Pediatric Examination and Board Review (85 page)

13.
(B)
The stool description is consistent with
C difficile
infection. Although there is an increasing incidence of community-acquired
C difficile
, most cases in children are associated with recent antibiotic exposure. Well water exposure would raise the concern for parasitic infection, and exposure to other sick children would likely indicate a viral gastroenteritis. Both of these are unlikely to yield mucoid or heme-positive stool. Lactose intolerance would likely lead to increased gas and bloating with loose, watery, and acidic stools.

14.
(A)
Although in adults clindamycin is the antibiotic most associated with
C difficile
, in pediatrics many more patients take amoxicillin; therefore it is the antibiotic most frequently associated with
C difficile
. This situation may change as epidemic community-acquired methicillin-resistance
Staphylococcus aureus
(MRSA) necessitates increasing use of clindamycin.

15.
(B)
Although infectious causes are always possible, the most common cause of diarrhea in this age group is protein intolerance. Lactose intolerance presents with increased gas and bloating with loose watery, nonbloody stools and is rare in this age group. Children with congenital C1-losing diarrhea present earlier and are very ill. Fat malabsorption presents with foul smelling, oily, nonbloody stool

16.
(B)
The intolerance is to the cow’s milk protein. Up to 50% of those children will also be allergic to soy formula. Going directly to a hydrolyzed formula is indicated for these patients. The presence or absence of lactose is not relevant to this patient’s symptoms.

17.
(D)
The symptoms are due to exposure to cow’s milk protein. The treatment is to restrict the exposure to cow’s milk, components of which can cross into the mother’s breast milk.

18.
(E)
Up to 70% of infants will be carriers of
C difficile
and no treatment is necessary even when the toxin is detected. The toxin receptor is absent from the intestinal cells of a neonate.

S
UGGESTED
R
EADING

Book L. Diagnosing celiac disease in 2002: who, why, and how.
Pediatrics.
2002;109:952-954.

Leung AK, Robson WL. Evaluating the child with chronic diarrhea.
Am Fam Physician.
1996;53:635-643.

Pietzak MM, Thomas DW. Childhood malabsorption.
Pediatr Rev.
2003;24:195-206.

Chapter 7

GENERAL PEDIATRICS

CASE 53: A 12-YEAR-OLD WITH EAR DISCHARGE

A 12-year-old child comes to your office during the summer because of left-sided ear pain for 2 days followed by “smelly stuff” coming out of the same ear for 2 days. This has never happened before. The ear pain does not respond to acetaminophen. It hurts his jaw to chew food. He has had no fever and no upper respiratory tract symptoms.

SELECT THE ONE BEST ANSWER

1.
Which of the following are possible diagnoses from this history?

(A) otitis externa

(B) otitis media

(C) otitis media with effusion

(D) tuberculous otitis media

(E) A and B

2.
On examination, you note thick, yellow-white foulsmelling discharge in the ear canal with underlying erythema. After flushing with water, you see that the tympanic membrane (TM) is intact and appears slightly erythematous. The examination also reveals tenderness when you gently tug on the pinna of the left ear and some small (<1 cm), tender, mobile anterior cervical and preauricular lymph nodes on the left side.

Of the following, which is the least likely pathogen that has caused this problem?

(A)
Candida

(B)
Staphylococcus aureus

(C)
Pseudomonas aeruginosa

(D) group A streptococci

(E) C and D are both unlikely

3.
Which of the following is not a risk factor for otitis externa?

(A) otitis media

(B) swimming

(C) cotton swab use

(D) foreign body

(E) all are risk factors

4.
Which of the following is/are treatment(s) for otitis externa?

(A) antipyrine with benzocaine

(B) polymyxin B/neomycin sulfate otic drops

(C) acetic acid or boric acid solutions

(D) B and C

(E) all of the above

5.
Which of the following is a cause of bloody otorrhea?

(A) acute otitis media (AOM)

(B) Langerhans cell histiocytosis

(C) chronic otitis externa

(D) bullous myringitis

(E) all of the above

6.
What is the most important test to perform on clear fluid associated with otorrhea?

(A) bacterial culture

(B) glucose level

(C) pH

(D) potassium hydroxide (KOH) prep

(E) none of the above need to be done

7.
Which of the following is a potential cause of clear otorrhea?

(A) bullous myringitis

(B) AOM

(C) fungal otitis externa

(D) perforated TM

(E) A and D

8.
A 3-year-old boy is brought to the emergency department by his mother because of ear pain that started the day before and is progressing in intensity. He has had minimal relief from acetaminophen given at home. He has not been ill in the last 2 weeks but was at a birthday party 3 days earlier, where his mother is “sure he caught something from one of the other kids.” On examination he has normal vital signs, profuse white, slightly foul smelling discharge from the right ear, clear nares, normal oropharynx, and no lymphadenopathy. What is the best course of action?

(A) placement of an ear wick

(B) ciprofloxacin/hydrocortisone otic drops

(C) water lavage

(D) topical lidocaine

(E) oral amoxicillin

9.
On further otoscopy, you find what you believe to be a small disk-shaped battery, presumably from a toy. You attempt a gentle removal, but it is unsuccessful. You should next

(A) observe for 24 hours

(B) send him to the emergency department for ear, nose, and throat (ENT) consultation

(C) apply topical lidocaine into the ear

(D) start preventive ciprofloxacin/hydrocortisone drops

(E) start oral amoxicillin

10.
A 6-year-old is brought to your office for a routine checkup. Her mother says that she “failed” her hearing screen performed at her school 3 months ago and was instructed to get further hearing testing. She reminds you that her daughter has had multiple ear infections in the last year. On examination you note no conjunctival injection, clear nares, normal oropharynx, no lymphadenopathy, but clear effusion behind a mobile TM on the left. What is the most appropriate next step?

(A) reevaluate her effusion in 3 months

(B) automated auditory brainstem response testing

(C) otoacoustic emissions testing

(D) pure tone audiometry testing

(E) tympanometry

11.
What is the most common type of hearing loss in children?

(A) sensorineural

(B) conductive

(C) combined

(D) attention deficit disorder

(E) A and B occur with equal frequency

12.
What is the most common cause of conductive hearing loss in the United States?

(A) cholesteatoma

(B) middle ear effusion

(C) impacted cerumen

(D) foreign body

(E) perforated TM

13.
What is the most common infectious cause of sensorineural hearing loss in the United States?

(A) rubella

(B) syphilis

(C) cytomegalovirus

(D) toxoplasmosis

(E) herpesvirus

Match the following syndromes with the type of hearing loss associated with it.

14.
Down                                   (A) conductive