Pediatric Examination and Board Review (77 page)

S
UGGESTED
R
EADING

Hyams JS. Crohn’s disease in children.
Pediatr Clin North Am.
1996;43:255-277.

Kirschner BS. Ulcerative colitis.
Pediatr Clin North Am.
1996;43:235-254.

Kohli R, Li BU. Differential diagnosis of recurrent abdominal pain: new considerations.
Pediatr Ann.
2004;33:113-122.

CASE 48: A 4-YEAR-OLD BOY WITH RECTAL BLEEDING

A 4-year-old boy is brought to your clinic by his mother with a complaint of having 2 large maroon-colored stools on the morning of the visit. The mother is unsure whether the stools were accompanied by abdominal pain. She does report that the child seems less active than usual.

On examination, this is a quiet child with a heart rate (HR) of 165 and a respiratory rate (RR) of 40. He has nonicteric sclera and dry mucous membranes. His abdomen is nondistended with decreased bowel sounds and nontender without palpable masses. The remainder of the examination is unremarkable.

SELECT THE ONE BEST ANSWER

1.
Your first step is

(A) reassure the parent because this is likely a fissure

(B) transfer to an emergency department for stabilization and evaluation

(C) admit to the hospital, collect stool cultures, and monitor closely

(D) send home to collect stool cultures before further workup

(E) order a CBC

2.
The initial management should include

(A) gastric lavage

(B) fluid resuscitation

(C) abdominal ultrasound

(D) Meckel scan

(E) all of the above

3.
The most likely diagnosis in this child is

(A) juvenile polyp

(B) Meckel diverticulum

(C) inflammatory bowel disease

(D) intussusception

(E) peptic ulcer

4.
The diagnostic procedure required is

(A) barium enema

(B) abdominal ultrasound

(C) technetium-99m pertechnetate (Meckel) scan

(D) colonoscopy

(E) tagged red cell study

5.
Had the mother described cramping abdominal pain before these “currant jelly” stools, the likely diagnosis would be

(A) Meckel diverticulum

(B) juvenile polyp

(C) intussusception

(D) infectious colitis

(E) inflammatory bowel disease

6.
The treatment of choice for the patient in question 5 is

(A) contrast enema

(B) antibiotics to treat infectious colitis

(C) colonoscopy and removal of polyp

(D) exploratory laparotomy

(E) referral to a gastroenterologist

7.
The mother asks what the chance is that the problem in question 5 will recur. Your answer is

(A) 2-5% no matter how treatment is rendered

(B) 10% no matter how treatment is rendered

(C) 20% no matter how treatment is rendered

(D) 50% no matter how treatment is rendered

(E) that it depends on the treatment rendered

8.
Had the child passed bright red blood per rectum, had a HR of 98 and a RR of 24, and had a normal physical examination, your first step would be to

(A) reassure the parent because this is likely a fissure

(B) send the child home to collect stool cultures before further workup

(C) transfer the child to an emergency department for stabilization

(D) admit the child to the hospital, collect stool cultures, and monitor closely

(E) schedule emergent endoscopy

9.
If the child has a single juvenile polyp, what is the possibility that this condition is a precursor to cancer?

(A) 50%

(B) less than 10%

(C) less than 1%

(D) there is not enough known about this entity to make a prediction

(E) the risk depends on whether there is a family history of colon cancer

10.
Had the child in question 8 had dark, pigmented lips, his diagnosis would likely be

(A) Peutz-Jeghers syndrome

(B) Gardner syndrome

(C) Turcot syndrome

(D) multiple juvenile polyps

(E) familial adenomatous polyposis

11.
A 15-year old presented with rectal bleeding and had a family history of colon cancer in multiple family members in their 30s. It is known that those family members had mutations in the
APC
gene. The diagnosis could be all of the following
except
(A) Peutz-Jeghers syndrome

(B) Gardner syndrome

(C) Turcot syndrome

(D) attenuated adenomatous polyposis coli (AAPC)

(E) familial adenomatous polyposis

12.
If a 4-year-old had come in vomiting a large amount of bright red blood and tachycardic, your first step would be to

(A) send the patient for CBC

(B) send the child home to start H
₂
blocker therapy

(C) refer the child to a gastroenterologist

(D) refer to the emergency department for stabilization and evaluation

(E) admit the child to the hospital for intravenous (IV) H
₂
blocker therapy and a GI consult

13.
The management of the patient in question 12 should include

(A) fluid resuscitation

(B) gastric lavage

(C) PT, hepatic function panel

(D) type and cross

(E) all of the above

14.
The most likely diagnosis of the patient in question 12 is

(A) peptic ulcer/gastritis

(B) swallowed blood from epistaxis

(C) gastroesophageal reflux disease (GERD)

(D)
Helicobacter pylori
infection

(E) variceal bleed

15.
Had the vomiting of blood occurred after multiple episodes of vomiting, then the most likely diagnosis would be

(A) viral gastritis

(B) malrotation

(C) Mallory-Weiss lesion

(D) arteriovenous malformation rupture

(E) esophageal varices

16.
If the patient in question 12 was a 15-year-old from a lower socioeconomic background, then the most likely diagnosis would be

(A) peptic ulcer/gastritis

(B) herpetic esophagitis

(C) GERD

(D)
H pylori
infection

(E) esophageal varices

17.
In regard to
H pylori
infection, the most appropriate test and treatment plan is

(A) serum antibodies and therapy with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole

(B) stool antigen and therapy with a proton pump inhibitor, amoxicillin, and clarithromycin or metronidazole

(C) urea breath test and therapy with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole

(D) endoscopy and therapy with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole

(E) there is no gold standard, and any of the preceding choices is acceptable

18.
If on physical examination the patient from question 12 had a small firm liver and spleen with ascites, the treatment would be

(A) transfer to the emergency department for stabilization

(B) correction of coagulopathy and the low platelet count

(C) somatostatin infusion