Pediatric Examination and Board Review (99 page)

11.
(A)
For children younger than 1 year of age, congenital anomalies are the number-one cause of death.

12.
(A)
Male teen drivers are the most likely group to be involved in a MVA. In addition, teens are 5-10 times more likely to be involved in a fatal MVA while driving at night versus driving during the day.

13.
(D)

14.
(B)
Portable heaters should always be placed 3 feet or more from any material that could be flammable (bedding, curtains, etc). Children younger than 5 years and the elderly are at highest risk of injury from residential fires. Smoke detectors decrease the risk of fatality in a house fire by approximately 60-70%, but among smoke detectors that failed to alarm in a fire, 59% had been disconnected because of false or battery-related alarms. Smoke inhalation kills more people than direct fire-related injuries.

15.
(E)
Infants and children can drown in as little as 2-3 inches of water in a bucket or bathtub. Children often do not splash or make noise when they are drowning. Reports from survivors have suggested that they either are too young to maneuver out of the water, or if older, simply cannot think of what to do at that moment, and quietly slip underneath the water. Full 5-feet surround fences are the only proven way to prevent pool drownings because children can too easily climb over chain-link and picket fences. Children should wear properly fitting life vests or use personal flotation devices for a minimum of 2 years after they learn to swim, at which time constant supervision is still necessary.

16.
(B)
The AAP recommends that children younger than 12 years of age not use push-type mowers, that children younger than 16 years not use sit-down mowers, and that no children ride on a sit-down mowers as a passenger. Sturdy shoes and eye protection should always be worn during mowing.

17.
(E)

18.
(D)
DEET-containing products are the most effective insect repellents. They should never be applied under clothing and cannot be combined with other insect repellants. The concentration of DEET ranges from 5% to 30%, at which point the maximum efficacy is obtained. The percentage directly correlates with the number of hours of protection given (eg, 10% gives about 2 hours of protection; 24% gives about 5 hours).

S
UGGESTED
R
EADING

American Academy of Pediatrics Web site.
www.aap.org
. Accessed June 2010.

Injury Prevention & Control: Data and Statistics. Ten leading causes of death and injury. CDC Web site.
http://www.cdc.gov/ injury/wisqars/LeadingCauses.html
. Accessed June 2010.

McKay MP, Curtis L. Children in cars: keeping them safe at every age.
Contemp Pediatr.
2003;20(9):65-78, 81.

Johnston B, Rivara F. Injury control: new challenges.
Pediatr Rev.
2003;24:111-117.

National Highway Traffic Safety Administration Web site.
www.nhtsa.gov
. Accessed June 2010.

CASE 61: AN 8-YEAR-OLD WITH CONGESTION

An 8-year-old boy comes to your office with his mother because of congestion for 5 days. In addition he has sneezing, rhinorrhea, and a mild cough. He has no fever and his symptoms are worse at night. He has no previous medical conditions.

On examination, he has mild bilateral conjunctival injection, clear rhinorrhea, red swollen turbinates, and a mildly erythematous pharynx.

SELECT THE ONE BEST ANSWER

1.
What is his most likely diagnosis at this time?

(A) allergic rhinitis

(B) rhinovirus

(C) influenza

(D) sinusitis

(E) Coxsackie virus

2.
How many typical upper respiratory tract infections per year does a healthy child have?

(A) 2-3

(B) 3-4

(C) 4-5

(D) 5-6

(E) more than 6

3.
He returns 14 days later with continued congestion. He no longer has a “runny” nose or sneezing, although his cough is still present and worse at night. His mother is concerned because he has never had a “cold” for this long before. On examination, he is afebrile, has mild bilateral preseptal edema, thick purulent nasal discharge, swollen turbinates, and a mildly erythematous pharynx. What is his most likely diagnosis at this time?

(A) allergic rhinitis

(B) rhinovirus

(C) influenza

(D) sinusitis

(E) immotile cilia syndrome

4.
Which of the following is
not
implicated in causing acute bacterial sinusitis?

(A)
Streptococcus pneumoniae

(B)
Moraxella catarrhalis

(C)
Haemophilus influenzae

(D) adenovirus

(E) Coxsackie virus

5.
At what time would you diagnose his condition as “chronic”?

(A) 4 weeks

(B) 6 weeks

(C) 8 weeks

(D) 12 weeks

(E) 16 weeks

6.
By what age could this child develop frontal sinusitis?

(A) 1 year

(B) 2 years

(C) 3 years

(D) 4 years

(E) 5 years

7.
A 9-year-old girl comes in to see you with fever. She had a “runny” nose several days ago, which has now changed to a thick yellow discharge. Three days ago she developed a fever of 103°F (39.4°C), which has remained until today. She also has a mild headache and a nighttime cough but no other symptoms. What is her diagnosis?

(A) allergic rhinitis

(B) rhinovirus

(C) influenza

(D) sinusitis

(E) immotile cilia syndrome

8.
What should your next course of action be with the patient in question 7?

(A) plain films of the sinuses

(B) intranasal steroid spray

(C) antibiotics

(D) CT of sinuses

(E) prescription antihistamine not associated with drowsiness

9.
If you chose to use antibiotics, which would be your first choice?

(A) amoxicillin at 45 mg/kg per day

(B) amoxicillin at 90 mg/kg per day

(C) amoxicillin (600 mg/5 mL)–clavulanate (42.9 mg/5 mL) at 90 mg/kg per day of amoxicillin

(D) azithromycin

(E) trimethoprim-sulfamethoxazole

10.
How long will you treat her?

(A) 7 days

(B) 10-14 days

(C) 3 weeks

(D) 1 month

(E) 2 months

11.
After beginning antibiotics, when would you expect clinical improvement (decrease in symptoms and increase in well-being)?

(A) 1 day

(B) 3 days

(C) 7 days

(D) 10 days

(E) 14 days

12.
Which of the following might prompt you to change your medical therapy?

(A) day-care attendance

(B) recent treatment with amoxicillin

(C) presence of frontal or sphenoidal sinusitis

(D) otitis media

(E) B and C

13.
She returns 10 days later still on your original prescription with eye pain. On examination she has left-sided preseptal edema, erythema, proptosis, and a fever of 103°F (39.4°C). What is your next step?

(A) change to a different oral antibiotic

(B) start IV

(C) ophthalmology referral

(D) sinus aspiration

(E) oral prednisone

14.
You see a 12-year-old boy who has had a month and a half of congestion and cough, day and night. He does not have fever but has a mild sore throat every day. On examination you confirm nasal congestion. His pharynx is mildly erythematous. He has normal-appearing tonsils, no lymphadenopathy, and no wheezing. What is his most likely diagnosis?

(A) allergic rhinitis

(B) rhinovirus

(C) influenza

(D) sinusitis

(E) immotile cilia syndrome