple neurodevelopment impairments including neurosensory, developmental, and motor disabilities. Children with craniosynostosis (Apert, Crouzon, Pfeiffer) have a range of cognitive and learning disorders but not CP.

TABLE 22-1.
Cerebral Palsy Syndromes

Abbreviations: IVH, intraventricular hemorrhage; PVL, periventricular leukomalacia; VLBW, very low birthweight.

11.
(B)
Most state Early Intervention regulations require a delay of two standard deviations in one area for program eligibility. Sarah meets these criteria on both motor and developmental tasks.

12.
(D)
Crawling is a 9- to 10-month developmental motor skill. This would be too difficult for Sarah.

13.
(C)
Children develop a mature pincer between 9 and 11 months. This would be difficult for Sarah at this time.

14.
(D)
Sharing with others does not become common until after the second birthday.

15.
(B)
See
Table 22-1
: Cerebral Palsy Syndromes.

16.
(D)
Children with diplegia have a 90% probability of becoming ambulatory. They are able to learn selfcare skills. They have higher rates of learning disorders and attentional disorders. Although Sarah will have some gait differences, she should be viewed as a child who will continue to develop learning and adaptive skills.

S
UGGESTED
R
EADING