ASIPP Pediatric Questions Flashcards
1
Q
- A 2-year-old child cannot raise his arm completely on
the right and has torticollis. He has no other congenital
abnormalities. Which of following is the most likely
diagnosis?
A. Slipped capital femoral epiphysis
B. Juvenile rheumatoid arthritis
C. Sprengel deformity
D. Amold-Chiari malformation
E. Cerebral palsy
A
- Answer: C
Explanation:
(Seidel, 5/e, p 762.)
A child with Sprengel deformity
cannot raise one arm completely due to a small and
elevated scapula. Torticollis (wry neck due to shortening
of the sternocleidomastoid muscle) often accompanies the
deformity. Adolescents with slipped capital femoral
epiphysis (SCFE) are often obese African American males
who present with thigh or knee pain. SCFE is a disorder of
unknown etiology that causes posterior and medial
displacement of the femoral head. Children with juvenile
rheumatoid arthritis (JRA) present with fever, salmoncolored
rash, arthritis, hepatosplenomegaly, nodules,
pericarditis, and iridocyclitis (may lead to blindness).
There is no diagnostic test for JRA, but the disease resolves
by puberty in the majority of children. Arnold-Chiari
malformation is an abnormality of neural tube closure.
Cerebral palsy (CP) is a nonprogressive disorder
resulting from a perinatal insult; it causes either a spastic
paresis of the limbs or extrapyramidal symptoms (chorea,
athetosis, ataxia). Patients with CP often have an
associated seizure disorder, mental retardation, and speech
or sensory defi cits
2
Q
1665.The most common cause of chronic pediatric pelvic pain is A. Giardia infection B. Endometriosis C. Psychogenic D. Sexual abuse in young childhood E. PME (Pelvic Migraine Equivalent)
A
- Answer: B
Source: Goodwin J, Board Review 2005
3
Q
1666.The most common form of abdominal pain in children is A. Abdominal Migraine B. Endometriosis C. Recurrent Abdominal Pain D. Irritable Bowel Syndrome E. Gas
A
- Answer: C
Source: Goodwin J, Board Review 2005
4
Q
1667. Which of the following fracture types is more suspicious of child abuse? A. Epiphyseal B. Diaphyseal C. Growth plate D. Metaphyseal E. Torus
A
- Answer: D
Explanation:
Metaphyseal fractures, such as bucket handle and corner
fractures are more likely in abuse situations. Other
common fi ndings in abuse include posterior rib, sternum,
spinous process fractures and fractures of different ages.
Source: Boswell MV, Board Review 2004
5
Q
1668. The most common malignant bone tumor in children is A. Osteosarcoma B. Ewing’s sarcoma C. Neuroblastoma D. Wilm’s tumor E. Leukemia
A
- Answer: A
Explanation:
Malignancies of the bone, with an average annual
incidence rate of 8.7 per million children younger than 20
years of age, comprised about 6% of childhood cancer. In
the US, 650-700 children and adolescents younger than 20
years of age are diagnosed with bone tumors each year of
which approximately 400 are osteosarcoma and 200 are
Ewing’s sarcoma. The two types of malignant bone cancer
that predominated in children are osteosarcomas and
Ewing’s sarcomas, about 56% and 34% of the malignant
bone tumors, respectively
Source: Boswell MV, Board Review 2004
6
Q
1669.Two weeks after a viral syndrome, a 9-year-old girl
presents to your clinic with a complaint of several days
of drooping of her mouth. In addition to the drooping of
the left side of her mouth, you note that she is unable to
completely shut her left eye. Her smile is asymmetric, but
her examination is otherwise normal. This girl likely has
A. Guillain-Barre syndrome
B. Botulism
C. Cerebral vascular accident
D. Brainstem tumor
E. Bell’s palsy
A
- Answer: E
Explanation:
Reference: Behrman, 16/e, p 1893. McMillan, 3/e, p 1963.
Rudolph, 21/e, p 2366.
Bell’s palsy is an acute, unilateral facial nerve palsy that
begins about 2 weeks after a viral infection. The exact
pathophysiology is unknown, but it is thought to be
immune. On the affected side, the upper and lower face are
typically paretic, the mouth droops, and the patient cannot
close the eye. Treatment consists of maintaining moisture
to the affected eye (especially at night) to prevent keratitis.
Complete, spontaneous resolution occurs in about 85% of
cases, 10% of cases have mild residual disease, and about
5% of cases do not resolve.
Source: Yetman and Hormann
7
Q
1670. The most common form of abdominal pain in children is A. Pelvic infl ammatory disease B. Recurrent abdominal pain C. Abdominal migraine D. Mesenteric adenitis E. Appendicitis
A
- Answer: B
Explanation:
A. Pelvic infl ammatory disease is common in adult
females
B. Recurrent abdominal pain is the 2nd most common
benign pain syndrome in children, with an incidence of
about 10%.
C. Abdominal migraine is rare
D. Mesenteric adenitis is in the differential for
appendicitis.
E. Appendicitis is the most common reason for
exploratory laparotomy, with an incidence of 4/1000
children under the age of 14 years.
Source: Boswell MV, Board Review 2004
8
Q
1671. The most accurate pain assessment tools for preverbal children are A. Spatial scales B. Facial scales C. Numerical scales D. Physiologic measurements E. McGills Pain Questionnaire
A
- Answer: D
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
9
Q
- Your 6-year-old son awakens at 1:00 A.M. screaming. He
has been hyperventilating, tachycardic, and has dilated
pupils. He cannot be consoled, does not respond, and
is unaware of his environment. After a few minutes, he
returns to normal sleep. He recalls nothing the following
morning. The most likely diagnosis is
A. Seizure disorder
B. Night terrors
C. Drug ingestion
D. Psychiatric disorder
E. Migraine headache
A
- Answer: B
Explanation:
Reference: Behrman, 16/e, pp 16, 1829. McMillan, 3/e, p - Rudolph, 21/e, pp 34, 418, 2273.
Night terrors are most common in boys between the ages
of 5 and 7 years. The child awakens suddenly, appears
frightened and unaware of his surroundings, and has the
clinical signs outlined in the question. He cannot be
consoled by the parents. After a few minutes, sleep returns,
and the patient cannot recall the event in the morning.
Sleepwalking is common in these children. Exploring the
family dynamics for emotional disorders may be helpful;
usually pharmacologic therapy is not required, and family
reassurance is indicated.
Source: Yetman and Hormann
10
Q
1673.A 9-year-old child has developed headaches that are
more frequent in the morning and are followed by
vomiting. Over the previous few months, his family has
noted a change in his behavior (generally more irritable
than usual) and his school performance has begun to
drop. Imaging of this child is most likely to reveal a lesion
that is
A. Subtentorial
B. Supratentorial
C. Intraventricular
D. In the spinal canal
E. In the peripheral nervous system
A
- Answer: A
Explanation:
Reference: Behrman, 16/e, pp 1858-1862. McMillan, 3/e,
pp 1511-1513. Rudolph, 21/e, pp 2207-2210.
Between 50 and 60% of tumors of the nervous system in
children 4 to 11 years old are infrartentorial (posterior
fossa) and include cerebellar and brainstem tumors, often
either medulloblastoma or cerebellar astrocytoma. In
adults and infants, most intracranial tumors originate
above the tentorium; only 25 to 30% of brain tumors in
adults are subtentorial.
Source: Yetman and Hormann
11
Q
- Spina bifida occult is a congenital abnormality that is
present in what percent of the population?
A. 5%
B. 10%
C. 20%
D. 40%
E. 50%
A
- Answer: C
Explanation:
Isolated, clinically insignifi cant spina bifi da occult is
present in approximately 20% of the population
Source: Boswell MV, Board Review 2004
12
Q
1675. The most common benign pediatric pain syndrome is A. Headache B. Chest pain C. Limb pain D. Back pain E. Abdominal pain
A
- Answer: A
Explanation:
headache
Source: Boswell MV, Board Review 2004
13
Q
- The examination of a newborn’s back reveals a quartersize
“lump” of soft tissue overlying the lower spine.
Evaluation with ultrasound of this lesions may
A. Ebstein pearl
B. Mongolian spot
C. Cephalohematoma
D. Omphalocele
E. Occult spina bifi da
A
- Answer: E
Explanation:
Reference: Behrman, 16/e, p 1803-1806. McMillan, 3/e, p
223-224. Rudolph, 21/e, p2185.
Mongolian spot is not related to any abnormality. Virtually
any abnormality (except Mongolian spots) over the lower
spine points to the possibility of occult spinal dysraphism.
This designation includes a number of spinal cord and
vertebral anomalies that frequently produce severe loss of
neurologic function, particularly in the region of the back,
the lower extremities, and the urinary system. Examples of
these abnormalities are subcutaneous
lipomeningomyelocele, diastematomyelia, hamartoma,
lipoma, tight fi lum terminale, tethered cord, dermal and
epidermal cysts, dermal sinuses, neurenteric canals, and angiomas. Occasionally, the loss of neurologic function
from such anomalies is mild and, as a result, easily
overlooked. Prompt evaluation of these lesions via CT,
MRI, or ultrasound is indicated.
Source: Yetman and Hormann
14
Q
- With regard to the fetal circulation
A. the right ventricle ejects one-third of the ventricular
output
B. it is arranged in series
C. placental blood is well oxygenated
D. 50 percent of the blood entering the pulmonary artery is
shunted to the aorta
E. 20 percent of the blood entering the pulmonary artery is
shunted to the aorta
A
- Answer: C
Explanation:
(Miller, 4/e. p 2078.)
The right ventricle ejects two-thirds of the combined
ventricular output. The adult circulation is arranged in
series; the fetal circulation is in parallel. Blood returning
from the placenta is well oxygenated. Approximately 95
percent blood entering the pulmonary artery is shunted
through the ductus arteriosus to the aorta.
Source: Curry S.
15
Q
1678.The maximum dose of bupivacaine for continuous epidural infusion in the neonate is A. 0.4 mg/kg /hour B. 0.8 mg/kg /hour C. 1.5 mg/kg /hour D. 5 mg/kg /hour E. 7 mg/kg /hour
A
- Answer: A
Explanation:
0.4 mg/kg/hr
Source: Boswell MV, Board Review 2004
16
Q
- A 4-year-old child falls from the back of a three-wheeled
vehicle, hitting his head. He experiences no loss of
consciousness. In the emergency room, he is alert and
oriented without focal fi ndings on examination. He has
blood behind his left tympanic membrane. CT scan of the
skull is likely to show
A. Subdural hematoma
B. Epidural hematoma
C. Intraventricular hemorrhage
D. Basilar skull fracture
E. Hydrocephalus
A
- Answer: D
Explanation:
Reference: Behrman, 16/e, p 1961. McMillan, 3/e, p 611.
Rudolph, 21/e, p2242-2244.
The history, signs, and symptoms as outlined in the
question are characteristics of a basilar skull fracture.
Those patients with rupture of the tympanic membrane
allowing otorrhea and those with rhinorrhea after the
injury are at increased risk of complications of infection.
For these children, a semi-upright position and
observation for 72 h for evidence of increased intracranial
pressure or infection without use of prophylactic
antibiotics is appropriate. Cerebrospinal fl uid (CSF)
drainage frequently stops within 72h. Drainage beyond 72
h can require surgical closure; the risk of complications
such as infection increases after this time.
Source: Yetman and Hormann
17
Q
1680.Of all of the scales described to measure pain in small
children, which scale is used best for children from 3 to
12 years of age
A. McGrath’s scale (nine faces depicting varying degrees
of pain)
B. Oucher scale
C. Visual analog scale (VAS)
D. McGill’s questionnaire
E. Numeric Pain Scale
A
- Answer: B
Source: Raj, Pain Review 2nd Edition
18
Q
- A 9-year-old girl is brought to you with the complaint of
severe intermittent headaches for the last several months.
The physical examination, including a careful neurologic
examination, is normal. The following characteristics
support the diagnosis of childhood migraine in this
patient:
A. Strong family history of migraine
B. Frequently isolated to the occipital region
C. Frequently associated with attention defi cit hyperactive
disorder
D. Duration of headache more than 24h
E. Persistence of headache after sleep
A
- Answer: A
Explanation:
Reference: Behrman, 16/e, pp 1832-1834. McMillan, 3/e,
pp 679-680, 1931-1932, 2027-2029. Rudolph, 21/e, pp
2274-2276.
In contrast to adults, children with migraine
most often have “common” migraine: bifrontal headache
without an aura or diffuse throbbing headache of only a
few hours’ duration. As with adults, the headaches can be
terminated with vomiting or sleep. Family history is
frequently positive. Association with attention defi cit
hyperactive disorder is not common, but a relationship with seizure disorder can be seen.
Source: Yetman and Hormann
19
Q
- Pain assessment and measurement in children between
the ages of 2 and 7 years is best evaluated by
A. visual analogue scale rating
B. body movements and facial expressions
C. self-report
D. Oucher scale (faces scale)
E. All of the above
A
- Answer: D
Explanation:
(Ferrante, pp 487-488.)
Children between the ages of 2
and 7 years lack abstract thinking and the verbal skills
necessary to express their feelings of pain. Therefore,
nonverbal techniques are used to assess the intensity of
their pain. A practical, reliable, and easy-to-apply bedside
guide is a faces scale, such as the Oucher scale.
Source: Kahn and Desio
20
Q
1683.All the following statements concerning the fetal
hematologic system are true EXCEPT
A. physiologic anemia occurs at 1 month of age
B. fetal hemoglobin has P-50 of 19mmHg compared with
26mmHg for adult hemoglobin
C. fetal hemoglobin has a greater affi nity for O2, and this
manifests as decreased O2 delivery to the periphery
compared with adult hemoglobin
D. the decreased P-50 of fetal hemoglobin causes a shift to
the left of the oxygen dissociation curve
E. decreased release of oxygen by fetal hemoglobin is offset
by increased oxygen delivery provided by elevated hemoglobin
concentrations in neonates
A
- Answer: A
Explanation:
(Stoelting, Anesthesia and Co-Existing Disease, 3/e. p
583.)
There are differences between fetal hemoglobin and adult
hemoglobin that infl uence O2 transport and delivery. Fetal
hemoglobin has a greater affi nity for oxygen, which results
in a lower P-50 (19 mmHg) and causes a shift to the left
of the O2 dissociation curve. For these reasons, there is
decreased release of O2 to the periphery. However, there is
a greater amount of fetal hemoglobin, and this offsets the
increased affi nity by increasing delivery of O2. Physiologic
anemia occurs at about 2 to 3 months of age, when
production of adult hemoglobin begin in earnest.
Source: Curry S.
21
Q
1684.A previously healthy 7-year-old child suddenly complains
of a headache and falls to the fl oor. When examined in the
emergency room, he is lethargic and has a left central
facial weakness and left hemiparesis with conjugate
ocular deviation to the right. The most likely diagnosis is
A. Hemiplegic migraine
B. Supratentorial tumor
C. Todd’s paralysis
D. Acute subdural hematoma
E. Acute infantile hemiplegia
A
- Answer: E
Explanation:
Reference: Behrman, 16/e, pp 1854-1855. McMillan, 3/e,
pp 614-615, 1929,1931-1933. Rudolph, 21/e, pp 2246-
2248, 2257-2258, 2261, 2274-2275.
The abrupt onset of a hemisyndrome, especially with the
eyes looking away from the paralyzed side, strongly
indicates a diagnosis of acute infantile hemiplegia. Most
frequently, this represents a thromboembolic occlusion of
the middle cerebral artery or one of its major branches.
Hemiplegic migraine commonly occurs in children with a
history of migraine headaches. Todd’s paralysis follows
after a focal or Jacksonian seizure and generally does not
last more than 24 to 48 h. The clinical onset of
supratentorial brain tumor is subacute, with repeated
headaches and gradually developing weakness. A history
of trauma usually precedes the signs of an acute subdural
hematoma. Clinical signs of other diseases can appear
fairly rapidly, but not often with the abruptness of
occlusive vascular disease.
Source: Yetman and Hormann
22
Q
1685. Which of the following is a more common form of pain in children? A. Migraine headache B. Abdominal pain C. Chest pain D. Limb pain E. Back pain
A
- Answer: B
Explanation:
Abdominal pain is the second most common type of
benign
pain in children. Overall, headache is more common
(tension). Migraine headache occurs in about 5% of
children.
Source: Boswell MV, Board Review 2004
23
Q
- A 16-year old high school student was running track
and developed sudden pain in the leg with tenderness on
palpation and tingling. Subsequently, pain increased in
intensity with ankle swelling and erythema. MRI showed
no evidence of fracture but edema of muscles in the lower
leg was observed. The most likely diagnosis is:
A. Complex regional pain syndrome
B. Tarsal tunnel syndrome
C. Peroneal tenosynovitis
D. Compartment syndrome
E. Achilles tendonitis
A
- Answer: C
Explanation:
The sudden onset with exercise, swelling and tingling
suggest compartment syndrome. All the conditions may
cause leg and ankle pain. Different Achilles affl ictions
present with distinctive clinical features. Achilles tendon
tears can be sustained during a traumatic incident and can
mimic other tendonopathies. Tarsal tunnel syndrome
involves the motor and sensory branches of the tibial
nerve (L4 to S3) as it travels deep to the fl exor
retinaculum. Ischemia to the tibial nerve occurs after
fracture of the medial malleolus, calcaneus, or
sustentaculum tali. Continued distally, a “joggers’ foot” is
typically associated with medial plantar nerve entrapment
due to hyperpronation (eccentric loading) in long distance
runners. Impression occurs at the abductor hallucis
insertion with the patient complaining of symptoms from
the medial longitudinal arc to the toes during and after
exercise.
With the chronic compartment syndrome, the changes are
reversible and the involved muscles may be completely
normal between episodes. The patient’s initial complaint
includes a deep ankle pain over the anterolateral
compartments of the leg during or after a relatively long
period of exercise; the pain disappears with cessation of
activity. Symptoms often interfere enough to cause the
athlete to either rest or reduce the intensity of the activity,
and the symptoms may be reproduced by either
dorsifl exion or plantarfl exion of the foot. Patients with
recurrent exertion compartment syndrome are at risk for
developing peroneal muscle herniations at the fascial
tunnel in the anterolateral distal leg. This tunnel serves as
a hiatus and source of intercompartment relief of pressure
buildup.
In acute compartment syndrome, continued, mounting
pressure causes pain out of proportion, pulselessness, and
dramatic pain on passive stretching of the muscle in the
involved compartment; this causes irreversible tissue
necrosis.
Exertional compartment syndromes are often exerciseinduced,
and typically occur either chronically in well
trained athletes or acutely in individuals preforming
unaccustomed exercises, such as marching or prolonged
running. A compartment syndrome occurs when
increased pressure within a limited space comprises the
circulation to the contents of that space, resulting in
reduction of muscle and nerve profusion. In both traumatic and exercise-induced compartment syndromes,
the muscles
within the compartment enlarge with lactate and cause a
reduction in blood fl ow to the relatively small anterior and
lateral crural compartments. Muscle bulk increases by
20% after exercise. This is not to be confused with
anterior shin splint syndrome, which shows no pressure
elevation with the anterolateral compartment of the leg.
Individual variation in the relationship of muscle bulk to
the compartment volume may account for the
susceptibility of certain persons to exercise-induced
compartment syndrome. Even though the
pathophysiology of both forms of compartment syndrome
are essentially the same, the end result of the acute form
differs from that of the chronic. In both conditions,
ischemia resulting from abnormal pressure causes pain.
24
Q
- A 7 -year-old boy presents with a I-year history of pain
of the left anterior thigh. He has no history of trauma.
On physical examination, he has limited hip motion,
especially with abduction and internal rotation. A slight
limp is noticeable with ambulation. Pain is brought on by
activity and improves with rest. Which of the following is
the most likely diagnosis?
A. Osteochondrosis
B. Osgood-Schlatter disease
C. Muscular dystrophy
D. Rickets
E. juvenile rheumatoid arthritis
A
- Answer: A
Explanation:
A. Osteochondrosis is an uncommon disorder that affects
boys more than girls between the ages of 2 and 12.
* The hallmark is avascular necrosis of the capital femoral
epiphysis, which has the potential to regenerate new bone.
- Consequently, children with osteochondrosis are of
short stature and present with a painless limp.
B. Osgood-schlatter disease occurs in adolescence and is
usually self-limiting.
- It is due to patellar tendon stress, which causes pain in
the region of the tibial tuberosity especially when the
patient extends the knee against resistance.
C. Muscular dystrophy is characterized by progressive
weakness and muscle atrophy.
D. Rickets is attributed to vitamin D defi ciency and is
manifested by bowing of the long bones, enlargement of
the epiphyses of the long bones, delayed closure of the
fontanels, and enlargement of the costochondral junctions
of the ribs (rachitic rosary).
E. Juvenile rheumatoid arthritis is an infl ammatory
disorder that begins in childhood and may produce
extraarticular symptoms, including iridocyclitis, fever,
rash, anemia, and pericarditis.
Source: Seidel
25
Q
- A 16-year-old basketball player complains of pain in
his knees. A physical examination reveals, in addition to
tenderness, a swollen and prominent tibial tuberosity.
Radiographs of the area are unremarkable. The most likely diagnosis is
A. Osgood-Schlatter disease
B. Popliteal cyst
C. Slipped capital femoral epiphysis
D. Osteochondrosis
E. Gonococcal arthritis
A
- Answer: A
Explanation:
Reference: Behrman, 16/e, pp 2075-2076, 2080-2082, - McMillan, 3/e, pp 749, 2109-2110. Rudolph, 21/e,
pp 2432, 2437-2438.
This history is typical of Osgood-Schlatter disease.
Microfractures in the area of the insertion of the patellar
tendon into the tibial tubercle are common in athletic
adolescents. Swelling, tenderness, and an increase in size of
the tibial tuberosity are found. Radiographs can be
necessary to rule out other conditions. Treatment consists
of rest.
Osteochondrosis is avascular necrosis of the femoral head.
This condition usually produces mild or intermittent pain
in the anterior thigh but can also present as a painless
limp.
Gonococcal arthritis, although common in this age range,
is uncommon in this anatomic site. More signifi cant
systemic signs and symptoms, including chills, fever,
migratory polyarthralgias, and rash, are commonly seen.
Slipped capital femoral epiphysis is usually seen in a
younger, more obese child (mean age about 10 years) or in
a thinner, older child who has just undergone a rapid
growth spurt. Paid upon movement of the hip is
diagnostic.
Popliteal cysts are found on the posterior aspect of the
knee.
Source: Yetman and Hormann
26
Q
- A 3-year-old boy’s parents complain that their child has
diffi culty walking. The child rolled, sat, and fi rst stood at
essentially normal ages and fi rst walked at 13 months of
age. Over the past several months, the family has noticed
an increased inward curvature of the lower spine as he
walks and that his gait has become more “waddling” in
nature. On examination, you confi rm these fi ndings and
also notice that he has enlargement of his calves. This
child most likely has
A. Occult spina bifi da
B. Muscular dystrophy
C. Brain tumor
D. Guillain-Barre syndrome
E. Botulism
A
- Answer: B
Explanation:
Reference: Behrman, 16/e, pp 1873-1877. McMillan, 3/e,
pp 1972-1976. Rudolph, 21/e, pp 2289-2293.
The most common form of muscular dystrophy is
Duchenne muscular dystrophy. It is inherited as an Xlinked
recessive trait. Male infants are rarely diagnosed at
birth or early infancy since they often reach gross
milestone at the expected age. Soon after beginning to
walk, however, the features of this disease become more
evident. While these children walk at the appropriate age,
the hip girdle weakness is seen by age 2. Increased lordosis
when standing is evidence of gluteal weakness. Gower sign
(use of the hands to “climb up” the legs in order to assume
the upright position) is seen by 3 to 5 years of age, as is
the
hip waddle gait. Ambulation ability remains through
about 7 to 12 years, after which use of a wheelchair is
common. Associated features include mental impairment
and cardiomyopathy. Death due to respiratory failure,
heart
failure, pneumonia, or aspiration is common by 18 years
of age.
Source: Yetman and Hormann
