Q 1:
An
18-month-old boy lives with his single mother and three older siblings, ages 3,
5, and 6 years. He takes most of his fluids by bottle and has nursing bottle
caries. His mother states that he cries inconsolably when she tries to take the
bottle away, and she can't tolerate the crying. She leaves a bottle containing
milk in his crib so that he can drink during the night without waking her. As
you are discussing the problems associated with dental caries, the mother bursts
into tears.
Of
the following, the BEST intervention is to:
A. refer
him to a pediatric dentist
B. refer
the family to a mental health clinician
C. slowly
wean him from the bottle over 1 to 2 months
D. stop
all bottle feedings to encourage the transition to using a cup
E. stop
the night feedings, but allow him to continue taking the daytime bottle
Answer
B
Answer
B
The
mother described in the vignette has multiple stresses and needs the assistance
and support of a mental health professional. The signs of a disordered
relationship between infant and mother are manifested by feeding the infant to
quiet him and difficulty with weaning from the bottle. Other common indications
of a disordered relationship between parent and child include poor growth,
immunization delay, poor hygiene with chronic dermatitis, recurrent missed
appointments, and behavior problems in older children.
The
children in this family are at increased risk for abuse and neglect. Parents at
high risk of becoming abusive to their children tend to be young, single, and
poor, with a history of exposure to violence. Children at high risk of being
abused include preterm infants, children who have chronic medical conditions,
babies who have colic, and children who have behavior problems.
The
child in the vignette should see a dentist, but this is not the primary concern
for the family. The bottle should be weaned, but the increased stress caused by
this intervention may cause more difficulty in this family and should be
deferred until the family can receive assistance.
-----------------------------------------
Q 2:
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Q 2:
A mother brings in her 6-month-old child for a health supervision visit.
She explains that the
family just moved from a rural area where they had obtained their water
from a private well. In the past, she needed to give supplemental fluoride to
her children beginning at age 6 months and wonders if this is necessary for
this child.
Of the following, you are MOST likely to reply that
A. all children should receive fluoride supplementation starting at
birth
B. children should not be supplemented if bottled drinking water is used
C. fluoride 0.25 mg/d supplementation should begin at age 6 months if
there is less than 0.03 ppm in
community water
D. once the baby’s teeth erupt, fluoridated toothpaste will be
sufficient
E. supplementation may stop when the child’s deciduous teeth begin to
fall out
Answer:
C
--------------------
Q 3:
A 6-month-old previously healthy girl is brought to your office because she has not been eating
well today. The mother reports that the baby is interested in taking the bottle, but stops feeding
within 1 minute and seems to have trouble breathing. She is irritable but consolable in her
mother’s arms. She is pale, afebrile, and has a respiratory rate of 70 breaths/min. Her heart rate
is too fast to count, she has palpable pulses in all extremities, and her perfusion is fair, with a
capillary refill time of 2 to 3 seconds.
Of the following, the MOST likely additional finding expected in this child is
A. crackles over the lungs
B. conjunctivitis
C. hepatomegaly
D. nuchal rigidity
E. rash on the extremities
Answer
C
The infant described in the vignette has a heart rate that is too fast to count and most likely
suffers from an atrial arrhythmia such as supraventricular tachycardia. Because the heart rate
in such disorders is typically greater than 240 beats/min, time for the ventricle to fill during
diastole is greatly diminished. This leads to rising left atrial pressure, with subsequent pulmonary
congestion as the pulmonary vessels face increased downstream pressure. The rising
pressure in the pulmonary circuit leads to an increase in pressure on the right heart, which also
faces the difficulty of diminished diastolic time with rising right atrial pressure. This is transmitted
to the systemic veins and often is manifested on physical examination by distension of the
jugular veins and hepatic congestion with hepatomegaly. The tachypnea that results from the
pulmonary vascular congestion leads to difficulty feeding and may exacerbate the appearance
of irritability. In addition, for children who have significant alteration of cardiac output resulting
from the arrhythmia, irritability and lethargy may be the result of inadequate cerebral perfusion.
Children may manifest crackles over the lungs when in congestive heart failure, but this is
not as typical a finding as it is in adults. One reason may be the relative inability of children to
cooperate with deep and prolonged inspiration. Cardiac dysrhythmias would not present with
conjunctivitis, nuchal rigidity, or rash, as might be expected with systemic or central nervous
system infection.
-----------------
Q 3
A 9-month-old infant who had been born at 25 weeks’ gestation is receiving daily diuretics and nasal cannula oxygen with a baseline of 0.1 L/min flow. His mother called this morning, reporting that he had a temperature of 100.5°F (38.1°C), nasal congestion, increased work of breathing with a rapid respiratory rate, and “wheezing” cough. You instructed her to increase the oxygen flow rate to 0.5 L/min and advised her to bring him to your office. On arrival at the clinic, pulse oximetry reveals an oxygen saturation of 85% at rest. On physical examination, you note intercostal and subcostal retractions, a respiratory rate of 80 breaths/min, a heart rate of 140 beats/min, and a prolonged expiratory phase with audible wheezing. A copious clear nasal
discharge is present. There is no heart murmur or gallop.
Of the following, the BEST explanation for this child’s presenting signs of respiratory distress is
A. acute cor pulmonale
B. acute sinusitis
C. gastroesophageal reflux
D. lower respiratory tract infection
E. upper respiratory tract infection
Answer:
C
--------------------
Q 3:
A 6-month-old previously healthy girl is brought to your office because she has not been eating
well today. The mother reports that the baby is interested in taking the bottle, but stops feeding
within 1 minute and seems to have trouble breathing. She is irritable but consolable in her
mother’s arms. She is pale, afebrile, and has a respiratory rate of 70 breaths/min. Her heart rate
is too fast to count, she has palpable pulses in all extremities, and her perfusion is fair, with a
capillary refill time of 2 to 3 seconds.
Of the following, the MOST likely additional finding expected in this child is
A. crackles over the lungs
B. conjunctivitis
C. hepatomegaly
D. nuchal rigidity
E. rash on the extremities
Answer
C
The infant described in the vignette has a heart rate that is too fast to count and most likely
suffers from an atrial arrhythmia such as supraventricular tachycardia. Because the heart rate
in such disorders is typically greater than 240 beats/min, time for the ventricle to fill during
diastole is greatly diminished. This leads to rising left atrial pressure, with subsequent pulmonary
congestion as the pulmonary vessels face increased downstream pressure. The rising
pressure in the pulmonary circuit leads to an increase in pressure on the right heart, which also
faces the difficulty of diminished diastolic time with rising right atrial pressure. This is transmitted
to the systemic veins and often is manifested on physical examination by distension of the
jugular veins and hepatic congestion with hepatomegaly. The tachypnea that results from the
pulmonary vascular congestion leads to difficulty feeding and may exacerbate the appearance
of irritability. In addition, for children who have significant alteration of cardiac output resulting
from the arrhythmia, irritability and lethargy may be the result of inadequate cerebral perfusion.
Children may manifest crackles over the lungs when in congestive heart failure, but this is
not as typical a finding as it is in adults. One reason may be the relative inability of children to
cooperate with deep and prolonged inspiration. Cardiac dysrhythmias would not present with
conjunctivitis, nuchal rigidity, or rash, as might be expected with systemic or central nervous
system infection.
-----------------
Q 3
A 9-month-old infant who had been born at 25 weeks’ gestation is receiving daily diuretics and nasal cannula oxygen with a baseline of 0.1 L/min flow. His mother called this morning, reporting that he had a temperature of 100.5°F (38.1°C), nasal congestion, increased work of breathing with a rapid respiratory rate, and “wheezing” cough. You instructed her to increase the oxygen flow rate to 0.5 L/min and advised her to bring him to your office. On arrival at the clinic, pulse oximetry reveals an oxygen saturation of 85% at rest. On physical examination, you note intercostal and subcostal retractions, a respiratory rate of 80 breaths/min, a heart rate of 140 beats/min, and a prolonged expiratory phase with audible wheezing. A copious clear nasal
discharge is present. There is no heart murmur or gallop.
Of the following, the BEST explanation for this child’s presenting signs of respiratory distress is
A. acute cor pulmonale
B. acute sinusitis
C. gastroesophageal reflux
D. lower respiratory tract infection
E. upper respiratory tract infection
Answer
D
The preterm infant who has chronic lung disease (CLD) with an oxygen requirement at the time
of discharge from the neonatal intensive care unit is at risk for a number of complications in the
first 12 to 24 months at home. Chief among these are infections that may compromise
pulmonary function. The infant described in the vignette was an extremely low-birthweight
(ELBW) (<1,000 g) preterm infant whose CLD is being managed with diuretics and oxygen. The
sudden onset of a low-grade fever, upper respiratory tract signs of congestion, lower respiratory
tract signs of small airways constriction (wheezing and a prolonged expiratory phase),
increased work of breathing, and increased oxygen requirement are best explained by a lower
respiratory tract infection. Common viral pathogens include respiratory syncytial virus,
parainfluenza virus, and human metapneumovirus. Lower respiratory tract processes may
involve bronchiolitis or pneumonia. Chest radiographs may demonstrate hyperinflation with airtrapping,
atelectasis, and patchy interstitial infiltrates.
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