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Introduction: These clinical problems translate the objectives and competencies of the curriculum into real life patient

encounters that students can expect in a general pediatric clerkship. The brief clinical vignettes represent typical presenting complaints or questions encountered in pediatric practice and parallel the content areas of the pediatric curriculum. The vignettes have been kept brief to serve as "triggers", giving only enough detail to direct further investigation or discussion. The clinical problems are designed to stimulate discussion of appropriate differential diagnoses, initial evaluation and management, and anticipatory guidance and counseling. Vignettes have been grouped into the same chapters as the National Core Curriculum although some overlap exists. For example, the topic of "prevention" is applicable to several of the chapters not just the Prevention chapter. This clinical problem set can be used in a variety of ways. A clerkship director may use only a few of these problems or the entire set. Faculty can use them to stimulate group discussion about specific curricular objectives. Selected problems or the entire set can be used when developing a program of student self-directed learning. Importantly, the problems are not designed to provide an exhaustive overview of the pediatric clerkship experience but to supplement the student's clinical experience. The current format of clinical problems has not been developed for use in a final clerkship evaluation. In order to use these clinical problems for examination purposes the clerkship director will need to expand the clinical scenario, define the questions further and develop a key of acceptable answers for different grading levels. COMSEP Curriculum Task Force members met in Nashville, TN during the 2002 annual meeting to review, revise, and update the 1995 clinical problem set. This version represents the first step in the revision process. While task force members strove to ensure style consistency and careful linkage to National Core Curriculum objectives, errors or omissions are likely. The Curriculum Task Force envisions that the clinical problem supplement as a "living document," one that is subject to constant revision and review as errors are corrected, new issues arise, or new data accumulate. The Curriculum Task Force will continuously monitor this document and post revised editions yearly. Professional Conduct and Attitudes 1. In a crowded elevator a fellow medical student begins discussing a fascinating patient that he had seen earlier in the day. How would you respond? Consider the patients privacy and confidentiality. Suggest to your colleague that he wait until the two of you are in a more private setting before discussing the case. Never use/discuss a patients name or any other identifying information in public areas of medical facilities such as elevators, cafeterias or hallways. 2. While on attending rounds with the Pediatric Clerkship director (who assigns the final grade for the rotation), you are asked if one of your patients has been febrile during the past 24 hours. You cannot remember if the patient has been afebrile or not. What should you tell the attending? Be honest with the attending and let him/her know that you do not remember. Reporting false information can potentially result in harm to the patient 3. You and two other students are alone waiting for attending rounds to begin. One of the students makes a racist remark about a patient he had seen earlier in the day. What should your response be? Pull your colleague aside and inform him/her that the comment was not only inappropriate and unprofessional, but disrespectful as well. If this behavior continues, bring it to the attention of your team leader. 4. During a routine health care supervision visit, a sixteen-year old girl confides to you confidentially that she has been sexually active, has tried marijuana, and on a few occasions snorted cocaine. That evening her mother calls you. She is very concerned about her daughter's behavior and demands to know if the daughter is using drugs or having sex. What are your ethical and legal obligations? What would you tell the mother? The healthcare provider is ethically and legally obligated to maintain confidentiality unless the pt. threatens to harm self or others. Suggest to the mother that she ask her daughter about whats been going on, and to try having a discussion with her daughter about her behavior and her concerns regarding the behavior. 5. The mother of a six-year-old boy is upset that you examined his testicles and penis during a well-child examination. She feels that this part of the examination is private and best left to family discussions.

What would you say to her? Explain to the mother that as a healthcare provider you are responsible for evaluating each of your patients from head to toe and documenting all that is normal and abnormal. It may be helpful to describe the importance of evaluating growth and symmetry of the male genitalia, as well as potential pathological processes that can involve male genitalia in the pediatric age group (i.e. signs of child abuse, infection, etc.) 6. Brothers aged 10 and 16 present for a routine health care supervision visit with their mother. How would you interview these patients? How would your interview strategy or questions differ? The ten year old can be interviewed and examined with his mother in the room. The sixteen year old should be interviewed (especially for questions involving HEADSSS) and examined in a separate room. Consider asking the mother if she has any concerns regarding development or behavior of the sixteen year old before interviewing him so that those issues can be addressed when you do interview him 7. After informing the mother of a two-year-old infant that the child has a viral infection, the mother demands antibiotic for the child. How would you respond? Explain to the mother that infections can be caused by viruses and bacteria. Bacteria are living microorganisms whereas viruses are not. Antibiotics only fight living bugs (i.e. bacteria). It may be helpful to educate the mother about breeding resistance to antibiotics. Giving him unnecessary antibiotics jeopardizes the future usefulness in treating bacterial diseases. 8. A previously healthy 16 year-old girl presents for a routine health care supervision visit with her mother. When you ask the mother to leave the room, she refuses. How would you approach this situation? Inform the mother that in order to provide optimal care for her daughter, you, as the healthcare provider, need her daughter to be completely honest and open with you. Explain that adolescents are often reluctant to answer certain questions, or answer them untruthfully when a parent/guardian is present in the room because of multiple reasons such as shame, guilt, or fear of being reprimanded. Explain to the mother that you would like her daughter to feel as comfortable as possible during the examination in order to develop a trusting patient- physician relationship. 9. The clerkship director has scheduled a mandatory meeting with all the students on the rotation to discuss the final examination. Just before the meeting time, a sixteen-year old girl with cystic fibrosis whom you have been following on the ward says that she needs to talk with you right away and begins to cry. What should you do? Address the patients concerns. Report the encounter to a team leader. Explain situation to clerkship director and have the team leader address clerkship director on your behalf if necessary. 10. During bedside attending rounds, a girl admitted the previous night with a diagnosis of cellulitis is diagnosed with pernio. The mother requests more information about this topic. What would you do? What resources are available? Inform the mother of educational websites, and books online that she can visit for more info. If she does not feel comfortable doing this, offer to retrieve an article from the web for her. Make sure the article is written to be understood by patients rather than physicians. The physician may have pamphlets with more info as well. Health Supervision 1. What advice would you give first-time parents of a two-day old infant regarding feeding, sleeping, and general care of their new baby? When should they expect to see you for "routine care"? If the baby is formula fed, he/she should be fed 3-4 oz every 3-4 hours. Formula feedings should last no more than 10-20 min. If the baby is breastfed, the baby should be fed for approximately 10-15 minutes on each breast 8-12 times a day. Burp the baby in an upright position after feedings. Always place the baby on his/her back to sleep to reduce the risk of sudden infant death syndrome. Make sure the crib mattress is firm and covered by a sheet with no pillows or blankets that could block the babys mouth or nose. A newborn will spend most of the time sleeping. However, if the baby is rarely alert, does not wake up for feedings, or seems too tired or uninterested to eat, call a physician immediately. A newborn only needs to be bathed 2-3 times a week during the first year. Give sponge baths during the first two weeks or until the umbilical cord falls off. You can then bathe the baby in a basin filled with 2 inches of warm water. Be sure

to support the babys head at all times during the bathing. Never leave your baby unattended in the bath. Whenever you travel in a car, place your baby in a car seat that is installed correctly in back seat facing the back. Childproof the home. Dont allow smoking or smoke around your baby. Do not expose the baby to excessive sunlight. The child should be brought in for a 2-week, 1 month, 2 month, 4 month, 6 month, 9 month, 12 month, 15 month, 18 month and 2 year visit. After age 2 the child can be brought in annually for physical examination. The baby should receive most of the immunizations before his or her second birthday. 2. A healthy ten month old is starting to "cruise." What advice would you give to parents to make their house safe? Install safety latches on cabinets and drawers; keep step stools and chairs away from counters; install window guards in rooms on the second floor and above; move chairs, cribs, beds, and other furniture away from windows; secure wires and cords so lamps, TVs, etc., cant be pulled down; screw dressers and bookshelves to the wall, or buy specially designed straps to attach them to walls, so eager climbers cant tip them over; a toy chest should have safety hinges to it cant close on your childs fingers or neck; protect sockets near the sink from water; outlets in the bathroom and kitchen should have ground-fault circuit interrupters which turn off the power source if they get wet, clear your counters by putting curling irons, hair dryers, nail scissors and other dangerous objects in a latched cabinet. 3. A fifteen-month-old child is seen for "routine care". He is due to receive his MMR. On exam he has a temperature of 99 F and a runny nose. Should he still be immunized? What are the contraindications to immunization? This patient should still be immunized. Contraindications for any vaccine include a serious allergic reaction (anaphylaxis) after a previous vaccine dose, to a vaccine component, or preservative in the agent. In general, live virus vaccines are not given to pregnant and severely immunocompromised patients. Contraindications specifically for MMR vaccine include pregnancy, anaphylactic reaction to neomycin or gelatin, and known altered immunodeficiency (hematologic, and solid tumors, severe HIV infection, congenital immunodeficiency, and long term immunosuppressive therapy) 4. A twelve-month-old child has been taking 2 mg/kg/day of oral prednisone for the past two weeks for asthma. He is due for his routine immunizations. Would you modify his immunization schedule and if so, why? Data are lacking on whether persons receiving inhaled, nasal, or topical steroids without evidence of immunity can be vaccinated safely. However, most experts agree that vaccination of these persons is generally well tolerated. Persons without evidence of immunity who are receiving systemic steroids for certain conditions (e.g., asthma) and who are not otherwise immunocompromised can be vaccinated if they are receiving less than 2 mg/kg of body weight or total of less than 20 mg/day of prednisone or its equivalent. Some experts suggest withholding steroids for 2-3 weeks after vaccination if that can be done safely. Persons who are receiving high doses of systemic steroids (i.e., greater than or equal to 2 mg/kg prednisone) for greater than or equal to 2 weeks may be vaccinated once steroid therapy has been discontinued for at least 1 month. 5. In the nursery, parents are informed that blood tests need to be drawn from their newborn for "screening tests". Describe to the parents what these are and why they are performed. All states screen newborns for certain metabolic birth defects. (Metabolic refers to chemical changes that take place within living cells.) These conditions cannot be seen in the newborn, but can cause physical problems, mental retardation and, in some cases, death. Fortunately, most babies receive a clean bill of health when tested. When test results show that the baby has a birth defect, early diagnosis and treatment can make the difference between lifelong disabilities and healthy development. Many of the tests use a blood specimen taken before the baby leaves the hospital. The babys heel is pricked to obtain a few drops of blood for laboratory analysis 6. A five-year old boy is seen in your clinic for a pre-kindergarten exam. Why would you perform a vision and hearing test? A hearing and vision test should be performed before a child enters kindergarten in order to identify any vision or hearing difficulties before entering school. If these problems are not identified early, the childs learning and success in school may be hindered

7. A two-month old girl is brought to the office for a well child examination. The mother is concerned about the potential complications of immunizing her child. How would you address this issue with the mother? Let the mother know that pediatric immunizations are extraordinarily safe. Although adverse reactions are associated with many vaccinations, the risk of the child having an adverse reaction is extremely low, especially when compared to the benefit of preventing morbidity and mortality from communicable diseases. The most common adverse events include pain, redness, and/or swelling at the injection site, and fever. 8. A four-month old boy is seen for a well child examination. Following his first set of immunizations he had a temperature of 103 for a day and extreme irritability. The parents are concerned about giving the second set of immunizations. How would you address their concerns? Can he be immunized today? The child can be immunized today. Let the mother know that several of the 4- month vaccines have fever listed as an adverse reaction (including DTaP, HepB, and PCV. The mom can give an appropriate amount of Tylenol (based on weight) every 4-6 hrs for fever. True contraindications to a particular vaccine include immediate hypersensitivity reactions to the given vaccine, vaccine component, or the preservative agent. True egg hypersensitivity is a contraindication to influenza and yellow fever vaccination. Patients having encephalopathy or encephalitis after receiving diphtheria, tetanus, and pertussis vaccine do not receive subsequent doses 9. The parents of a previously healthy nine-month-old girl want to know why a hemoglobin level was drawn on her and what will be done with that information. How would you answer their concerns? Hemoglobin levels are checked at nine-months in order to determine if the child has sufficient levels or iron for hemoglobin synthesis. This is done in order to assess whether or not the child is receiving sufficient amounts of iron in their diet. At nine months, continue to give 3-5 feedings of breast milk or an iron fortified formula (24-32 oz) and 4 or more tablespoons of cereal. These are the major sources of iron. Also include vegetables and fruit 1-2 times each day. Start giving more protein containing foods including well-cooked, strained or ground plain meats, yogurt, mild cheese, or egg yolks. Low hemoglobin levels can also be caused by lead poisoning, so lead levels are checked at 9-12 months also. 10. The parents of a previously healthy three-year-old boy would like their son tested for tuberculosis. What are the indications for tuberculosis testing? Indications for tuberculosis screening include any person who is suspected of having active TB; close contacts of persons known or suspected to have TB; foreign born persons, including children recently arrived (within 5 years) from or have recently traveled to countries that have high TB incidence or prevalence; medically underserved/low income populations; high-risk racial or ethnic minority populations as defined locally; infants, children and adolescents exposed to adults in high risk categories. 11. The parents of a 14-month-old girl feel that she is not developing at the same pace as her older brother. How would you evaluate her development? What tools are available for developmental screening? The gross motor, fine (visual) motor, language, and social/adaptive developmental milestones should be evaluated. The two developmental screens most commonly employed by pediatricians are the Denver II developmental screening test and the Clinical Adaptive Test/ Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS). The Denver II evaluates children birth-6 years of age and divides streams of development into gross motor, fine motor-adaptive language, and personal-social. The CAT rates problem-solving/visual motor ability and the CLAMS assesses language development between birth and 3 years of age. 12. The mother of a twelve-month old girl living in a house built four years ago wants to know why her daughter should undergo lead testing. How would your respond to her concerns? The primary source of lead today is lead-containing paint present in buildings constructed before 1950. Children can be exposed to lead not only in there homes, but also in daycare facilities or family members homes (i.e. if grandma watches them during the day). Lead exposure can also occur if the child is exposed to batteries, pottery, ammunition, or folk remedies such as kohl, greta, and pay-loo-ah. Lead poisoning disproportionately affects lower socioeconomic populations

Growth And Development 1. A three-month-old full-term infant has gained 15 ounces (420 gm) since birth. Her height velocity is normal. Her parents want to know if this is adequate. What would you tell them? This is not adequate. Newborns gain approximately 30 g/day (1 oz/day) until three months of age. Infants gain approximately 20 g/day (0.67 oz/day) between three and six months of age and approximately 10 g/day between 6 and 12 months. Infants double their birth weight by four months of age and triple their birth weight by one year 2. A fifteen-month-old boy says no recognizable words. His parents are concerned and wonder if he needs speech therapy. How would you respond to their concern? Speech therapy would be recommended because at 15 months, an infant should be able to say 4-6 words. 3. An infant rolled over at four months and sat with assistance at six months, but at one year he is unable to stand or sit alone. His parents are quite concerned and ask if this is normal. Explain your answer. This would be considered abnormal. A child should be able to sit alone at six months and be able to stand at one year of age. Further history and physical evaluation should be performed to assess gross motor delay. 4. The parents of a nine-month-old infant are concerned because she is not sitting. She has increased tone and scissoring of her lower extremities. She can grasp a rattle, but does not reach for objects. She coos and has a social smile. What would you tell her parents? At nine months of age, an infant should be able to reach for objects, get into a sitting position, say dada and mama, and wave bye-bye. This infant is developmentally delayed in all domains 5. A six-month-old has a head circumference in the 50th percentile, height in the fifth percentile, and weight in the fifth percentile (baby was at 5oth percentile for all measurements at three months). How would you evaluate this child? Evaluation should focus on familial or constitutional growth delay, endocrine growth failure, or caloric insufficiency. Complete history and physical examination of infant, Mid-parental heights and pubertal development of the parents should be evaluated. Growth hormone and factors should be measured. Dietary and social history should be obtained 6. The parents of a fourteen-month-old boy born at 30 weeks gestational age are concerned he is not walking. He sat alone at nine months and says two to three words in addition to Mama and Dada. How would you counsel these parents? A twelve-month-old infant should be able to walk, sit alone, and say mam and dada in addition to 2-3 other words. However, there may be some delay in development sometimes from prematurity. This delay in walking would not be concerning unless it is past the age of fifteen months. Parents should be counseled that close monitoring of his development is best at this time 7. The mother of a ten-year-old girl wants to know when she might start her periods. What would you tell her? Menarche, which is the onset of menses, usually occurs between the ages of 10 and 15 years. The average age is 12.2 years for Caucasian and 12.9 years for African American females 8. A twelve-year-old boy complains that he is the shortest person in his class. He is 54 inches tall. He wants to know if he should take a "growing medicine". What additional information do you need from the history and physical examination before counseling him regarding his growth potential? Look at growth curve for child to assess if he falls of the chart or if his growth is steady Order labs to rule out abnormal processes - CBC (anemia), ESR (chronic inflammatory disease), electrolytes (acidosis or renal abnormalities), general health chemistry panel (hepatitis, liver dysfunction), urinalysis (infection, renal disease), thyroid function tests (hypothyroidism), and finally IGF-1 and IGFBP3 levels (GH deficiency). Any abnormalities as indicated by above mentioned labs could point towards an underlying condition as the reason for his growth failure. o If IGF-1/IGF-BP3 levels are low the next step is to confirm that with a GH stimulation test, which a pediatric endocrinologist should interpret. When that is confirmed and the child is diagnosed with growth hormone deficiency, replacement therapy with GH injections several times a week should be

initiated. In GHD, bone ages are delayed indicating catch up growth potential. Also the child demonstrates a growth rate that is slow, usually falling away from the normal growth. Know parents heights and their age of puberty - if one or both parents demonstrated a pubertal development delay and ultimately normal adult height than it is possible that this boy has constitutional growth delay (a condition in which a healthy child grows slower than expected. bone age = height age) If both parents are short, then the child is exhibiting familial short stature, which would include a growth curve that shows growth parallel to a growth line at or just below the third to fifth percentile. If child does not fall into any of the above categories, his growth delay would be defined as idiopathic short stature. Knowing the etiology of the growth delay will help you counsel the patient with either reassurance that this it is not a pathological cause or that it is due to a problem requiring treatment. 9. The parents of an eight-year-old girl want to know how tall she will be. She has consistently been at the 25% for age for both height and weight for the past four years. What would you tell her? What additional family information may modify your response? To calculate the girls height: (Mothers height (cm) + [Fathers height (cm)-13]/2. Any information that might indicate an underlying condition causing this pause in growth would modify my response... such indications include: poor appetite, weight loss, abdominal pain or diarrhea, unexplained fevers, headaches or vomiting, weight gain out of proportion to height, or dysmorphic features. 10. A six-month old infant is seen for a well child examination. His height and weight have remained at the 25% but his OFC has gone from the 25% to greater than the 95% over the past four months. What would you be most concerned about? How would you evaluate this child? OFC (occipital frontal circumference AKA head circumference) that is growing at alarming rate would cause a concern about hydrocephalus, macrocephaly, or megalencephaly. Anatomic megalencephaly is caused by an increase in the size or number of brain cells in the absence of metabolic disease or acute encephalopathy. Most common is familial megalencephaly. In children with normal neuro exam, normal development, no clinical feature suggestive of a specific syndrome, and no family history of abnormal neuro or development problem, familial megalencephaly can be confirmed by measuring the parents head circumferences and plotting on Weaver curves. Other causes of anatomic megalencephaly include: neurocutaneous disorders, autism spectrum disorder, achondroplasia, cerebral gigantism, fragile x syndrome, Cowden syndrome, nevoid basal cell carcinoma. Hydrocephalus is another cause of an increased OFC. IT is a disorder in which the cerebral ventricular system contains an excessive amount of CSF, resulting in increased pressure and dilation. Evaluation of macrocephaly should be initiated when a single OFC measurement is abnormal, when serial measurements reveal progressive enlargement, or when there is an in increase in OFC of >2cm/month. From there, in order to evaluate the pathological cause, neuroimaging (plain radiographs, ultrasonography, CT or MRI) and other tests (genetic test, EEGs, and skeletal surveys) should be used. Behavior 1. The parents of a three-year-old boy are concerned that he is not yet toilet trained. How would you counsel them? Enuresis is the voluntary or involuntary repeated discharge of urine after a developmental age when bladder control should be present (age 5). I would reassure the parents that there is no need to worry until the age of 5 when they are expected to be fully toilet trained by then 2. A sixteen-month-old has had several episodes of breath holding and cyanosis that leave him limp for a few seconds. They occur when he is angry or upset. What is the most likely diagnosis? How would you counsel the parents? This breath holding spells. Two forms exist. Cyanotic spells consist of a brief shrill cry followed by prolonged expiration and apnea. Resulting cyanosis, unconsciousness and generalizes clonic jerks can ensue. Such spells tend to occur after scolding. Peaks at about age two but resolves by age 5. Avoidance of reinforcing this behavior is the treatment of choice. Pallid breath holding spells are less common and are caused by a painful experience. With these events, they will stop breathing, lose conscious, become pale and hypotonic and may have brief tonic episodes

3. The parents of a three-month-old girl are surprised that she is not yet sleeping through the night. What would you tell them? Most three month olds are able to sleep through out the night by this age however a few lag behind without exhibiting any other abnormalities. Typically three month olds sleep 15 out of the 24 hours. It is important to advice the parents to keep a feed/sleep/wake cycle as it is possible the most of the sleeping the baby is doing is in the day time resulting in wakefulness at night. Also it is important to rule out the possibility of any illness/problems (like otitis media) that may be causing the infant to not sleep throughout the night. When no other problems are found, assuring the parents is the best approach 4. A seven-year-old boy is still wetting the bed at night. How would you evaluate the patient and counsel him and the family? By the age of 5 a child should be fully toilet trained and no longer wetting the bed. To evaluate this child you have to first determine if this is primary or secondary enuresis in which primary they have never experienced a dry period and in secondary they have some point experienced a dry period of at least 6 mos. Primary enuresis is usually nocturnal. Hyposecretion of ADH and/or receptor dysfunction could be the problem as well as anatomic problems, or diminished arousability during sleep. Management is achieved by taking a thorough history and physical. It is important to involve the child with use of chart dryness and/or reward system. Parents should not reprimand or humiliate the child. Other steps to take is have the child void before sleeping, set an alarm 2-3 hours after sleep to alert child to use bathroom. and pharmacotherapy if above methods fail (DDVAP or imipramine). The possible causes for secondary enuresis can be psychological, due to UTI, constipation or diabetes. It is more commonly seen in girls and can be evaluated via UA. Management is to treat the underlying disorders 5. The parents of a two-year-old are concerned because he "refuses to eat". How would you evaluate him and counsel his family? 6. A fifteen-year-old boy who had been an honor student is reported for truancy. He seems withdrawn form his parent sand friends. He quits the soccer team after a fight with his coach. Describe your approach to the evaluation of this child. 7. The parents of a seven-year-old boy receive a call from the child's teacher because he is having difficulty following directions and behaving in class. She feels he has a short attention span. How should you proceed? 8. Her parents bring a fourteen-year-old girl to the clinic after running away from home two days after an argument with them. How would you evaluate this patient? Describe the confidentiality issues that may arise. 9. A seven-year-old girl complains of a stomachache several times a week, often keeping her home from school. It is not associated with vomiting, diarrhea, or fever. How would you evaluate this child? 10. The mother of a ten-month-old girl is concerned because whereas she used to go contentedly to the baby-sitter, she now cries when her mother leaves. What would you tell her mother? 11. After being hospitalized for pneumonia a three-year-old girl begins to wet her pants, talk "baby talk", and ask for the bottle. Her parents are quite distressed and seek your advice. How would you counsel them? 12. The parents of a two-year-old ask how to control their son's temper tantrums. Describe how you would address this situation and what advice you would give. I would let the parents know that this is totally normal and expected behavior in a child this age when communication is not optimal and during the time of transition between complete dependence to some form of independence with a need to still maintain some degree of dependence on the parents. I would advise the parents that temper tantrums can be handled in one of three ways: One option is positive reinforcement, another is non-acknowledgement, and the third is negative reinforcement. If electing to participate in positive reinforcement, the child should be rewarded and praised for positive behavior in order to prevent the child from behavior that would not receive praise. In the second option, the temper tantrum should not be acknowledged by parents. To acknowledge the temper tantrum in any way would encourage the child to continue this kind of behavior. When the child has a temper tantrum, the parents should leave the room and/or turn their backs to the child in order to show that the displayed behavior will not gain the kind of response for which the child is looking. Once the tantrum is over, the parents can

then return to nurturing the child and addressing the issue at hand. This kind of approach takes great discipline on the part of the parents. The last option of negative reinforcement calls for a child to be placed in "time out" for the offense and negative behavior Nutrition 1. Parents of a newborn infant want to know the advantages and disadvantages of breastfeeding compared to bottle-feeding. How would you counsel them? I would counsel them that breastfeeding is the best and most nutritionally valuable method of feeding infants. Some of the benefits of breastfeeding include bonding between the infant and mother, decreased food allergy and eczema risk, enhanced cognitive development, reduced risk of obesity, and increased host defense. Mothers also benefit from breastfeeding. Mothers return to their prepregnancy weight more quickly, experience less severe postpartum bleeding, an display better postpartum bone remineralization. Disadvantages of breastfeeding include possible breast engorgement, mastitis, nipple cracking, and clogged milk ducts. However, the likelihood of these issues arising can be decreased by using a warm cloth on breasts, frequent feedings, and milk expression between feedings 2. A mother who is unable to breast-feed because of breast reduction surgery wants to know what types of formula are available and which would be appropriate for her child. How would you counsel her? Commercially available formulas are available and are acceptable substitutes for breast milk. 3 forms are available: canned powder, canned concentrate, and ready-to-feed. The varieties of formula are cow's milk, soy milk, lactose-free, casein hydrolysate, whey hydrolysate, and elemental. The cow's milk formulas are appropriate for her child unless a documented milk protein allergy exists. Cow's milk formulas typically are considered as a first-line replacement because they most closely imitate breast milk due to their similar carbohydrate, protein, and fat content. 3. A healthy 4-month-old breast-fed child presents for a well-child examination. The parents want to know when he can begin solid foods and when he should be weaned from breast milk. How would you counsel them? Healthy infants can begin consuming solid foods at about 4-6 months of age once adequate head control, intact normal swallowing function, disappearance of tongue extrusion reflex, and the ability to sit have been established. The child should begin being weaned from breast milk to whole cow's milk at the age of one year. At that time, whole milk should be limited to 24-ounces daily to avoid iron-deficiency anemia. At age 3 years, the child should be switched to low-fat milk if the child still desires to consume milk. 4. A mother is concerned that her 5-day-old infant is not breast-feeding well. What historical or physical examination findings would help you investigate her concerns? What additional resources may be available to help support this mother? A 5-day old infant who is not breastfeeding well should be examined for tongue tie. The frequency and amount of time spent feeding should also be clarified. Possible reasons to further explore could be neglect, dysfunctional mother-infant interaction, incorrect feeding technique, swallowing/sucking dysfunction due to neurologic impairment, choanal atresia, or cleft palate, or genetic syndromes. Once all these possible causes for infant breastfeeding difficulty are ruled out, a lactation consultant should be contacted to aid the mother in breastfeeding techniques that could improve the infant's ability to feed. 5. A healthy two-month-old infant is seen in your office for a routine visit. The mother asks about the need for vitamin and fluoride supplementation in her child. Discuss which supplements should be considered and at what age. Infants may require supplementation of vitamin D, fluoride, and iron. The American Academy of Pediatrics recommends that all infants who are breastfed receive vitamin D supplementation. Formulafed infants receive their required vitamin D from the formula alone. Infants who are fed standard ironcontaining formula usually do not require iron supplementation. Infants who are breastfed have adequate iron stores until 4-6 months of age. After 4 months of age, iron-fortified cereals and foods should be offered to both formula- and breast milk-fed infants. According to the AAP, fluoride supplementation is only required if the water supply consists of less than 0.3 parts per million of fluoride. Other vitamin deficiencies could result from unique feeding circumstances. Vitamin B12 deficiency could occur in

strictly vegan mothers breastfeeding, infants fed exclusively goat's milk could be deficient of folate, and zinc deficiency could occur in infants with acrodermatitis enteropathica or chronic malnutrition 6. A five-year-old boy is now at the 95% for weight and 50% for height whereas previously he had been at the 50% for both height and weight. How would you counsel him and his family? Include the consequences of child hood obesity in your discussion. Childhood obesity is a growing epidemic. In order to combat this issue, a multidisciplinary regimen of dietary management, psychological counseling, exercise, and family involvement. Some long-lasting consequences of childhood obesity coxa vara, obstructive sleep apnea, hypertension, hyperlipidemia, insulin resistance, early puberty, early ventilation, and slipped capital femoral epiphysis could occur 7. A thirteen-year-old girl wants to "go on a diet. Her birthday was last week. Her current weight is 45 kg, and height is 157 cm. How would you evaluate and counsel her? BMI is approximately 18.2 (41% percentile) is considered a healthy weight. Ask her why she wants to lose weight Ask her about eating habits. Reassure her that weight is fine, begin/continue healthy eating, have regular activity, no need for diet. If seems to have distorted view of her body, consider recommending her for counseling 8. The health conscious parents of a 15-month-old child ask if they can switch her to nonfat milk, as they are concerned about obesity and heart disease. How would you counsel them? Dietary fat is necessary for early brain development continue whole milk 2008 Pediatrics recommendations suggests giving lowfat milk (after 12 months) for patients with family history of obesity and heart disease Regarding concern keep healthy eating habits (fruits/veggies/whole grains) and encourage activity 9. A two month old born at term weighing 3.3 kg presents for a well child visit. Today his weight is 4.0 kg, length 56 cm, and head circumference is 39 cm. He is taking four ounces of Enfamil with iron every 3-4 hours. How would you evaluate whether this intake is adequate? Intake adequate if baby is gaining the appropriate amount of weight. In this scenario, baby is not gaining the appropriate amount. On average, infants gain about 1 kilogram per month for the first 3 months, kilogram per month from 3-6 months of age, 1/3 kilogram per month from 6-9 months of age and kilogram per month from 9-12 months of age. Full term infants double their birth weight by 4 months of age and triple it by 12 months of age 10. A 9 month old is drinking formula. Her parents ask if they can change from formula to cow's milk as they could save a lot of money. How would you counsel them? Do not recommend child could have allergy avoid until 12 months of age Remember also to avoid honey, shellfish, and, nuts 11. An 18 month old is drinking 48 ounces of whole milk a day. Is this appropriate? How would you discuss this with the parents? Too much milk should have max about 24 oz. Assess diet at this age solids should be majority of nutrition. Is child drinking too much and not eating enough? Recommend giving milk only with meals at dinner table and water if thirsty between meals 12. A 15-year-old wrestler comes in for an annual visit and wants to know your views on supplements and vitamins. How would you evaluate and counsel him? Multivitamin is good sometimes diet does not adequately provide all the necessary vitamins/minerals However, excess, especially of fat-soluble, is not good either moderation! Supplements not recommended Not regulated safety is a concern 13. In evaluating an 8-year-old child on routine physical exam, you discover that there is a strong family history of diabetes and the father had a heart attack at age 35. How would you counsel the patient and his family? Maintain healthy diet (fruits/veggies, fiber) and exercise Screening at annual physical glucose, fasting lipid panel Prevention

1. Three brothers ages 1, 10, and 16 present for a routine health care supervision visit. What anticipatory guidance would you give each? How does anticipatory guidance regarding injury prevention change with age? 1-year-old: firearm hazard, auto-pedestrian safety, discuss punishment options, nutritional counseling (introduce whole milk), avoid using walkers, using proper shoes and make sure home is childproof. Leading causes of death injuries, congenital malformations and chromosomal abnormalities, malignant neoplasms 10-year-old: Injury and violence prevention as well as nutrition counseling, Sports safety, firearm hazard, smoking and substance abuse prevention. Reinforce school and after-school programs. Avoid domestic violence and avoid media violence. Leading cause of death in this group injuries, malignant neoplasms, suicide 16-year-old: This age group requires education on alcohol and drug use, sexual safety, suicide, depression, and driving safely. Injury prevention, violence prevention and nutrition counseling Leading cause of death in this group accidents/injuries, homicide, suicide 2. During a routine office visit, the father of a six-year-old boy states that he recently purchased a new shotgun for hunting. What questions would you consider asking the father about storing the gun? What advice would you give to help prevent an accidental injury? Gun Safety-be sure to inform the father that he needs to keep the gun locked up. If possible, ask him to lock the bullets and the actual weapon separately. Always keep the safety and be sure to put it in places that the children cant get to it. Also make sure the father is teaching the child gun safety and how to stay away from the weapon. Take the ammunition out of the gun. Lock the gun and keep it out of the reach of children. Lock the ammunition and store it apart from the gun. Store the keys for the gun and the ammunition in an area separate from where the household keys are stored. Keep the keys out of reach of children. Lock up the gun-cleaning supplies, which are often poisonous. 3. A sixteen-year-old girl presents for a routine health care supervision visit. She has had two sexual partners and has used birth control inconsistently. What advice would you give to help prevent a sexually transmitted disease or pregnancy? STI transmission: Encourage her to practice safe (condoms) and educate her on exposure as it pertains to her amount of partners. Educate her on the proper use contraception and its inefficacy when used improperly. Also discuss pregnancy and the increase chance that comes with her sporadic use of contraception. Also offer STD and HIV/AIDS testing 4. A ten-year-old boy is seen with a severe headache after falling from his bicycle. He was not wearing a helmet. What advice would you give him? Helmet Safety: Helmets should be worn at all time. Assure that the helmet fits properly (once placed on the head it should not be able to move from side to side or up and down). Also, look inside the helmet for a Consumer Product Safety Committee sticker and this ensures that the helmet will provide a high level of protection on impact. 5. A nine-month-old boy is seen for a routine health care supervision visit. The parents want to know what types of foods he can eat. What foods should he not be offered? At nine months of age, the baby CANNOT eat foods with high allergy potential (fish, peanuts, nuts, dairy products, and eggs) Hot dogs, grapes, and nuts present a risk of aspiration and airway obstruction. Honey should also be avoided until age 1-2 6. The parents of a newborn want to know why the infant has to face backwards in the car seat and ride in the back seat of the car. What would you say to them? Car Seat Safety: Rear-facing is safest for both adults and children, but especially for babies, who would face a greater risk of spinal cord injury in a front-facing car seat during a frontal crash.

Rear-facing car seats spread frontal crash forces over the whole area of a child's back, head and neck; they also prevent the head from snapping relative to the body in a frontal crash. Rear-facing carseats may not be quite as effective in a rear end crash, but severe frontal and frontal offset crashes are far more frequent and far more severe than severe rear end crashes. Rear-facing carseats are NOT a safety risk just because a child's legs are bent at the knees or because they can touch/kick the vehicle seat. Rear-facing as long as possible is the recommendation of the American Academy of Pediatricians, and can reduce injuries and deaths. Motor Vehicle Crashes are the #1 overall cause of death for children 14 and under 7. The parents of a two-month-old girl want to know why their child has to be immunized. None of their friends, family members, or neighbors has ever had hepatitis B virus infection, tetanus, diphtheria, or polio. What would be your response? Prior to immunizations, many children died or were permanently disabled after contacting those disease. Immunizations will protect their child from disease and its complications 8. A nine-year-old boy has been at the 95% for weight or more for the past three years and at the 10% for height during this same time. What are the long-term health consequences of this condition? How would you counsel the patient and the family? Childhood obesity is an epidemic in the U.S. The parents should be counseled on changing their eating habits and exercising as a family. A weight loss plan should be started to prevent the complications of obesity. (eg. Diabetes, heart disease, hypertension) 9. A 12-year-old girl is presents for a pre-participation sports physical examination. What are the key components of the "sports" history and physical examination? Key components of pre-participation exam: get a thorough history (especially PMH, Family History,) and physical exam. Ask if they have any pain or current health issues. Evaluate the patients with HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behavior, Suicidality and depression). 10. The parents of a newborn are concerned about Sudden Infant Death Syndrome and have purchased a baby alarm. What advice would you give them to help prevent SIDS in their infant? To prevent SIDS: Infants should not share a bed with their parents or siblings. They should always be placed to sleep on their backs in a crib. No stuffed animals or toys should be in their cribs, no smoking in the house, avoid overheating the infant (ie. Dont place too many blankets in cribs) Apnea alarms can be helpful but have not been proven to prevent SIDS. Issues Unique to Adolescence 1. A fourteen-year-old female is seen in the clinic with her mother for acute onset of dysuria and urinary frequency. How would you evaluate and manage this patient? HPIOPQRST o onset, duration, location of pain o Describe the pain o Does the pain radiate? o Has she taken any medicine for pain? ROS o Ask if any other symptoms are present? (eg. fever) HPI, Sexual/Reproductive History, ROS will be key info to obtain. Before obtaining the sexual and social history, you can ask the parents to leave the room. Now evaluate the patients with HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behavior, Suicidality and depression). Ask about environment at home, what activities patient is involved in, sexual history (if patient is sexually active, in a relationship, etc.) Develop your differential diagnosis: Also labs will key to helping differential diagnosis: o Urinalysis If urinalysis is positive for UTI, began treatment with antibiotics






o CBC o Pelvic Exam (perform if patient is sexually active) If pelvic exam shows purulent discharge or cervical motion tenderness, then strongly suspect STD. Treatment would be ceftriaxone (250 mg intramuscularly in a single dose) and doxycyline (100 mg orally twice a day for 14 days) for gonorrhea/chlamydia His parents bring a fifteen-year-old boy to your clinic, after he threatened to "take a bunch of pills". Although he seems depressed in affect, he is not currently suicidal. Explain your approach to this young man, including important history, physical exam findings, diagnostic studies, management principles and advice to his parents. In this patient, when obtaining the history, social history is key. Is environment safe at home? Does he get along with his family? Does he have friends? How is school? Has patient had thoughts of suicide before? Why does he want to commit suicide? Is there a history of psychiatric illness or substance abuse in the family? o Diagnostic studies: CBC or blood culture to determine if he has taken any substance o Management: Refer patient and his family to counseling with a psychiatrist to help him deal with issues he has. A seventeen-year-old female sees you for a pre-college physical. Describe your approach to history, physical exam, and guidance/counseling. Must ensure comfort of this adolescent female. It is crucial that she trust you so that she may open up to you about any issues. Confidentiality is important. When taking the history, make sure it is detailed and pay attention to nonverbal cues. Bear the following things in mind. This visit is used to screen for the problems and asymptomatic diseases that are most likely to harm this female. Major causes of morbidity and mortality in adolescents are accidents, homicide, and suicide. The adolescent visit focuses on the evaluation of the young persons development, warning signs of problems, and risk taking behaviors. Gather the social history using the HEADSSS (Home, education/employment, activities, drugs, sexual activity/orientation, suicidal ideation, and sexual/physical/emotional abuse) screen. Be sensitive to her comfort. During physical exam, only uncover the area being examined. Do a complete head to toe physical exam. As far as guidance/counseling, answer any questions that she has. Encourage a positive physician-patient relationship A sixteen-year-old boy presents to your clinic with polyuria and weight loss over the past three weeks. Describe the important aspects of the history and physical exam, diagnostic considerations, differential diagnosis, and basic management principles. Type 1 diabetes mellitus is most likely diagnosis. This is the usual childhood form. Prevalence of 1 in 500 and an incidence of 15 per 1000,000 new cases per year in children <18 years old. More common in whites. Most patients present with polyuria, polydipsia, polyphagia (with weight loss), and lassitude. Blood glucose is high and glucosuria is present. Type 2 (insulin resistance) is an emerging concern in overweight teens and is a differential diagnosis. Other things on the differential include: diseases of the exocrine system (CF, hereditary hemochromatosis, and chronic pancreatitis); endocrine abnormalities in glucose regulation (cushings syndrome, GH excess, glucagon-secreting tumors, catecholamine excess in pheochromocytoma); Drug-induced diabetes (glucocorticosteroids, HIV protease inhibitors, atypical antipsychotic agents). A new diabetic must be taught about the disease, the dosage and administration of insulin, monitoring of blood and urine glucose levels, and diet. Mainstay of chronic treatment is insulin administration (typically 1 unit/kg per day divided into three or four daily doses). Goal of control in this 16 y/o is 70 to 150 mg/dL. Alert family that serum glucose values <70 or >180 mg/dL require medical attention. Family and child must be aware of signs of hypoglycemia (sweating, tremor, anxiety, or mental status changes). Treat immediately with oral sugar. Close follow up is key. Hb A1c is assessed every 3 months. The mother of a thirteen-year-old female expresses concern that her daughter has not yet had the onset of menses. How would you counsel her? Educate and reassure the mother. In girls, the first sign of puberty is breast enlargement, following by pubic hair, a growth spurt, and then menarche (2 years later). A sixteen-year-old male presents with fever, fatigue, and sore throat for four days. Discuss what

aspects of physical exam and lab data will help establish a diagnosis. Infectious Mononucleosis is the most likely diagnosis. IM is characterized by fever, pharyngitis, fatigue, and lymphadenopathy. Other findings can include splenomegaly and palatal petechiae. Cervical lymphadenopathy tends to involve the posterior chain of lymph nodes. Patients with suspected IM, based upon the history and physical examination, should have a white blood cell count with differential and a heterophile test. In addition, patients should also have a diagnostic evaluation for streptococcal infection by culture or antigen testing. Common laboratory findings include an absolute or relative lymphocytosis, an increased proportion of atypical lymphocytes, and elevated aminotransferases 7. A fourteen-year-old female well known to your practice makes an appointment to see you alone regarding a desire for contraception. What advice would you give her? What are her rights to confidentiality? What are your responsibilities to inform her parents? Before initiating contraception, it is important to review the adolescent's history for absolute or relative contraindications, discuss the risk and benefits, and obtain consent. Contraception counseling should include education about the anticipated adverse effects (eg, breakthrough bleeding), the need to use condoms to protect against sexually transmitted infections, the availability of and indications for emergency contraception, and strategies to increase adherence. The clinician should recognize and respect the adolescent's need for privacy as a basic premise for providing confidential services. This goal can be achieved by facilitating a relationship with the adolescent that is independent of the relationship with her parents. 8. A seventeen-year-old female presents to Teen-OB clinic for prenatal care. What screening tests should be performed? Rhesus type and antibody screen, Hct or hemoglobin and MCV, cervical cytology, Rubella immunity testing, urinary culture, syphilis, Hep B antigen, Chlamydia, Thyroid function, HIV testing, Down syndrome screening 9. A fourteen-year-old male presents for a football sports physical. What are the important points to cover in the history and physical exam? Detailed past medical history to assure that any previous injuries/ conditions (orthopedic injuries, cardiovascular, immunodeficiencies, neurological conditions, etc) have been adequately rehabilitated so athlete is not at risk for further injury. Detailed physical to screen for any previously undiagnosed conditions especially heart and musculoskeletal conditions that might make sports participation unsafe. Check growth charts and patients physical habitus for possible constitutional delay or bone pathology. Make sure all immunizations are up to date. Educate patient and parent about injury prevention, conditioning, and training appropriate for level of physical maturity, as well as healthy nutritional approaches to sport participation. 10. Late one Sunday night, his parents bring a previously healthy fifteen-year-old male to you after he returned home from a party confused and combative. Describe your approach to this clinical problem. Ask parents about patients school and home life. Have there been similar occurrences in the past? Is the patient performing well in school? Is he withdrawn from family life? These questions help determine how long drug/ alcohol use has been going on. Perform basic vitals, physical and a drug screen on the patient. Admit him and give patient supportive care if drug (PCP) toxicity is high. Speak to parents and educate them on effects of PCP and give them ideas on how to monitor their sons well being. Schedule for patient to return to your office for confidential counseling on how, why he is doing drugs and detrimental effects. If physician determines that patient is abusing or dependent on drugs, refer to a treatment program. Also, refer to a psychiatrist. 11. A fifteen-year old boy is concerned that he is not yet developing facial hair and is now considerably shorter than most of his peers. How would you evaluate and counsel him? Take a detailed history to determine if family members have pubertal or constitutional growth delay. Also check for any abnormalities that may point to certain endocrine disorders.

Assess growth charts to determine if patient is consistent in their growth. If patient is below 2 SD from the normal, then constitutional delay or endocrinopathies maybe considered. Assess Tanner staging for testicular size and pubic hair, if those are normal (Tanner stage 3 or 4) then a lack of facial hair isnt a concern. If patient is Tanner 1, then further testing is required to assess pubertal delay. Educate patient on your findings. If they are normal reassure the patient and parents that his growth is normal and they shouldnt have reason to worry 12. A sixteen-year old girl presents with fever and lower abdominal pain but denies urinary urgency or frequency. She is sexually active and uses condoms infrequently. How would you evaluate this patient? Take a detailed history focusing specifically on gynecologic history. Determine when sexual activity started and how many partners is she currently sexually active with. How long have her symptoms been bothering her? Has she had any vaginal discharge in the past and does she have any discharge now? Does her pain occur with meals? Perform physical exam focus on cardio, chest, abdomen (assess McBurneys point, suprapubic tenderness, CVA tenderness and rebound tenderness) and pelvic exam with speculum (assess cervical motion tenderness, size of uterus and ovaries, is patient in pain during pelvic exam, etc). Do not perform a pap smear but send GC/ Chlamydia and do a wet mount. Also send clean catch urine specimen for UA and culture. Perform abdominal and pelvic ultrasound. Consider differentials such as pelvic inflammatory disease, UTI, appendicitis, and cholecystitis. If patient has PID or UTI then treat with antibiotics, if its appendicitis or cholecystitis then obtain a surgery consult. Educate patient on healthy sexual behaviors, consistent use of condoms and risk of infertility with PID Issues Unique to the Newborn 1. A newborn has an APGAR score of 5 at one minute and 9 at five minutes. What are the components of the APGAR score? How is the APGAR scored used? Appearance, Pulse, Grimace, Activity, Respiration. At 1 minute, APGAR reflects intrauterine environment and birth process At 5 minutes, APGAR = success at transitioning / success of resuscitation 2. A 6-hour-old infant born at term is persistently tachypneic with respiratory rates in the 80's. What additional information would be helpful in evaluating the infant? Discuss the diagnostic considerations and initial approach to the evaluation of this child. Assess work of breathing (grunting/ retraction/flaring), heart rate, circulation/cyanosis, auscultate heart/lungs, oxygen saturation Give supplemental oxygen and provide assisted ventilation if needed. Arterial blood gases Chest radiograph should be obtained to assist in diagnosis and to identify complications such as pneumothorax that may require urgent treatment. Appropriate fluid, metabolic management, and provision of a neutral thermal environment will reduce the infant's energy and oxygen consumption 3. A full-term infant appears yellow at 48 hours of age. The total bilirubin is 13 mg/dl. What components of the history, physical examination, and laboratory data would be helpful in your evaluating this child? Total and direct bilirubin/ nomogram, birth trauma, ABO/Rh/DAT, history of previous Rh baby, family history of RBC defects/hemoglobinopathies/enzyme defects, occurrence of 1st stool, color of stool, progression of jaundice (cephalocaudal) 4. An otherwise thriving 14-day-old infant appears yellow. What additional history and evaluation would be important in assessing this infant? Feeding history (breast, bottle, volume, duration of feed), total and direct bilirubin, progression of jaundice 5. A 24-hour-old infant has not yet stooled. Discuss the possible explanations and your concerns.

Explanation - Functional ileus, Meconium ileus (cystic fibrosis?), Hirschsprung, anal stenosis, stricture following necrotizing enterocolitis, Concerned about jaundice 6. The mother of a newborn infant asks your advice about why she should breast-feed her infant. She will need to return to work in 8 weeks and wonders if she should just bottle feed. How would you counsel her? Mother-infant bonding; provides immunity; sustainable food source in times of emergency; breast milk is ideal for infants digestive system; lactose/whey/casein/fat are easily digested; use breast pump and give breast milk via bottle so that baby still gets the benefits and mother continues to produce milk 7. A term newborn weighs 4800 grams. What components of the history and physical examination would be helpful in your assessment? What immediate complications might this infant experience? Gestational diabetes, Postmaturity Complications (1) hypoglycemia, (2) shoulder dystocia if born via SVD 8. A mother with no prenatal care and a history of known substance abuse has just delivered a baby. What special medical and social concerns do you have about caring for this infant? Sepsis, GBS meningitis, TORCH infections, drug withdrawal in newborn 9. The parents of a newborn boy ask your opinion about whether the baby should be circumcised. What should you consider in counseling these parents? Easier hygiene and reduction in UTI, cancer, penile inflammation, HIV. Con - stricture, damage. 10. Outline the anticipatory guidance you would give the parents of a healthy, full-term first born infant at the time of discharge home from the newborn nursery Sleep on back, crib safety, SIDS, smoke alarms, shaken baby syndrome, turn down hot water to <120 degrees, car seat in back seat facing rear, take rectal temperature, if fever <97 or >100.4 /irritable/ dehydration contact doctor, no bottle propping 11. The breast-feeding mother of a 4-week-old infant is concerned that her baby is not gaining enough weight. Her mother-in-law has encouraged her to start formula supplements. The baby's birth weight was 7lb 8oz. His current weight is 9lb. How would you evaluate this infant and counsel the mother? What cultural beliefs might be important to discuss? Ask how often, how much is consumed, duration of feeding, good latching, dehydration/jaundice/number of stools and wet diapers each day, irritability, food refusal. Plot weight, height, head circumference on growth charts; failure to thrive is below 3% or falling off previously established percentile. Discuss beliefs about introduction of liquid and solid foods, prelacteal feeding, adding sugar to baby bottles, and feeding an infant carbonated beverages, rituals regarding milk production, concerns about colostrum, sexual taboos, and beliefs about wet-nursing 12. A full term newborn weighs 2000 grams. What factors might have contributed to this infant's small size? How do you assess the maturity of this infant? Tobacco use, drug exposure, placental dysfunction, infection, fetal distress.-Perform Ballard exam (physical and neuromuscular maturity) 13. A term female is delivered via C-section because of frank breech presentation. What features of the history and physical examination would support your concern about development hip dysplasia in this child? Positive (clunk) Ortolani and Barlow, gluteal fold asymmetry, positive family history of developmental dysplasia of the hip, DDH is associated with clubfoot/ congenital torticollis/ metatarsus adductus/ infantile scoliosis Medical Genetics and Dysmorphology 1. A three-year-old girl presents for evaluation of recurrent pneumonia (five times in two years) and chronic diarrhea. She is at the fifth percentile for height and weight. What are your differential diagnoses? Construct a family pedigree as if her aunt (mother's sister) and cousin (mother's brother's child) have the same condition. Immunodeficiency Hyper IgM, Selective IgA deficiency, CVID (?? Typically presents during second or







third decade of life) A newborn infant has prominent epicanthal folds, small ears, hypotonia, short, broad hands and feet, brachycephaly, and a heart murmur. The mother notes that the baby "looks different" than her two previous children. How would you evaluate this infant and counsel the mother? Karyotype, hearing and vision screening, echocardiogram, repeat thyroid studies at 6 months and yearly thereafter, evaluate atlantoaxial instability Mention that all children with trisomy 21 have developmental disabilities but it varies. Avoid presenting details about the genetic basis. Suggest prenatal screening if parents considering another pregnancy (PAPP, alpha FP, estriol, hCG, detailed ultrasonography). Suggest support groups The parents of a two-year-old boy with developmental delay report a history of mental retardation in several male members of their family. What are your differential diagnoses and what diagnostic screening would you recommend? Fragile X Klinefelter Autism Southern blot analysis provides a more accurate estimation of the number of CGG triplet repeats if a full mutation ion is present (with a large CGG expansion). It can also be used to evaluate the degree of methylation at the CGG repeat site. PCR is faster, requires a minimal sample, and is less expensive than Southern blot analysis. Additionally, PCR more accurately estimates the number of CGG triplet repeats if a pre-mutation is present (with small-to-moderate increases in CGG repeats). Recent success with fluorescent methylation-specific PCR and GeneScan analysis may further expand diagnostic options A 16 year-old girl presents with primary amenorrhea. She has been doing well at school but is not athletic and her height is less than the 5% for age. On physical examination, she has redundant neck skin and broadly spaced nipples. How would you evaluate and counsel this her? Evaluate for coarctation (femoral pulses weak, upper extremity hypertension, nonspecific ejection murmur, chest radiograph for aortic knob and cardiomegaly, ECG) Karyotype testing Gonadotropin levels are elevated Patient should know short stature and infertility are likely, mental retardation is unlikely, some congenital anomalies may be present. Emphasize that with medical supervision and psychosocial counseling and support, girls with Turner syndrome may lead healthy, satisfying lives. The mother of a newborn tells you she has taken phenytoin throughout her pregnancy and wants to know what effect this may have on her baby. How would you counsel the mother? Phenytoin has not been formally assigned to a pregnancy category. An increased risk of congenital malformations has been associated with the use of anticonvulsants agents (including phenytoin) in epileptic women during pregnancy. Anomalies associated with anticonvulsant use in pregnancy include neural tube defects, cleft lips, cleft palates, cardiac defects, and microcephaly. Avoid breastfeeding while taking Phenytoin. Phenytoin is excreted into human milk in small amounts. Typical doses given to a nursing mother would be expected to result in very small infant doses. You are asked to evaluate a baby in the nursery who is small for gestational age and microcephalic. How would you evaluate the infant? What questions would be important to ask the mother? Check for hypothermia, hypoglycemia, hypocalcemia, hyponatremia, polycythemia, adequate oxygen, neuro defects, and seizures. Ask mother about weight gain, HTN, infection, substance use, and smoking during pregnancy A mother of a two-year-old child with sickle cell disease is pregnant and wants to know the likelihood that this child will have sickle cell disease. How would you counsel her? Parents are carriers and have 50% chance of passing allele to offspring. A child born to parents who are carriers have the trait has a 25% chance. A child born to one parent with the disease and one who is a carrier has a 50% chance of having disease or trait. If another sibling already has disease, will likelihood change for next child?

NO. If they ask the likelihood of having 2 future children in a row with disease, likelihood is 1/4 * 1/4 = 1/16 8. The pregnant mother of one of your patients calls to say that a prenatal ultrasound revealed that her fetus might have spina bifida. She wants to know the implications of the disease. How would you counsel her? Should any special precautions be taken at the time of delivery and in neonatal period? Surgery to drain spinal fluid and protect children against hydrocephalus if performed in the first 48 hours of life, much more likely to live. School programs should be flexible to accommodate special needs. Need training to learn to manage their bowel and bladder functions. Some require catheterization, or the insertion of a tube to permit passage of urine Children with spina bifida who also have a history of hydrocephalus experience learning problems. Difficulty with paying attention, expressing or understanding language, and grasping reading and math. Early intervention with children who experience learning problems can help considerably to prepare them for school. Need to learn mobility skills, and often require the aid of crutches, braces, or wheelchairs. A cesarean delivery is often performed to decrease the risk of damage to the spinal cord that may occur during a vaginal delivery. Babies usually require care in the NICU for evaluation and or surgery to close the defect Fever 1. A two-week-old presents with a fever of 101 F. Her exam is unremarkable. What are your concerns? How would you evaluate and manage this patient? You should be concerned about neonatal sepsis. Rapid application of ABCs of resuscitation. In addition obtain CBC with differential to get information about neutrophil count, WBC count, CRP, platelets, etc Obtain chest x-ray if pneumonia is suspected Blood cultures are crucial for patients with suspected sepsis and LP should be reserved for documented (positive cultures) or presumed sepsis. Most common organisms in early onset sepsis are GBS, E. coli, H. flu, Listeria. Late onset organisms are S. aureus, E. coli, Klebsiella, Pseudomonas, Enterobacter, candida, GBS. Administer IV antibiotics directed at pathogens mentioned above 2. A seven-month-old girl presents with a fever to 103F, mild irritability, and poor feeding. What are your concerns? How would you evaluate and manage this patient? Concerned about UTI, Kawasakis disease, aspirin overdose, immunization-associated fever, meningococcemia, HSV, bacterial tracheitis and occult bacteremia. Manage patient by administering acetaminophen or ibuprofen to lower fever and maintain patient hydrated (20 cc/kg of normal saline in a bolus, then maintenance fluids as well). Do a detailed history and physical exam with a focus on HEENT, Cardio, lungs, abdomen and GU systems. Evaluate CBC with differential, blood cultures if sepsis or occult bacteremia is suspected. Look for dehydration, cap refill, poor skin turgor, seizures, etc 3. An eight-year-old presents with fevers of 102 F and headache. He has nuchal rigidity. What are your concerns? How would you evaluate and manage this patient? Concerned about meningitis. Most common causes in this age group are S. pneumoniae, N. meningitides and enterovirus. Obtain an LP and determine WBC count, glucose, and protein levels as well as cultures of CSF. If bacterial then antibiotics targeted at micro-organisms should be used. Empiric broad-spectrum antibiotic treatment can also be used such as 3rd generation cephalosporins. If cause is viral, then supportive care. 4. A six-month-old has had a high fever for three days and an otherwise normal exam. On day four he breaks out in an erythematous macular-papular rash shortly after his fever resolves. What is the most likely diagnosis? How would you manage this patient? The most likely dx is Roseola or sixth disease caused by HHV-6 or HHV-7 (less common). The tx is

supportive in nature. If the fever is not disturbing the child, it need not be treated. Tylenol can be used to lower fever. The child should be kept comfortable and not be overdressed; bathing in tepid water can also help to reduce the fever 5. A seven-year-old girl presents with a history of cough, coryza, conjunctivitis and fever to 103 F now has a macular rash that starts on her face and neck that is spreading to the rest of her body. What are your concerns? How would you evaluate and manage this patient? Main concern would be Measles or Rubeola virus. Dx is mainly clinical. It is recommended that the diagnosis is confirmed via blood test for IgM, and if positive, viral cultures should be obtained. The state and local health dept should be notified immediately. Pt put in isolation with supportive care. Pt is put on bed rest and is to remain well hydrated until fever subsides 6. A 4-year-old boy presents with a five-day history of fever and rash. He has received acetaminophen and amoxicillin without improvement. He is very irritable with a temperature of 103.6 F, bilateral non-purulent conjunctivitis, enlarged cervical nodes, puffy hands, and a maculopapular rash. How would you evaluate and manage this patient? The presenting symptoms suggest Kawasaki disease. Leukocytosis and elevated ESR and CRP values are some characteristic lab values. The pt should immediately be started on high dose aspirin and IV immunoglobins; plasmapheresis can be performed if initial tx is unsuccessful Sore Throat 1. A six-year-old presents with fever, headache, sore throat, and raised, rough, red rash in his axillae and groin. What is the most likely diagnosis? How would you evaluate and manage this patient? The most likely diagnosis is Scarlet Fever. The main risk factor is infection by Group A strep (strep pyogenes), which causes strep throat. The rough bright red rash typically feels like sandpaper. It appears on the face, neck, elbows, armpits, and groin. Other symptoms include high fever (at or above 101), swollen glands in the neck, weakness before rash, red sore throat, and peeling of the skin afterward (especially palms). The rash appears 1-2 days after the fever and can last for more than a week. As the rash fades, peeling (desquamation) may occur around the fingertips, toes, and groin area. The rash blanches on pressure. One may see strawberry tonguethe tongue first appears white but the red edematous papillae later project through the coating. The white coating eventually peels off. Abdominal pain, chills, muscle aches, and vomiting are other common symptoms. Diagnosis: Physical exam, throat culture (positive for Group A strep), and rapid antigen detection test (via a throat swab) o CBC: Leukocytosis, neutrophilia, high ESR, high CRP, and high ASO titer Treatment: Antibiotics are used to kill the bacteria that causes the throat infection. This is crucial to prevent rheumatic fever, a serious complication of strep throat and scarlet fever. o Penicillin V (DOC) o Clindamycin, erythromycin, or 1st generation cephalosporin if have penicillin allergy Prognosis: With proper antibiotic treatment, the symptoms of scarlet fever should get better quickly. However, the rash can last for up to 2 - 3 weeks before it fully goes away. Complications: acute rheumatic fever, bone or joint problems, ear infection, glomerulonephritis, liver damage, meningitis, pneumonia, sinusitis, erythema nodosum Scarlet fever can develop from a skin infection (impetigo) 2. A nine-year-old presents with a sore throat and fever of 101 F. He has small minimally tender anterior cervical lymph nodes and a red pharynx. What is your differential diagnosis? How would you evaluate and manage this patient? Differential Diagnosis: Strep throat (Group A), Influenza, Adenovirus, CMV, URI, Pneumococcal infection (pneumonia), Mononucleosis, Kawasaki, an Abscess Evaluation o Ask about immunizations!!! o Sick contacts? o Ask about nausea, vomiting, headache, difficulty swallowing Headache, sore throat , fever = strep pharyngitis

Also abdominal pain and emesis How long has the fever lasted? (>5 days is Kawasaki) Gastroenteritis, Conjunctivitis? could be adenovirus o Physical exam- check for splenomegaly, rash, exudates in pharynx, is there a protrusion in the throat or the patient (possible abscess also consider this if trouble swallowing, decreased appetite, and has difficulty moving neck) o CBC look for leukocytosis and/or lymphocytosis, o Throat culture, throat swab for rapid antigen assay o Antibodies anti-DNase B antibodies, ASO enzyme antibodies o If patient has periorbital edema, HTN, hematuria, proteinuria, dark colored urine, low complement levels may have post-strep glomerulonephritis Management o Same as above if strep (which I think it is) o If viral, supportive care treat symptoms if necessary will resolve on its own o Return if symptoms dont resolve in 1-2 weeks o Will need further workup if have glomerulonephritis 3. A fourteen-year-old female presents with fever, headache and sore throat. She has exudative pharyngitis, enlarged posterior cervical lymph nodes, and splenomegaly. What is your differential diagnosis? How would you evaluate and manage this patient? Differential: same as # 2 Also consider CMV infection has fever, splenomegaly, and atypical lymphocytosis, but no posterior lymphadenopathy and no exudates in pharynx Evaluation and Management same as above I believe this patient has EBV Infectious mono. If this is correct then: o Notice that this has POSTerior lymphadenopathy. Or generalized lymphadenopathy Anterior lymphadenopathy is often seen with other things, like strep o Symptomatic care only. Splenomegaly is common remember this person shouldnt play sports. Should last 2-4 weeks o Difficulty swallowing? Fatigue? Enlarged tonsils? Petechiae on palate or uvula? o Also, may develop rash if is taking an antibiotic (ampicillin, penicillin, or amoxicillin) for txt o May see atypical lymphocytes, thrombocytopenia, elevated liver function tests o Monospot test assay for heterophil antibodies - useful in those older than 5yo Check for EBV viral capsid antigen, EBV nuclear antigen and early antigen IgM and IgG o Sick contacts? Kissing disease so may have boyfriend/girlfriend who was sick o May see otitis media, ab pain, and diarrhea Complications = Bells palsy, seizures, meningitis, optic neuritis, parotitis, orchitis Otalgia 1. An eighteen-month-old male with a four-day history of URI symptoms presents with fever, irritability, and pulling at his left ear for the past 24 hours. What is your differential diagnosis? How would you evaluate and manage this patient? Differential diagnosis otitis media, otitis externa, ear trauma, mastoiditis, foreign body, TMJ syndrome, tooth pain Evaluation: Ask about up to date immunizations. Ask about sick contacts Ask how long the ear pain has been going on. Ask if patient has been swimming or under water recently Ask if has trouble hearing. Ask if it hurts to touch the outside of the ear (tragus or ear lobe) Physical Exam see if there is pain, swelling, and redness outside around the ear; look for ear drainage (blood, pus) pus could mean the TM has ruptured Pain or redness of bone behind the ear = mastoiditis

Tenderness of the jaw, or hearing a popping noise when opening and closing the mouth = TMJ syndrome Pain when biting down, chewing if feel pain on tooth and ear tooth could be the problem pain is radiating to the ear Check to see if there is a foreign object in the ear may have pain when touching tragus Check for erythema, fluid in the air, tympanic membrane that doesnt move with pneumatic otoscope and/or tympanometry, bulging of TM CBC: to check for infection WBC count Thyroid function test and ESR checks for thyroiditis and temporal arteritis MCC strep pneumo, moraxella catarrhalis, pseudomonas, H. influ., RSV Management: If foreign object, remove if possible. If cant remove, refer to ENT for removal NSAIDS for pain Amoxicillin for bacterial cause; if resistant, use amoxicillin-clavulanate. Can also use a thirdgeneration cephalosporin Complications mastoiditis, meningitis, abscess 2. A two-year-old has had six episodes of otitis media (which you have diagnosed and treated) over the past seven months. What are the risk factors for recurrent otitis media? What treatment options are available? Risk factors for recurrent otitis media URI, exposure to other children who are sick, exposure to air with irritants (tobacco smoke), having otitis media prior to 6 months of age makes one more likely to have otitis later in childhood, children who are bottle fed are more prone to otitis media, swollen adenoids Treatment options: if antibiotics arent helping, have PE tubes implanted (esp if have hearing loss of 30dB or more). Possibly remove adenoids. Also refer to ENT May use tympanocentesis removes fluid from behind TM 3. A fifteen-month-old was treated for acute otitis media three weeks ago. Today his tympanic membrane looks dull, gray, and has poor movement. How would you manage this patient? Try another antibiotic. Check for another cause of the OM by asking about other symptoms (URI, allergies, etc). Consider PE tubes if there is a poor response to antibiotics. May need to refer to otolaryngologist. Nasal Discharge 1. A three-year-old presents with runny nose, mild irritability, with temperatures of 99 F over the past forty-eight hours. Other than clear nasal discharge, his examination is unremarkable. How would you evaluate and manage this child? a. The pt most likely has a viral URI. The management/ tx of the pt is supportive in nature. The temperature should be monitored and pt should be kept comfortable 2. An eleven-year-old has springtime nasal congestion and itchy eyes which have become more of a problem over the last three years. What is your differential diagnosis? How would you evaluate and manage this child? a. The differential dx consist of allergic rhinitis, infectious rhinitis, sinusitis, vasomotor rhinitis, and rhinitis medicamentosa. Due to temporal aspect of condition and other factors, the most likely dx is allergic rhinitis. Allergen avoidance is the most effective tx but might not be practical. H1 blockers are a mainstay tx. IN cromolyn, nasal steroids, oral leukotriene receptor blockers, sympathomimetics, and immunotherapy also have shown to be effective. 3. A sixteen-month-old presents with a history of nasal discharge for the past week presents with a swollen, red eye and fevers to 103 F. What are you most concerned about? How would you evaluate this patient?

a. The most pressing concern would be AOM w/ non typical H. Influenza. The symptoms of an URI followed by conjunctivitis and +/- otalgia are suggestive. The pts ears should be evaluated for signs of inflammation or infection. Pt should be treated empirically with augmentin for 10 days. Abdominal Pain 1. A ten-month-old presents with bouts of irritability during which he draws up his legs and appears to be in pain. His stools are bloody and he appears lethargic. What is your differential diagnosis? How would you evaluate this patient? Causes of pain, lethargy, and bloody stools have to be evaluated----First O,P,Q,R,S,T needs to be considered. Then a pertinent review of systems as to the define the etiology of the chief complaints. Differential diagnoses include the following but are not limited to: Anorectal fissures Milk or soy-induced enterocolitis (allergic colitis) Intussusception Meckel's diverticulum Hemolytic uremic syndrome and Henoch-Schnlein purpura Lymphonodular hyperplasia Gastrointestinal duplication Meningitis Infections with the following can cause bloody diarrhea: Campylobacter, entamoeba histolytica, shigella, e-coli, salmonella 2. A three-year-old has had forty-eight hours of fever, vomiting, and diarrhea. Describe your approach to the differential diagnosis. Discuss management principles based on diagnosis and physical exam findings. As a clinician, I would first examine the patient as to the severity of presentation, so as to decide if fluids are needed. I would evaluate the history of present illness (O,P,Q,R,S,T,) of the fever, vomiting, and diarrhea and form my differential based on that. I would work up the fever first and include a urine culture stool culture (which also works for vomiting and diarrhea), blood culture, and a chest x-ray. I would also evaluate causes of vomiting and diarrhea which include but are not limited to: gastroenteritis, celiac disease, cystic fibrosis, systemic infection, and bacterial, viral, and parasitic causes. This will guide my approach to treatment 3. A fourteen-year-old male presents with six hours of severe abdominal pain that is now more right sided. He has had no diarrhea. How would you evaluate this patient? How would your approach differ if the patient were a girl? I will first try to elicit important info regarding the abdominal pain if possible so as to narrow my differential. Imaging such as an abdominal radiograph or plain x-ray of the abdomen will be used to guide my diagnosis. I would also get a CBC with diff, CMP, amylase, lipase, liver enzymes etc to rule out infection, anemia, pancreatitis, and liver toxicity/failure. If this patient was a girl, I would first think ectopic pregnancy, so a B-HCG test would be considered to rule in/out (ectopic) pregnancy; also, ovarian causes will also be considered. If negative for the girl, further evaluation for causes of the abdominal pain will be similar for both. 4. An eight-year-old female presents with abdominal pain, pruritic lesions on the buttocks and lower extremities, and joint swelling. What is your differential diagnosis? How would you evaluate this patient? HPI including the famous OPQRST will be ascertained; differential includes HSP, JIA (Juvenile idiopathic arthritis), SLE, juvenile dermatomyositis, sarcoidosis, scleroderma, rheumatic fever, Lyme disease, etc. I would then examine this patient with the aforementioned information soundly in mind and order some labs including CBC with diff, CMP, ESR, CRP, RF, lupus panel, creatinine kinase, blood cultures and urine cultures, and urinalysis 5. The mother of a fourteen-month-old baby's feels an abdominal mass while giving her son a bath. What concerns do you have? How would you evaluate this child?

I will obtain a HPI of the mass so as to properly attain adequate differential diagnoses which my include: neuroblastoma, Wilms tumor, adrenal tumors, hernias, hepatoblastomas, metastatic tumors. Even though this list is not exhaustive, they should be included. Depending on the HPI and pertinent ROS, a cause as to the nature of the mass will hopefully be identified and further guide other laboratory studies, etc. 6. The parents of a four-month old boy feel that he is constipated because he squirms and cries while passing stools. How would you evaluate the patient and counsel the parents? Once again, a pertinent HPI will be obtained and will guide further questioning. I will counsel the counsel the parents that this probably functional constipation, if no primary anatomic or biochemical cause is identified and is more common than many people think. The less common etiology would be metabolic, neuropathic, intestinal and muscle disorders, or miscellaneous disorders including cows milk protein intolerance, lead ingestion, Vit D toxicity, and/or botulism. All of these will be evaluated Diarrhea 1. A one-year-old presents with vomiting and diarrhea for three to four days. How would you evaluate and manage this patient? Acute diarrhea is defined as diarrhea for <14 days. Rapid rehydration and maintenance of hydration until the diarrhea resolves as well as provision of adequate nutrient intake are the mainstays of therapy. Oral rehydration and maintenance can be done with electrolyte solutions such as Pedialyte available OTC. Clinical parameters (eg, weight gain, return of normal pulse, urine output and specific gravity, skin turgor, and overall activity level) can be used to judge the effectiveness of rehydration. IV rehydration should be used for severe dehydration with symptoms of shock, stool volume greater than 10 mL/kg/h, an ileus, or monosaccharide intolerance. In these patients, normal saline IV should be used for deficit rehydration followed by 0.5 normal saline for maintenance. Most acute diarrheal disease in children results from infectious agents with rotavirus being the most common pathogen for gastroenteritis in children. Identification of an etiologic agent is often not necessary because the disease process is selflimited and treatment is similar regardless of the cause. However, if leukocytes and/or gross blood is present in the stool, or the child is toxic-appearing, the likelihood of invasive bacterial infection is greater, and stool cultures should be obtained. Similarly, diarrhea in a child who is immunocompromised or hospitalized requires more extensive evaluation because of the risk of opportunistic infection. Food may be re-started with the BRAT diet (bananas, rice, applesauce, toast) and advanced to normal diet as tolerated 2. Several children in a daycare center have presented with watery, foul-smelling stools, flatulence and anorexia. How would you evaluate and manage this situation? Giardiasis is a parasite that may be transmitted in daycare centers from person to person through fecaloral routes. Acute symptoms include watery, foul-smelling diarrhea often with bloating, flatulence, and abdominal cramps. General public health guidelines for a daycare or school outbreak include exclusion of infected children until symptoms have resolved and prevention of infected staff from handling food. Negative specimens may be required. Giardia may also be transmitted through contaminated or untreated water. Potable water is an unlikely source as it is treated, but it may need to be investigated in a massive outbreak. Remember, rotaviruses have been found to be the most important cause of acute gastroenteritis in infants and young children in all countries. Symptoms include diarrhea, fever, and vomiting. Occasionally, congestion and coryza precede the onset of intestinal symptoms. Stools are watery and rarely contain blood, mucus, or white blood cells. Adenovirus is the 2nd most common cause of acute gastroenteritis in young children. It has similar symptoms as rotavirus, but is milder in presentation with prolonged diarrhea. Like rotavirus, it can present with upper resp. symptoms. Although there are more common infectious causes for diarrhea outbreak in a daycare population, neither rotavirus nor adenovirus have the foul-smelling diarrhea with flatulence characteristic of Giardia. 3. A six-year-old boy presents with pallor and irritability following a week of abdominal pain and blood tinged diarrheal stools. What would you be most concerned about? How would you evaluate and manage this patient? This child is likely experiencing inflammatory diarrhea which presents with abdominal pain and blood or mucous in stools. It can also present with fever and tenesmus (spasms of the colon or rectum followed by

urge to empty the bowel). To determine the pathogen, stool cultures should be obtained early and C. Diff toxin panel may be indicated if the child was recently taking antibiotics. A fecal leukocyte test to detect invasive cytotoxins from Shigella or Salmonella can aid in diagnosis. Fecal leukocytes are rarely present in EHEC and Entamoeba histolytica infections. The primary goal of treatment is rehydration with oral electrolyte solutions (i.e. Pedialyte). IV rehydration should be done if the dehydration is severe. Fruit juices, soda, jello, or tea should not be used as they can cause osmotic diarrhea and exacerbate the condition. Food should be started with the BRAT diet. Empiric antibiotics are generally not indicated, and antibiotic therapy should be pending the results of the stool culture. EHEC is NOT treated with antibiotics, as they cause a higher incidence of HUS Constipation 1. A six-year-old presents with chronic abdominal pain of six weeks' duration and episodic fecal soiling of his underwear. How would you evaluate this patient? Constipation is more frequent in young boys than in young girls. Only a minority of children have organic or anatomic causes for constipation. In the majority of children, the cause is a functional or behavioral problem. The most common nonorganic cause of constipation and encopresis in children is functional fecal retention, which also has been called psychogenic megacolon or behavioral or idiopathic constipation. It is caused by the voluntary withholding of stool secondary to fear of defecation. A careful history to uncover characteristic behaviors (stands stiff, moves around on tiptoes, crossing the legs, or sits with the heels pressed against the perineum) and a physical examination consistent with functional fecal retention (abdominal distention/pain) may be the only evaluation that is required for diagnosis. The physician needs to provide guidance and assure painless defecation by administering stool softeners. Parents are assigned the jobs of giving the medicine and securing private, unhurried time in the toilet for the child two or three times daily after meals (to take advantage of the gastrocolonic reflex). When sitting on the toilet, the child should press the feet firmly against the floor or a bench to facilitate defecation. After elimination of the rectal mass, treatment should be continued for several months with lower-dose cathartics. Agents most commonly used in this phase include lubricants such as mineral oil, osmotic agents such as lactulose or milk of magnesia, and stimulants such as bisacodyl or senna derivatives. After experiencing months of pain- and accident-free defecation, the child will indicate there is no need for the medicine Rashes 1. A four-year-old girl presents to your clinic with a diffuse pruritic rash. She has numerous evanescent raised, erythematous lesions with serpiginous borders and blanched centers. What is the appropriate diagnosis and treatment of this condition? The presence of serpiginous tracks suggest there is something burrowing or migrating under the skin. This raises suspicion of cutaneous larva migrans and scabies. Cutaneous larva migrans, or creeping eruption, is a clinical syndrome caused by nematode larvae that penetrate and migrate through the skin, causing intensely pruritic, serpiginous tracks. The disease is usually caused by the larvae of Ancylostoma braziliense or Ancyclostoma caninum (common hookworms of dogs and cats) which penetrate human skin and migrate along the epidermal-dermal junction. Lesions can occur almost anywhere, but often are found on the soles and dorsa of the feet, buttocks, face, and back. Generally, the infection is self-limited and requires no treatment. In persistent or severe infections, topical or oral thiabendazole or albendazole has been used. Control measures should focus on preventing skin contact or ingestion of moist soil contaminated with animal feces. Scabies is caused by the mite Sarcoptes scabiei hominis and presents as diffuse pruritis with threadlike burrows, but not typically as lesions with blanching centers. It is treated with permethrin. Sporotrichosis and Loaisis (Loa Loa infestation) can also present with pruritic, serpiginous rash, but are usually nodular and not raised erythematous patches. A diffuse, pruritic rash with evanescent, erythematous lesions with serpiginous borders and blanched centers is consistent with cutaneous larva migrans 2. A four-year-old presents with a dry, erythematous, itchy rash in the antecubital and popliteal fossae. Discuss the differential diagnosis and appropriate therapy.

Eczema is a broad term synonymous with dermatitis used to describe several inflammatory skin conditions including atopic dermatitis, contact dermatitis, and seborrheic dermatitis. The lesions of atopic dermatitis are pruritic and vary with age. Red, exudative, crusty or oozing lesions on the face or flexor surfaces in an infant; or dry, lichenified lesions over flexor surfaces (antecubital, popliteal, neck) in a juvenile or adult is suggestive of atopic dermatitis. Topical corticosteroids are the mainstay of therapy. 2/3rds of children outgrow by age 10. Atopic dermatitis is a part of the allergic trilogy which include asthma and allergic rhinitis. 3. An eighteen-month-old presents with many golden-yellow, crusted-weeping lesions around the nose which seem to be spreading according to the child's parents. Discuss the likely diagnosis and management considerations. The likely diagnosis is impetigo. This is a highly contagious bacterial skin infection. It is normally caused by Staph aureus and sometimes by Strep pyogenes. It affects children under the age of 2. It causes painless fluid-filled blisters that are red, itchy, but not sore. The blisters break and scab over with a yellow-colored crust. It is transmitted by direct contact with lesions and scratching may spread the lesions. Good hygiene practices can prevent impetigo from spreading. To treat this disease you use topical mupirocin for local disease. If the disease is widespread or nonresponsive to topical therapy then an oxacillin (dicloxacillin, flucloxacillin), or a 1st generation cephlasporin (cephalexin) should be used 4. A five-year-old boy presents following a dog bite on the hand. How would you care for this patient? Physical exam begins with the patient's general appearance and a full set of vital signs to include pain assessment. Vital signs should be frequently re-assessed. Next, examine and assess the bite wound. This begins with a description of the injury location (i.e., face, hands, legs, etc.). If possible, take pictures to help carefully document the wound. If a camera is not available, a hand-drawn diagram will suffice. Make sure to measure length and depth of the wound and classify it. Classification categories include abrasion, puncture, laceration, avulsion, or crush. Include the amount of devitalized tissue, which helps give an idea as to the extent of injury. Note any injury to other anatomic structures. This includes (but is not limited to) tendon, nerve, bone, and/or ligament damage. Also look for signs and symptoms of infection. Note any fever, chills, body aches, nausea, vomiting, weakness, pain, erythema, exudates, edema, heat, or foul odors coming from the injury. A thorough neurovascular and musculoskeletal exam (including range of motion) should be performed. Absent pulses distal to a bite wound can indicate vascular injury or be a sign of compartment syndrome. Consult a surgeon for more serious wounds (particularly those involving the hand). Puncture wounds that appear superficial are often very deep and penetrate deeper anatomic structures. Serious complications can arise quickly if these are not treated adequately. Even though thorough history and physical are the cornerstones of the diagnosis and management of dogbite wounds, ancillary tests can be valuable tools in deciding a plan of action. Consider radiographic evaluation if fracture, presence of foreign body, or infection is suspected. Since the depth of puncture wounds can be deceiving, those close to bones and joints usually require radiographic studies. X-rays are also indicated if the bite has penetrated the joint capsule or if septic arthritis is a concern. Osteomyelitis can be seen on x-ray; however, osteomyelitis usually occurs several days after a dog bite, while septic joints can occur quite rapidly. Consider a referral for vascular evaluation if there is a possibility of vascular injury; crush injuries have a higher propensity for vascular compromise than other wounds. Culturing the wound is necessary only if infection is suspected. Pasteurella multocida is the most common and most virulent organism responsible for infected dog-bite wounds. Infection caused by P. multocida will usually show signs and symptoms within 24 hours. Since different organisms grow at variable rates, wound cultures should be kept for at least seven days. Crush injuries are more likely to become infected than shearing-type wounds. If you suspect the infection is systemic, a complete blood count and blood cultures would also be prudent. If compartment syndrome is suspected, wick measurements or arterial line system manometers and other intracompartmental pressure monitors can be used. Treating the wound may involve irrigation of the wound with normal saline, debridement, amoxicillin/clavulanate which is effective against pasteurella. Tetanus and rabies immune globulin might also be considered.

5. A fifteen-year old boy is concerned that his acne is worsening. He has multiple open and closed comedones scattered over his face. How would you counsel and treat this patient? Acne is caused by the bacteria Propionibacterium acne, which forms free fatty acids within the sebaceous follicle. Open comedones are blackheads. Closed comedones are whiteheads and these more commonly become inflammatory. If comedones rupture, inflammatory lesions and contents spill in to the adjacent dermis. This will form papules and pustules if close to the surface. If deeper, it forms a nodule. Topical therapy for treatment of comedones and papulopustular acne includes benzoyl peroxide, tretinoin (single most effective agent for comedonal acne), adapalene (different gel), and topical erythromycin or clindamycin. You need to allow 4-8 weeks to assess the effect of the above agents. You use systemic treatment for those that dont respond to the topical treatment. This includes antibiotics such as tetracycline, erythromycin and clindamycin. Isotretinoin for moderate to severe nodulocyctic disease (very teratogenic and contraindicated in pregnancy). A trial of hormonal therapy can be used in those who are not candidates for isotretinoin. Corticosteroids may be used to aid healing painful nodulocystic lesions. Dermabrasion may help decrease visible scarring Limb/Joint Pain 1. A 15-year-old girl badly twisted her ankle while playing basketball earlier in the day. What advice would you give her? I would tell this girl about the RICE method: Rest, Ice, Compression, Elevation. She should rest the injured ankle and avoid any activity that causes further pain. She should apply ice as soon as possible to decrease pain and control the swelling. She should use crushed ice in a watertight bag covered with a thin cloth so its not too cold against the skin. The swollen area should the be compressed with an elastic bandage. It shouldnt be so tight as to cause more pain or cut off circulation. The injured ankle should be elevated as much as possible. This way gravity can drain some of the swelling. The ankle should be placed higher than the knee. Once the swelling is controlled, X rays may need to be taken. If the X rays dont show a fracture then you have a sprain. The patient should gradually engage in rehabilitation of the ankle starting with non-weight bearing exercises, then moving to weight-bearing, and finally to normal activity 2. An athletic 12-year-old boy complains of pain just below the knee when running and playing soccer. Discuss the possible causes and an approach to the problem. This is most likely cause by Osgood-Schlatter Disease. There is traction apophysitis of the tibial tubercle. This is an overuse injury in an active adolescent. There is swelling, tenderness, and increased prominence of the tubercle. The treatment is rest, restriction of activities, knee immobilization, and isometric exercises. Complete resolution takes 12-24 months. Other possible causes could be Sinding-Larsen-Johansen syndrome, which involves the patellar tendon and the lower margin of the patella bone, instead of the upper margin of the tibia. Tibial tubercle fracture, Patellar tendonitis, osteomyelitis of proximal tibia, pes anserinus bursitis. Bone radiographs and MRIs can be done to differentiate between these 3. A 14-month-old girl presents with the sudden onset of fever and refusal to walk. Discuss your differential diagnosis and evaluation of this child. Both osteomyelitis (Staph aureus, GBS, gram negative, pseudomonas, salmonella) and septic arthritis (almost all staph aureus) present this way. They present with pain, fever, and refusal to walk. Diagnosis is made with blood culture, CBC, ESR, CRP. Other differentials include trauma, foreign body, tumor. These are ruled out with plain film. Trabecular long bones do not show changes for 7-14 days. Septic arthritis shows widening of joint capsule and soft-tissue edema. You can do an ultrasound to look for joint effusion. The definitive test is to aspirate for culture and sensitivity. If you suspect osteomyelitis you do a bone biopsy for culture and sensitivity. If its septic arthritis you can do an ultrasound guided arthrocentesis for culture and sensitivity. You treat with antibiotics. You should always cover for Staph initially. You treat septic arthritis for 4 weeks and osteomyelitis for 4-6 weeks 4. A five-year-old presents with a swollen, red knee. Discuss your differential diagnosis and evaluation of this child. Take history first

Knee Injury-can be caused by trauma or misalignment. Diagnose using standard AP and lateral views of plain x-rays. MRI can be used to diagnose soft tissue injury of the knee. Juvenile Idiopathic Arthritis (JIA)-most common form of persistent arthritis in children. Persistent swelling of the affected joint which could include the knee, ankle, wrist, and small joints of hands and feet. Child may present with limping, lethargy, reduced physical activity, and poor appetite. May present with pain and morning stiffness. Make diagnosis with blood tests and x-rays. Look for antibodies and rheumatoid factor. Treat with NSAIDs, corticosteroids, and TNF alpha blockers Septic arthritis- purulent invasion of a joint by an infectious agent which produces arthritis. Usually only affects one joint but can affect more later. Diagnosis is by aspiration, gram stain, and culture of fluid from the joint. Fever, increased neutrophils, CRP, and ESR. Treat with IV antibiotics and analgesics Bursitis-inflammation of one of the bursa of synovial fluid in the body. Caused by repetitive movement and excessive pressure. Traumatic injury can also cause bursitis as the bone rubs against the inflamed area. It causes joint pain and stiffness. If its not infected it can be treated with ice, rest, antiinflammatory drugs, and elevation. If it is infected, antibiotic therapy is required. Osgood-Schlatter Disease- swelling, pain, and tenderness over the tibial tuberosity. Caused by repetitive stress to the distal insertion of the patellar tendon attachment to the proximal tibia. Usually occurs b/t age 10-15 during growth spurt. Pain with kneeling, running or jumping. Radiograph shows soft tissue swelling. Treated with activity modification and stretching exercises 5. A four-year-old presents with a one-week history of multiple joint pain and swelling. Discuss your differential diagnosis and evaluation of this child. Juvenile Idiopathic Arthritis (JIA)-most common form of persistent arthritis in children. Persistent swelling of the affected joint which could include the knee, ankle, wrist, and small joints of hands and feet. Child may present with limping, lethargy, reduced physical activity, and poor appetite. May present with pain and morning stiffness. Make diagnosis with blood tests and x-rays. Look for antibodies and rheumatoid factor. Treat with NSAIDs, corticosteroids, and TNF alpha blockers Septic Arthritis-purulent invasion of a joint by an infectious agent which produces arthritis. Usually only affects one joint but can affect more later. Diagnosis is by aspiration, gram stain, and culture of fluid from the joint. Fever, increased neutrophils, CRP, and ESR. Treat with IV antibiotics and analgesics Leukemia-malignant transformation and clonal expansion of hematopoietic cells at an early stage of differentiation. ALL most common in children. Child presents with lethargy, malaise, anorexia, and bone pain. Obtain a CBC and diagnose with bone marrow biopsy an aspirate. Treat with chemotherapy, radiation, steroids, bone marrow or stem cell transplants. Acute rheumatic fever, IBD, connective tissue diseases, HSP, septic arthritis, viral arthritis, Lyme disease, leukemia, neuroblastoma, and bone tumors can all present like arthritis. CNS Problems 1. A fourteen-year-old girl presents to the ER with a right-sided headache, which she describes as "the worst headache I've ever had." She reports seeing "flashing lights" prior to the onset of the headache. Discuss your initial assessment and treatment of this patient Migraine Aura precedes headaches Severe, throbbing, typically frontal or frontotemporal pain Lasting several hours Photophobia, vomiting, nausea Family history of migraine headaches Complicated migraines-migraine accompanied by weakness/paralysis, sensory loss, difficulty speaking, alterations in vision or mental status Treated with acetaminophen, ibuprofen, quietness, rest Subarachnoid hemorrhage Bleeding into the subarachnoid space Due to ruptured cerebral aneurysm

worst headache of life, vomiting, confusion Diagnosis made by CT scan or lumbar puncture Treatment Monitor blood pressure, respirations, and pulse Prevent deep vein thrombosis with compression stockings Large hematoma on CT scan may require surgical removal of blood or occlusion of the bleeding site through clipping (placing clips around the aneurysm) or coiling (platinum coils placed into aneurysm to cause blood clotting) Calcium channel blockers to prevent vasospasms 2. A nine-year-old boy is sent to the school nurse several times a week for headaches. His mother brings him to the pediatrician for evaluation. Discuss your assessment of this child. It is important to determine if the headache is primary (benign without neuropathology such as tension and migraine headaches) or secondary (due to increased intracranial pressure). Patients should be asked about the history, onset, progression, severity, location, duration, and timing of the headaches. Weakness, visual disturbances or abnormal sensations should be reported. If the symptoms are alleviated by medication should be noted Stress levels, recent life changes, and precipitating factors such as foods, exercise, fatigue, sleep deprivation, fasting, or caffeine. Benign Tension headaches associated with stress and fatigue described as generalized and constant respond to over-the-counter analgesics, stress management Migraine headaches Aura Severe, throbbing, typically frontal or frontotemporal pain Lasting several hours Photophobia, vomiting, nausea Family history of migraine headaches Complicated migraines-migraine accompanied by weakness/paralysis, sensory loss, difficulty speaking, alterations in vision or mental status Treated with acetaminophen, ibuprofen Sinusitis Headache caused by viral, bacterial, or allergic sinusitis Increased intracranial pressure Headache made worse by lying flat, bending, sneezing, or straining Increase in severity and frequency overtime Personality changes, gait disturbances, and visual abnormalities Headache may wake patient up from sleep Fundoscopic examination will reveal papilledema CN VI palsy may be present Ingestion of toxins Carbon monoxide, inhaled hydrocarbons, caffeine, tobacco, alcohol Physical Examination CT nor MRI is necessary for tension, migraine, or sinusitis headaches Neuroimaging only necessary for severe debilitating headaches or headaches due to increased intracranial pressure 3. A sixteen year old with a history of seizures wants to know if he can get a driver's license. What advice would you give him? In Tennessee: A person with epilepsy must be seizure free for a period of 6 months before applying for a license. An individual whose seizures have been controlled by medicine for 6 months may be approved

for driving privileges if the Department of Safety receives a favorable recommendation from the individuals physician and the Medical Review Board. A person whose license has been suspended or denied may appeal the decision by requesting an administrative hearing. The request must be made to the Department within 20 days of the proposed suspension notice. A petition for appeal from the outcome of the hearing must be filed within 10 days. The second administrative decision is a final order, and a petition for review in a chancery court must be filed within 60 days. Each state has its own set of rules PHYSICAL FINDINGS Heart Murmur 1. On routine physical exam, a five-year-old girl is found to have a heart murmur. How would you distinguish between an innocent and a pathologic murmur? Innocent murmurs: peripheral pulmonary stenosis- heard in early infancy that is caused by the bending and branching of the pulmonary artery Stills murmur-most common; due to the harmonic vibrations of the left ventricular outflow tract Pulmonary flow murmur-normal turbulence across the pulmonary valve and right ventricular outflow tract Venous hum-continuous murmur; normal turbulent flow patterns at the junction of the innominate vein drainage into the SVC Normal heart sounds 1/6 or 2/6 intensity of murmur Valsalva maneuver decreases sound of innocent murmur Pathologic murmurs: PDA, Coarctation of the aorta, VSD, ASD, Aortic stenosis, Pulmonary stenosis Shortness of breath, easy fatigability, failure to thrive, cyanosis, clubbing, increased or decreased pulses Splitting of heart sounds, S4 3/6 or < intensity of murmur Valsalva maneuver increases sound of mitral valve prolapsed When uncertain if a murmur is innocent or pathologic, a chest x-ray and electrocardiogram are good screening tools in this evaluation. Lymphadenopathy 1. A ten-month-old girl presents with recurrent pneumonia and failure to thrive. She has thrush and numerous axillary and inguinal nodes. How would you evaluate this patient? 2. A six-year-old, previously healthy, girl presents with a 3 by 5 em, tender anterior cervical lymph node. What historical and physical examination information is essential to develop an appropriate differential diagnosis? Splenomegaly 1. A four-year old boy presents with fevers and malaise for a week. He has petechiae, palpable axillary lymph nodes and his spleen is palpated 3 cm below the left cost margin. What is your differential diagnosis? How would you evaluate this patient? 2. A ten-year-old boy with sickle cell disease presents with the sudden onset of pallor and has an enlarged spleen. What would you be most concerned about? Hepatomegaly 1. A four-year-old child presents with nausea, vomiting, fever and fatigue. On physical exam he has scleral icterus and a tender liver edge palpable 3 em below the costal margin. Discuss your plan for

evaluating this patient. Possible Impaired Vision 1. The parents of a four month old are concerned because her eyes cross. What are your concerns? How would you evaluate this patient? 2. You are unable to see a red reflex when examining the eyes of a newborn. Discuss the causes and your approach to the patient. Impaired Bearing 1. The parents of a two-year-old boy are concerned that he is not talking. How would you evaluate the patient and counsel the parents? Bleeding 1. A previously healthy two-year-old presents with persistent nosebleeds over the past two days and petechiae on her extremities. What is your differential diagnosis? How would you evaluate this patient? 2. On a routine health supervision visit, a 1-year-old boy is found to have an Hgb 8.8, HCT 27%, and a MCV of 68. How would you manage this patient? Hematuria/Proteinuria 1. A ten-year-old boy complains of "dark urine" and a headache. Discuss your diagnostic approach to this patient. 2. A four-year-old boy is brought to the pediatrician because of "puffy eyes" and sudden weight gain. What is your differential diagnosis and how would you evaluate this patient? 3. A two-year-old girl evaluated for a febrile illness has 1+ ketones and 1+ protein in her urine. Assuming that the remainder of the urinalysis is normal, discuss your assessment. Differential Diagnosis of Proteinuria: Nephritic syndrome, Nephrotic syndrome, Diabetes, exercise, trauma, UTI, dehydration, acute tubular necrosis Types of Proteinuria Transient from fever, exercise, dehydration, cold exposure, CHF, seizures, and stress. Presents with normal renal function, bland urine sediment, normal blood pressure, absence of significant edema, quantitative protein excretion of usually less than 1 g/d. This is not indicative of significant underlying renal disease. Proteinuria disappears upon repeat testing. Orthostatic most common form of persistent proteinuria in school-aged children and adolescents ie, tall thin adolescents or adults younger than 30 y, may be associated with severe lordosis. Normal to slightly increased proteinuria in supine position but greatly increased in upright. May be exaggerated or normal response. Rule this out before any other evaluation is done. Renal function is normal and proteinuria usually is less than 1 g/d. Overnight urine collection shows normal protein excretion (ie, <50 mg during 8-h period). Fixed Glomerular or tubular disorders; suspect glomerular in any patient with a >1g/24 hours proteinuria or with accompanying hypertension, hematuria, or renal dysfunction. Chronic Illness and Disability 1. Smoke, dust, and exercise trigger asthma attacks in an II year-old-boy with asthma. Both or his





parents smoke and he is desperate to play basketball on the school team. Discuss the medical management of this child. How would you negotiate an asthma care plan with the child and family? Medical management: consider the type of asthma patient may have. If mild persistent asthma, prescribe inhaled steroids for maintenance and B-agonists for breakthroughs. If moderate persistent asthma, prescribe inhaled steroids, long acting B-agonists, and a short-acting B-agonists for breakthroughs. (see chart in Kaplan p 95 for Classification and Treatment of all classes of Asthma ) Plan: talk to parents about smoking outside, change clothes when they come back into the house, slowly cutting back on number of cigarettes in the interest of the childs health while playing sports A 15 year old boy with sickle cell disease is concerned because has not yet developed facial hair and is considerable shorter than his peers. How would you counsel him? We believe that one of the mechanisms accounting for zinc deficiency in SCD may be hyperzincuria and that growth retardation and hypogonadism in men so commonly seen in SCD may be related to zinc deficiency. Whereas zinc in plasma, red blood cells, and hair was decreased, the excretion of zinc in urine was increased in SCD patients as compared to the controls. Counsel patient to supplement diet with trace elements such as zinc to compensate for the hyperzincuria. Additional info related to growth defects: Patients with sickle cell disease can have a variety of growth defects due to the abnormal maturation of bone. The following growth defects are often seen in sickle cell disease: bone shortening (premature epiphyseal fusion), epiphyseal deformity with cupped metaphysis, peg-in-hole defect of distal femur, and decreased height of vertebrae (short stature and kyphoscoliosis). All of these factors can contribute to patients short stature. A 14-year-old girl with previously well-controlled insulin dependent diabetes mellitus presents in diabetic ketoacidosis for the third time in the past six months. What are the issues that might be adversely affecting her diabetes control? Compliance: Patient may not be taking her insulin at the scheduled times due to a number of possible reasons: rebellion, busy academic/sports schedule, change of school (may not have a place in school they feel comfortable giving themselves injections. Also, the parents have to actively involved in the childs treatment, making sure the child takes his/her medications at the appropriate time. Weight loss: Considering that this patient is a 14 year-old girl, she may be concerned about keep her weight down and noticed that skipping her insulin injection is a viable way to do so (no storage of glucose, simply voiding the carbs) A 17-month old girl is diagnosed with cystic fibrosis after her third hospitalization for pneumonia. Her mother is pregnant. What are the short and long term implications for this girl? What are the implications for the family including the unborn child? Short term implications: pancreatic insufficiency, GERD, failure to thrive, recurrent respiration infections. Long term implications: obstructive lung disease, followed by restrictive lung disease (fibrosis), Two acute potentially life-threatening complications: hemoptysis, spontaneous pneumothorax. Progressive obstruction and hypoxia in advanced disease can lead to pulmonary HTN and cor pumomale. Implications for the family: Antenatal diagnosis by mutational analysis in a family previously identified by birth of a child with CF; test spouse of carrier with standard panel of probes. Implications for unborn child: Since both parents are carriers, 25% child will have CF; however, if the unborn child has a different father than the 17 month old with CF, test partner with standard panel of probes. A newborn has hypotonia, downward slanting palpebral fissures, a single palmar crease, and an III/VI holosystolic murmur at the mid left sternal border. What would you tell the parents? What are the short-term implications? What are the long-term implications? tell them kid has Downs Syndrome Causes full trisomy 21 in 94% of patients, Mosaicism (2.4%) and translocations (3.3%). 75% of the unbalanced translocations are de novo, and 25% result from familial translocation. The most common error is maternal nondisjunction in the first meiotic division

Translocation cases occur when genetic material from chromosome 21 becomes attached to another chromosome, resulting in 46 chromosomes with one chromosome having extra material from chromosome 21 attached. Advanced maternal age risk factor for maternal meiotic nondisjunction. o With a maternal age of 35 years, the risk is 1 in 385. o With a maternal age of 40 years, the risk is 1 in 106. o With a maternal age of 45 years, the risk is 1 in 30. Down syndrome can be diagnosed prenatally with amniocentesis, percutaneous umbilical blood sampling (PUBS), chorionic villus sampling (CVS), and extraction of fetal cells from the maternal circulation. Short term implications: Down syndrome decreases prenatal viability and increases prenatal and postnatal morbidity. Affected children have delays in physical growth, maturation, bone development, and dental eruption. Approximately 75% of concepti with trisomy 21 die in embryonic or fetal life. Approximately 85% of infants survive to age 1 year, and 50% can be expected to live longer than age 50 years. Congenital heart disease is the most important factor that determines survival. In addition, esophageal atresia with or without transesophageal (TE) fistula, Hirschsprung disease, duodenal atresia, and leukemia contribute to mortality. Visual and hearing impairments in addition to mental retardation may further limit the child's overall function and may prevent him or her from participating in important learning processes and developing appropriate language and interpersonal skills. Absence of stools secondary to Hirschsprung disease Delay in cognitive abilities, motor development, language development (specifically expressive skills), and social competence Long-term implications: Predisposition to hyperuricemia and Diabetes mellitus, cataracts and Alzheimer disease. Children with Down syndrome are predisposed to developing leukemia, particularly transient myeloproliferative disorder and acute megakaryocytic leukemia. The extra copy of the proximal part of 21q22.3 appears to result in the typical physical phenotype: mental retardation, characteristic facial features, hand anomalies, and congenital heart defects, intestinal malabsorption. Frequent infections due to impaired immune responses, increased incidence of autoimmunity, including hypothyroidism and rare Hashimoto thyroiditis. Arrhythmia, fainting episodes, palpitations, or chest pain secondary to heart lesion Symptoms of sleep apnea, including snoring, restlessness during sleep, difficulty awaking, daytime somnolence, behavioral changes, and school problems Symptoms of atlantoaxial instability o Symptoms include easy fatigability, neck pain, limited neck mobility or head tilt, torticollis, difficulty walking, change in gait pattern, loss of motor skills, incoordination, clumsiness, sensory deficits, spasticity, hyperreflexia, clonus, extensor-plantar reflex, loss of upper-body strength, abnormal neurologic reflexes, change in bowel and bladder function, increased muscle tone in the legs, and changes in sensation in the hands and feet. Physical Exam Growth: Short stature and obesity occurs during adolescence. Behavior: Natural spontaneity, genuine warmth, cheerful, gentleness, patience, and tolerance are characteristics. A few patients exhibit anxiety and stubbornness. Seizure disorder (5-10%): Infantile spasms are the most common seizures observed in infancy, whereas tonic-clonic seizures are most common in older patients. Premature aging: Decreased skin tone, early graying or loss of hair, hypogonadism, cataracts, hearing loss, age-related increase in hypothyroidism, seizures, neoplasms, degenerative vascular disease, loss of adaptive abilities, and increased risk of senile dementia of Alzheimer type are observed.

Skull: Brachycephaly, microcephaly, a sloping forehead, a flat occiput, large fontanels with late closure, a patent metopic suture, absent frontal and sphenoid sinuses, and hypoplasia of the maxillary sinuses occur. Eyes: Up-slanting palpebral fissures, bilateral epicanthal folds, Brushfield spots (speckled iris), refractive errors (50%), strabismus (44%), nystagmus (20%), blepharitis (33%), conjunctivitis, tearing from stenotic nasolacrimal ducts, congenital cataracts (3%), pseudopapilledema, spasm nutans, acquired lens opacity (30-60%), and keratoconus in adults are observed. Nose: Hypoplastic nasal bone and flat nasal bridge are typical characteristics. Mouth and teeth: An open mouth with a tendency of tongue protrusion, a fissured and furrowed tongue, mouth breathing with drooling, a chapped lower lip, angular cheilitis, partial anodontia (50%), tooth agenesis, malformed teeth, delayed tooth eruption, microdontia (35-50%) in both the primary and secondary dentition, hypoplastic and hypocalcified teeth, malocclusion, taurodontism (0.54-5.6%), and increased periodontal destruction are noted. Ears: The ears are small with an overfolded helix (see the image below). Chronic otitis media and hearing loss are common. About 66-89% of children have a hearing loss of greater than 15-20 dB in at least 1 ear, as assessed by means of the auditory brainstem response (ABR). Neck: Atlantoaxial instability (14%) can result from laxity of transverse ligaments that ordinarily hold the odontoid process close to the anterior arch of the atlas. Laxity can cause backward displacement of the odontoid process, leading to spinal cord compression in about 2% of children with Down syndrome. Chest: The internipple distance is decreased. Congenital heart defects: o Congenital heart defects are common (40-50%); they are frequently observed in patients with Down syndrome who are hospitalized (62%) and are a common cause of death in this aneuploidy in the first 2 years of life. o The most common congenital heart defects are endocardial cushion defect (43%), ventricular septal defect (32%), secundum atrial septal defect (10%), tetralogy of Fallot (6%), and isolated patent ductus arteriosus (4%). About 30% of patients have several cardiac defects. The most common lesions are patent ductus arteriosus (16%) and pulmonic stenosis (9%). About 70% of all endocardial cushion defects are associated with Down syndrome. GI system (12%): Duodenal atresia or stenosis, Hirschsprung disease (<1%), TE fistula, Meckel diverticulum, imperforate anus, and omphalocele are observed. celiac disease (5-15%) Genitourinary tract: Renal malformations, hypospadias, micropenis, and cryptorchidism occur. Skeleton: Short and broad hands, clinodactyly of the fifth fingers with a single flexion crease (20%), hyperextensible finger joints, increased space between the great toe and the second toe, and acquired hip dislocation (6%) are typical presentations. o Diabetes and decreased fertility can occur. Skin: Xerosis, localized hyperkeratotic lesions, elastosis serpiginosa, alopecia areata (<10%), vitiligo, folliculitis, abscess formation, and recurrent skin infections are observed. Dermatoglyphics: Distal axial triradius in the palms, transverse palmar creases, a single flexion crease in the fifth finger, ulnar loops (often 10), a pattern in hypothenar, and interdigital III regions are observed. Trisomy 21 mosaicism o Trisomy 21 mosaicism can present with absent or minimal manifestations of Down syndrome and may be underdiagnosed as a cause of early-onset Alzheimer disease o The phenotype of persons having mosaicism for trisomy 21 and Down syndrome reflects the percentage of trisomic cells present in different tissues. 6. The parents of an 18-month-old boy are concerned because he is not yet walking. He has lower extremity hypertonia and hyperreflexia. How would you counsel the parents? The patients parents should be made aware that we have concerns about the way their child is developing. Although cerebral palsy is known to present with hypertonia, hyperreflexia, and delayed psychomotor development, we should not automatically jump to this conclusion. We should let the

parents know that we would like to get a detailed history and also run some laboratory tests to help aid in our diagnosis 7. During routine screening at 14 weeks gestation, the mother of one of your patients is found to be HIV antibody positive. What interventions can be done to minimize perinatal transmission? After delivery, how would you confirm or exclude HIV infection in the infant? In order to minimize perinatal transmission of HIV, all HIV positive mother should be started on a daily regimen of zidovudine. Furthermore, the American College of Obstetrics and Gynecology recommends that elective cesarean delivery should be discussed and recommended for all HIV-infected pregnant women with viral loads above 1000 copies/mL . HIV infection in infants can be diagnosed by 1 month of age and in nearly all infected infants by 6 months of age using viral diagnostic assays (RNA PCR, DNA PCR, or virus culture). Since maternal antibodies may be detectable until 12-15 months of age, a positive serologic test is not considered diagnostic until 18 months of age Therapeutics 1. A three-year-old has acute otitis media. She is not allergic to any medications. Which if any antibiotics would you prescribe and why? Initial approach: obtain thorough history (associated symptoms, rhinorrhea, cough, congestion, etc) Any history of previous OM and responsive therapy? Once you are reasonably confident it is Acute OM, the treatment of choice would be High-dose amoxicillin (90 mg/kg/day x 5 days or 10 days if < 2yrs old). Alternatively, one could prescribe Cefuroxime or Ceftriaxone. 2. An eighteen-month-old has purulent conjunctivitis without other findings. How would you manage this patient? With isolated conjunctivitis, topical erythromycin is sufficient. If orbital cellulitis is present, oral Augmentin would be necessary 3. A four-year-old girl urinary urgency and dysuria. A clean catch urine shows 50-100 white blood cells. How would you manage this child? Presence of WBC in the clean-catch urine sample are highly indicative of UTI. First, one should send off the urine to be cultured. Next, the patients blood pressure and blood urea nitrogen/creatinine levels should be obtained. Empiric treatment should begin with oral Amoxicillin (40mg/kg/day), TMP-SMX (612/mg/kg/day), or Cephalosporins for 10 days. If the patient is sick enough to be hospitalized, the antibiotics should be administered IV until the patient has improved and can reliably take them PO. It would also be important to differentiate this from bubble bath irritation, vaginitis, pinworms, masturbation or sexual abuse. 4. A mother asks whether she should use ibuprofen or acetaminophen for fever in her child what is the appropriate dose. What would you tell her? It is important first to ask what her childs temperature has been they may require immediate hospitalization if it is too high. To answer her question, either medication is effective as an antipyretic, however ibuprofen has the advantage of q6h dosing versus q4h for acetaminophen 5. A six-year-old boy has been coughing, particularly at night for 3 days. He has diffuse wheezes. Discuss your initial assessment and treatment. A full history and physical with particular attention to social history, potential exposures and allergies should be obtained. More likely than not, this child suffers from asthma and/or allergic rhinitis. Some allergen in his bedroom or house could possibly exacerbate his asthma and cause coughing. It is important to rule out any upper respiratory tract infection. If the etiology lies within the reactive airway spectrum, then inhaled corticosteroids, albuterol, and possibly Benadryl could help to control the coughing and improve the quality of the childs sleep. 6. A thirteen-year-old has had a persistent cough without other complaints or findings for the past week. It is now interfering with sleep. How would you manage this patient? There are many causes of chronic cough, including allergic rhinitis, asthma, GERD, bronchiectasis, eosinophilic esophagitis and perhaps environmental exposures. If the parents smoke, quitting or going outside to smoke would be the most important intervention to be made. Removing any other such allergens would help as well. Ordering an upper GI endoscopy with a biopsy would help to determine the

exact cause. Prescribing Benadryl, inhaled corticosteroids, or proton-pump inhibitors could help to reduce the symptoms and enable them to sleep soundly 7. A ten-year-old presents with a headache, nasal discharge and a mild cough. His examination is unremarkable. How would you manage this patient? Taking a detailed history is critical. If all of these symptoms are present in an afebrile child, the source is most likely allergic rhinitis. This can be managed by removing exposure to pet dander, dust, pollen, or mold. It may be impossible to avoid all of these, but attempts should be made. There are various effective OTC medications available, including Benadryl (at night), Loratadine (Claritin), cetirizine (Zyrtec) and decongestants. There are also various prescriptions, which may help, including fexofenadine (Allegra) and montelukast (Singulair). Immunotherapy (allergy shots) can also help to reduce allergies, but is expensive and time consuming 8. A two-year-old presents with a persistent pruritic rash on his arms and legs. He has patches of erythema with obvious excoriations on the extensor surfaces of his arms and legs and also in the antecubital fossae. How would you treat this condition? This patients symptoms are most suggestive of Eczema. Treatment would include removing the use of any triggering substances, including contact allergens, scented soaps and creams. Frequent washing of the affected areas with non-detergent soaps such as Dove and usage of lubricants and moisturizers such as Eucerin cream. Topical steroids are of great help, such as Hydrocortisone or the more powerful fluocinonide. There are oral immunomodulators, which have been found to help, such as tacrolimus or pimecrolimus. If the lesions are weeping, consider giving antibiotics for superinfection. 9. An eleven-year-old has a sore throat and a positive rapid streptococcal test. Discuss your assessment and initial management. Sore throat with positive Rapid Strep Test is diagnostic of GAS (Streptococcus pharyngitis), which can be treated with Penicillin VK (25-50mg/kg/day PO q6-8h x 10 days). Alternatives include Amoxicillin and Erythromycin 10. A known asthmatic complains of worsening cough and wheezing, unresponsive to inhaled albuterol. How would you manage this patient? This patient is in status asthmaticus - one needs to admit this patient! Prepare to intubate if needed, give IV fluids for hydration, obtain CBC with differential to evaluate for infectious causes, an ABG to determine the severity of the attack, a Chest X-Ray to evaluate for pneumonia, pneumothorax or CHF. They should be put on an albuterol nebulizer continuously and space out as tolerated with supplemental oxygen. Methylprednisone should be given IV as well. Antibiotics should be given if there are signs of infection. Lastly, sedation and mechanical ventilation can be used if the condition is severe and nonrefractory to treatment 11. A six-year-old swimmer complains of otalgia and ear discharge. His right external ear canal is filled with a purulent discharge. Discuss your diagnosis and initial treatment plan. This patient is suffering from Otitis Externa, commonly called "swimmer's ear." Infectious agents commonly include Pseudomonas aeruginosa and Staphylococcus aureus, and less commonly Streptococci, mycoplasma and fungi (Candida sp.). Treatment includes topical drops composed of combination antibiotic/steroid - such as Cortisporin otic suspension. Future reinfections can be prevented by avoiding precipitating factors and/or prophylaxis with topical drops of alcohol, boric or acetic acid sterilizing the auditory canal and restoring normal acidic pH. 12. The mother of two young children asks which sunscreen and insect repellent to use on a camping trip. What advice would you give her? The best sunscreen is the one with the highest SPF rating that is also designed to be sweat- proof and will stay on the longest. Reapplying sunscreen is important after several hours or toweling off. The best insect repellant is one that contains DEET, as it protects against tick bites preventing rickettsia, Lyme disease, RMSF and other tick-borne illnesses) and mosquito bites (preventing dengue fever, West Nile virus, EEE, WEEE and malaria). The mother should also be advised to perform routine checks for ticks 13. A breast-feeding mother is giving oral tetracycline for pneumonia. She wants to know if it safe to take the medication while breast-feeding. How would you counsel her? If the mother has already been taking the medication and nursing, one should reassure the mother that

there is little chance for exposure and damage to her infant. However, there is still considerable cause for concern, and if another antibiotic were effective to treat her Pneumonia, she should be switched away from the tetracycline. If no other antibiotic is effective, she should be advised to discontinue breastfeeding just in case 14. A two-year-old boy with multiple drug allergies is diagnosed with pneumonia. The physician would like to use doxycycline or ciprofloxacin to treat him. How would you counsel the parents? Both Doxycycline (member of the Tetracyclines) and Ciprofloxacin (member of the fluoroquinolones) are drugs with significant toxicity in children. Accordingly, they are rarely given to children younger than 8 years of age. In this situation, your son has a dangerous infection of his lungs, that if not treated can become very serious - even life threatening. Your son's situation is not unheard of, however, where he is allergic to all of our best therapeutics save these two. With respect to the side effects of doxycycline, the drug accumulates in bones. Fortunately, almost every bone structure in the body is constantly remodeled, with the exception of teeth. This means that the only long-term disfigurement of this drug would be staining of his teeth brown. With ciprofloxacin, the drug causes damage to cartilage of the weight-bearing joints. This has frequently led to joint pains, but the arthralgias have occasionally been reversible. Additionally, there are many reports of successful quinolone treatments without any significant adverse side effects. Unfortunately, we cannot guarantee absence of adverse effects with either drug, but ask that the parents choose which of the two treatments and potential side effects they would prefer. The alternative, no treatment, is possibly death Fluid and Electrolyte Management 1. A six-year-old girl admitted for elective surgery and is made NPO (she is not allowed to drink or eat anything). She weighs 21 kg (height is 54 inches). Write an order for her IV fluids prior to surgery. Maintenance fluids for 21kg = (4mL/kg/hr * 10kg) + (2mL/kg/hr * 10kg) + (1mL/kg/hr * 1kg) = D5 0.2% NS to run at 61 mL/hr continuous iv 2. A two-year-old has sustained a severe closed head injury and is comatose. He weighs 14 kg. What factors need to be considered when calculating his daily water requirements? How would this patient's fluid requirements differ from that of a 5-month-old girl admitted with fever to 39.5C and marked tachypnea? The patient who is comatose will require 0.2% NS maintenance fluids so long as they are comatose or otherwise unable to take fluids PO. One must consider their weight to calculate the appropriate fluids: 48mL/hr. One must also consider their urinary output, and consider altering the IV rate or prescribe diuretics if it is too low. The patient admitted with fever and tachypnea appears to have some of the signs of dehydration, meaning that they require replacement fluids (NS fluid bolus and 1/2 NS maintenance) until their deficit is replaced. 3. A seven-month-old infant has had fever, vomiting, and diarrhea for the past 24 hours. How would you determine whether to admit this patient to the hospital for intravenous fluids? If the patient is unable to take fluids orally (ie Pedialyte) and there are signs of dehydration (decreased UOP, dry mucous membranes, tachycardia, etc) then it will be necessary to admit the patient and administer intravenous replacement fluids 4. An infant weighing 8 kg is estimated to be 12% dehydrated. What is the calculated fluid deficit and how should it be replaced? What N solution(s) should be used? What laboratory tests should be ordered? If an infant weighing 8kg is 12% dehydrated, then they must have originally weighed approximately 9.1kg, and the deficit is thus 1.1 Liters. It should be replaced first with: Fluid Bolus of NS, 182mL (20mL/kg * 9.1kg) + Replacement fluids of 1/2 NS at a rate of 910mL/day (100mL * 9.1kg) + Maintenance fluids of 1/2 NS at a rate of 910mL/day (100mL * 9.1kg). Labs to order: BMP, CBC, Blood glucose, Urinalysis 5. A two-month-old infant is brought to the Emergency Department because of seizures. He has had diarrhea for five days and has been fed only water and apple juice. What might be the cause of the





seizures and how should they be treated? The seizures are due to hyponatremia from water intoxication. The infant lost salt in their diarrhea, but it was only replaced with water - when the parents should have given Pedialyte or Gatorade. Treatment should include immediate fluid replacement with hypertonic saline, intubation, and consider administering a Vasopressin antagonist. The rate of serum Na+ increase must not exceed 1.5mEq/L/h. A nine-month-old infant has diarrhea and signs of moderate dehydration. His electrolytes are Na+ 162, K+ 5.6, Cl- 122, and bicarbonate 12. During N rehydration the patient has a generalized seizure. What is the probable cause of the seizure? How should it be treated? In patients with hypernatremic dehydration, the fluid deficit must be corrected slowly (over the course of 48 hours). In this case, the deficit was corrected too quickly, leading to a rapid shift in osmolality and cerebral edema. First, the dehydration should be corrected with NS, then hypotonic fluids can be administered. The rate of plasma sodium concentration decrease should not exceed 12mEq/L/day A nine-month-old infant has vomiting and diarrhea. He has dry mucous membranes and decreased tearing and urination. What type(s) of liquids would you recommend that the mother give to this infant and how often? This infant appears to be ~ 10% dehydrated. The mother should give the infant Pedialyte (orally) or Gatorade, or some solution of 75-90mmol/L Na+, 20mmol/L K+, 30mmol/L base, 65- 85mmol/L Cl- and 2-2.5% glucose. They should be give 50mL/kg or 100mL/kg over 4 hours, plus replacement of stool losses. If they remain dehydrated, this can be repeated. However, if the dehydration exceeds 10%, intravenous fluids should be administered without delay A nine-year-old child with diabetic ketoacidosis has the following electrolytes: Na+ 132, K+ 5.4, Cl103, and Bicarb 9. As the fluid deficit is corrected, what is likely to happen to the serum K? How should this be managed? In DKA, the serum K+ level is misleadingly normal, when in fact total K+ is decreased. As fluids are restored, acidosis is resolved and insulin is administered, K+ will move back into the cells, reducing serum K+ to dangerous levels. It is thus prudent to administer 20-30meq K+ / L of fluid. A nine-month-old girl presents with two days of vomiting and diarrhea. She is listless and her heart rate is 210. What is the most appropriate initial management of this child? This infant must be admitted, she is severely dehydrated (vomiting, diarrhea and tachycardia) and hyponatremic (listless or lethargic). She must receive immediate intravenous fluid replacement with hypertonic saline, but the rate of serum Na+ increase must not exceed 1.5mEq/L/h.

Poisoning 1. An eighteen-month-old boy is found in the garage coughing and choking. A jar of paint thinner is spilled on the floor and on his clothing. What advice would you give to the parents over the phone? Should they give Ipecac? What is the most serious toxicity of this ingestion/exposure? Immediately remove the child from the garage and into an area with fresh air. Remove the childs clothing and rinse him in the shower. Do not give ipecac syrup or anything to induce vomiting. If the boy becomes drowsy, nonresponsive, experiences seizures, or has difficulty breathing, call 911. Otherwise, the parents can cause Poison Control and follow instructions given to them by the representative 2. A two-year-old boy is brought to the Emergency Department in a coma after his mother found him limp and unresponsive in his room. What questions would you want to ask the mother to help learn why this patient might be unresponsive? What was the child doing in his room before you found him? Does the child have any medical conditions? Does the child have access to any of his parents medications or other household items that could have caused him to become nonresponsive? Is the child taking any medications currently? Have the child been sick or acting unusual lately? 3. You receive a phone call from the mother of a 2-year-old child who was found eating the mother's prenatal vitamins. She thinks he may have swallowed 16 tablets. What is the toxic component of prenatal vitamins (if taken in excess)? What advice would you give the mother? Iron, if taken in excess, is a toxic component of prenatal vitamins. We should tell the mother to bring the child into the ER immediately

4. After a fight with her boyfriend, a sixteen-year-old girl takes 30 acetaminophen tablets. She presents to the emergency department six hours later when she is feeling nauseated. What is the appropriate management of this adolescent? We should perform immediate intervention to ensure that the patient is breathing and has adequate vital signs. We should then obtain blood plasma levels of acetaminophen. The minimal toxic dose for an adolescent is 7.5g to 10.0g. Next, we would need to plot the plasma level in the Rumack-Matthews nomogram to determine the patients risk for hepatotoxicity. If the patients risk for hepatotoxicity falls above the possible hepatotoxicity line on the nomogram, N-acetylcysteine (NAC) should be administered. NAC should also be administered if the patient was known to have consumed more than 7.5g to 10.0g of acetaminophen 5. A three-year-old is brought to the Emergency Department because of weakness, diarrhea, and drooling. He had been playing unsupervised in the garage. He is found to have pinpoint pupils and bradycardia. What is the most likely cause of these symptoms and how should the patient be treated? The most likely cause of these symptoms is organophosphate ingestion. The patient should be treated with atropine for the muscarinic symptoms (initial dose 0.02-0.05mg/kg IV) and pralidoxime for the nicotinic symptoms (initial dose 20-5- mg/kg IV). Supportive care is also important 6. A three-year-old child is seen in the clinic because of irritability, decreased appetite and intermittent abdominal pain. He has developmental delay and mild anemia. How would you evaluate and manage this child? I highly suspect that this three year old has lead poisoning because the symptoms are very characteristic of lead poisoning and this is how to approach the patient. A careful history should be obtained from the families of all children suspected of toxic lead exposure. The history should include: Onset and severity of symptoms of toxicity Nutritional history with particular attention to intake of iron and calcium History of pica Family history of lead poisoning Foreign birthplace and recent foreign residence Assessment of potential sources of lead exposure: work history of the parents and other significant caregivers, hobbies, age of the home and history of home renovations, source of water supply, location and condition of play areas, use of imported or glazed ceramics, and proximity to industrial facilities or hazardous waste sites. Physical examination The physical examination should assess the possible neurologic consequences of lead toxicity: language development and neurobehavioral function must be included. Lethargy is particularly concerning because it indicates encephalopathy. Lead lines, at the junction of the teeth and gums, are rarely seen. If present, they usually indicate severe and prolonged lead exposure Laboratory evaluation Lead levels The laboratory evaluation of the child with lead poisoning should include a repeat BLL to confirm the diagnosis. BLLs also should be obtained in the patient's siblings, housemates, and/or playmates. Confirmatory samples should be obtained through venous sampling and processed in leadfree collection tubes. Once diagnosis is made, treatment varies depending on the BLL and if patient is symptomatic or not. If asymptomatic, therapy could involve simple investigation of the childs environment, outpatient chelation or immediate hospitalization. Admission to the hospital, stabilization and chelation are appropriate therapy for symptomatic patients. Chelation in an asymptomatic patient is with CaEDTA (IM) or more commonly oral 2,3DMSA a succimer. 7. Parents bring a 12-month-old girl for a routine health care supervision visit. What guidance would you give them so as to minimize the likelihood of an accidental poisoning occurring in the house? Properly educating parents to use childproof medication containers, to store toxic substances in locked cabinets, and to label toxic chemicals properly is necessary for preventing ingestions. Kerosene and other

toxic liquids should not be stored in soda pop bottles, and children should not come in contact with clothing exposed to pesticides. Old or unused medications should be discarded, and currently used medications should not be left on table-tops or in the mothers purse. Avoid taking medications in front of children. Call medicine by correct names, never call it candy. Take extra care during stressful times such as vacations, or moving. Anticipate guidance and have numbers for Poison Control handy 8. A two year old girl is brought to the Emergency Room after ingesting an unknown quantity and type of her grandmother's pills. What findings in the physical exam will help to identify the type of pills? What resources are available to help identify and treat the ingestion? Findings in physical exam that would help identify causative agents are level of consciousness, pupillary size, presence of muscle fasciculations, bowel and bladder activity, cardiac arrhythmias, seizures, or hypothermia, breath odor, auscultation of lungs, skin color and fever. Resources that would be of help are toxin-drug assays, measurement of arterial blood gases and electrolytes, osmoles and glucose; calculation of anion or osmolar gap, a full 12-lead ECG, urine drug screen, liver function tests, CBC, x ray Pediatric Emergencies 1. A three-year-old child presents to the Emergency Department with acute onset of stridor and tachypnea. Discuss your approach to this patient, including important aspects of the history and physical exam, the differential diagnosis, and management principles On initial presentation, especially in patients with acute onset of symptoms, immediately assess the child for severity of stridor and respiratory compromise. Give special attention to the heart and respiratory rates, cyanosis, use of accessory muscles of respiration, nasal flaring, level of consciousness, and responsiveness. This childs good health just prior to the developing symptoms suggests foreign body aspiration or anaphylactic responses to an allergen. A carefully obtained history describing the childs state just prior to the onset of symptoms and a complete review of systems often is key to making the correct diagnosis. If distress is moderate to severe, further physical examination should be deferred until the patient reaches a facility equipped for emergent management of the pediatric airway. Physical examination of a patient with suspected acute epiglottitis is contraindicated. Note if patient prefers certain positions that alleviate the stridor. Use care when examining (especially palpating) the oral cavity or pharynx because sudden dislodgement of a foreign body or rupture of an abscess can cause further airway compromise. Drooling from the mouth suggests poor handling of secretions. Observe the character of the cough, cry, and voice. The presence of fever and toxicity generally implies serious bacterial infections. Careful auscultation of the nose, oropharynx, neck, and chest helps to discern the location of the stridor. Differential diagnosis for a child with stridor and tachypnea are divided into infectious and noninfectious etiologies. See table below Infections Noninfectious Acute laryngotracheobronchitis Foreign body aspiration Epiglottis Angioneurotic edema Pharyngitis Spasmodic croup Parapharyngeal abscess Ingestion of caustic or hot fluid Bacterial tracheitis Trauma, smoke inhalation Laryngopharyngeal diphtheria Laryngomalacia Laryngeal papillomatosis Congenital subglottic stenosis Management: for this child it seems it is a foreign body aspiration so the childs airway should be evaluated with rigid bronchoscopy, which is diagnostic and therapeutic. IV access should be established for administration of maintenance fluids and sedation for the procedure; the child should be NPO until the respiratory distress resolves. Oxygen saturation should be monitored closely 2. A four-month-old baby presents to the Emergency Department with a fever of 104 F and petechiae. What is your differential diagnosis? How would you evaluate and manage this patient?

Differential diagnoses are Viruses: Atypical measles, congenital rubella, congenital CMV, Enterovirus, parvovirus B19, HIV, Hemorrhagic fever viruses. Bacteria: (Sepsis: Meningococcal, gonococcal, pneumococcal, Hib), infective endocarditis, Ecthyma gangrenosum (Pseudomonas aeruginosa). Rickettsiae: Rocky Mountain spotted fever, Epidemic typhus, Ehrlichiosis. Fungi: Necrotic eschar (Aspergillus, Mucor) Others: Vasculitis, thrombocytopenia, HSP, Malaria. This is the meningococcal guideline: IV antibiotics should be given as soon as possible whenever meningococcal disease is suspected (im, or intraosseous, if iv access can not be obtained). Blood cultures should preferably be taken before the antibiotics are given. If this will lead to a delay of more than 5 minutes, then give antibiotics immediately. Cefotaxime or ceftriaxone are the first choice antibiotics (at RCH use cefotaxime). If unavailable, use benzyl penicillin. Other bacteriological investigations can be useful if collected early but should not delay antibiotic therapy A systematic approach is crucial for establishing a timely diagnosis, determining early therapy when appropriate, and considering isolation of the patient if necessary. Epidemiologic clues are important to pursue such as: Age of the patient Season of the year Travel history Geographic location Exposures including to insects, animals, and ill contacts Medications Immunizations and history of childhood illnesses The immune status of the host Features of the rash are also important to consider, including: Characteristics of the lesions Distribution and progression of the rash Timing of the onset in relation to fever Change in morphology, such as papules to vesicles or petechiae 3. A three-year-old boy presents to the Emergency Department with worsening cough, wheezing and shortness of breath. He has difficulty talking in the Emergency Department. How would you manage this child? After deep and careful thinking over this question, I gave up and refer you to the answer to question 1, they seem very similar. It also looks like foreign object aspiration 4. A previously healthy fourteen-month-old presents to the Emergency Department following 2-3 minutes of generalized, symmetric tonic-clonic movements. Discuss your approach to the following scenarios: (a) The child was sleepy initially but is now awake, alert, and easily consoled by her parents. Her temperature is 104 F The child probably had a febrile seizure event. Get a good history; ask if there is a positive family history of such seizures, if this was the first one or not, if there was any aura preceding the seizure. The child was well before the event, the seizure lasted < 10-15 minutes, and her sleepy state is the brief postictal period so these characteristics define the typical type of febrile seizure. Determine the cause of fever and rule out meningitis. No routine lab, EEG, neuroimaging is required. Control fever and reassure parents that there is no increased risk of epilepsy. (b) The child remains somnolent and appears to have nuchal rigidity? This child needs to be evaluated for presence of meningitis as seizures and nuchal rigidity are signs of meningitis. A careful history which includes course of illness, recent respiratory or ear infection, penetrating trauma or head injury, travel to an area with endemic meningococcal disease, and

immunization record. The physical examination should include vital signs, general appearance, presence of meningeal signs, neurologic and cutaneous examination. Head circumference should be measured in a child < 18months as in this case. Lab work includes two sets of blood cultures, PT, PTT, CBC with differential and platelet count, serum electrolytes, BUN, creatinine and glucose. Finally a lumbar puncture should be performed to obtain CSF 5. A four-year-old boy presents with brief loss of consciousness and vomiting after falling off a six-foot high slide. How would you evaluate him and what are your concerns? Assess the ABCs, assess for altered mental status, fractures or bleeding. Some concerns include concussion, epidural hemorrhage, subdural hemorrhage. The diagnosis of either of these can be confirmed with a CT scan 6. The mother of an 18-month-old calls to say her child has pulled splattered hot tea across his face and chest. How would you counsel her? Counsel the mother to immediately remove clothing from the burned areas, run cool (not cold) water over the burn until the pain lessens. Do not put any ointments, butter or other remedies on the burn as they can exacerbate the burns even more. Ibuprofen or acetaminophen may help with the pain 7. A four-year-old girl is brought to the Emergency Department following the acute onset of cough, increased work of breathing, and tachypnea while at a friend's birthday party. What is your differential diagnosis? How would you evaluate and manage this patient? DDx foreign body inhalation, asthma, bronchiolitis, pneumonia Evaluation - Determine the history of the coughs duration, frequency, character, and precipitating factors; then examine the patient. A chest x-ray may be warranted. Management Foreign body rigid bronchoscopy Asthma breathing treatment with beta-agonist Bronchiolitis supportive therapy, control of fever, good hydration, upper airway suctioning, O2 administration Pneumonia supportive and specific treatment, i.e. empirical antibiotic treatment 8. During a routine health care visit, a fifteen-year old girl with a history of depression confides to you that she would like to end her life. What should you do? Assess if she has a plan to carry out, assessing the risk level of actually attempting suicide. Options for immediate evaluation include hospitalization, transfer to an emergency department, or an appointment the same day with a mental health professional 9. A nine-month old boy presents with lethargy. What historical and physical examination findings will help you determine if he has overwhelming sepsis, meningitis, congestive heart failure, or respiratory insufficiency? Overwhelming sepsis - hypothermia or fever, tachycardia, tachypnea or hypocapnia, organ dysfunction, hypoperfusion, hypotension Meningitis in infants symptoms are nonspecific; thermal instatbility, poor feeding, emesis, seizures, irritability, and apnea, may also be hypertonic or hypotonic. In older children typical presentation consist of fever, headache, and nuchal rigidity CHF tachycardia, hepatomegaly, decreased urinary output, and worsening respiratory distress; chest xray show pulmonary congestion and may reveal cardiomegaly Respiratory insufficiency tachypnea, grunting, use of accessory muscles, tachycardia, hypertension, lethargic, irritable, anxious, may look cyanotic on general appearance 10. A mother rushes a 4-month old girl to the emergency department following finding her cyanotic in her crib. Her examination is normal. How would you evaluate this infant and counsel the mother? The evaluation of the infant with an ALTE begins with a careful history of the event, the circumstances surrounding the event, and any observations made by the care-giver, as well as the resuscitative measures used. Check for vital signs, including HR, RR, O2% and BP. Watch patient carefully and look for signs of neurologic deficit. Abdominal findings and any sign of trauma or bruising also should be noted. Laboratory and imaging studies should be performed on the basis of the history and physical examination.

Instruct the family about providing immediate care in the home and determine if the child should be brought in right away for evaluation. At home, if gentle stimulation fails to arouse the child, the caretaker should try more vigorous stimulation and provide CPR if necessary. Also educate the family about ways to prevent SIDS. Child Abuse 1. A four-year-old male presents to the clinic because of a sore throat for two days. During the physical examination, patterned bruises (including looped shaped marks) on his back and arms are seen. How would you evaluate and manage this patient. What would you tell the parents? Question the parent/caregiver about the marks on the child. Look for other signs that would indicate physical abuse like older, faded marks, which would indicate a pattern of behavior. Pay careful attention to the childs demeanor with the parent or caretaker looking especially for ear, watchfulness, passivity or if the child is withdrawn. Look for signs with the parent such a conflicting, unconvincing explanation or no explanation for the child's injury. Report the incidence and findings to CPS for follow-up. Explain to the parents why an inflicted injury is suspected, that the M.D. is legally obligated to report the findings, that the referral is made to protect the child, that the family will be provided with services and that a CPS worker and law enforcement worker will be involved. 2. A two-year-old presents to the emergency department after breaking her arm during a fall. The child was seen six months ago with a broken leg. What are your concerns? How would you evaluate this child? Concerns: Physical abuse, Childhood illnesses that can cause broken bones ( tumors, accidental injury, metabolic bone disease, skeletal dysplasia (including osteogenesis imperfecta [OI]), infection, drug toxicity, and congenital insensitivity to pain. A careful history and physical examination, in conjunction with additional laboratory tests or radiographic studies, if indicated, usually can lead to the proper diagnosis. Take an extensive history. Look for other signs of abuse such as fading or other fresh bruises. Question the parent or caretaker about the series of events which led to the broken leg being mindful to look out for conflicting or unconvincing explanations. 3. A seven-year-old female patient presents with vaginal discharge. How would you approach the history and physical exam? In addition to poor hygiene, what else is in the differential diagnosis? The best procedure is to generate an extensive differential diagnosis list, progress through a careful workup to exclude the diagnostic options, and, eventually, arrive at a diagnosis. Normal physiologic clearwhite mucoid discharge (ie, leukorrhea) should be differentiated from pathologic discharges. Differential diagnoses are as follows: Local irritation from abusive sexual contact, foreign body, chemical irritants, and restrictive clothing Infections, including STDs, fungal infections, nonspecific vulvovaginitis, group A streptococci, Staphylococcus aureus, Haemophilus influenzae, and Mycoplasma species Physiologic leukorrhea Structural abnormality, such as ectopic ureter, fistula, and draining pelvic abscess If sexual abuse suspected look for other signs such as anogenital bruising, anogenital redness, and genital bleeding. Also, obtain additional cultures with samples from the pharynx and rectum. 4. An eight-year-old male with urethral discharge grows N. gonorrhea from a urethral culture. What medical, legal, and social issues should you address? The American Academy of Pediatrics (AAP) views nonvertically transmitted gonorrhea as diagnostic of sexual abuse in the prepubertal child. Child protection and welfare considerations o Safety of the child from further sexual abuse is of the highest priority. Notification to statutory authority (CPS) vested with the legal responsibility of ensuring the safety of children, to investigate the report is necessary to ensure the protection and safety of the child. Legal considerations o Child sexual abuse is a crime. Since children do not have the capacity to consent to sexual contact, any person engaging in sexual activity with a child has committed an offence. Clinicians have a legal

obligation to report the suspicions and to preserve all records and laboratory results as possible future legal evidence. Investigation by police and charges being laid are possible following a report. Medical Officers who receive a report and/or provide medical examination may be called to provide expert opinion on medical findings in criminal proceedings. Medical care and follow-up concerns o Physical trauma and medical needs, such as concerns about sexually transmitted diseases and pregnancy must be addressed. Fears about permanent damage following sexual abuse need to be assessed and the child and non-offending parent reassured. Therapeutic and support considerations o Psychological/emotional impact on the child and non-offending parent needs to be considered and referral to specialist services where available should be offered. The disclosure of child sexual abuse often precipitates a crisis for which immediate counseling and support is strongly recommended. This counseling addresses practical issues, emotional impact and concerns, information and support through legal proceedings if necessary. 5. A two-month-old boy presents with lethargy and is poorly responsive. He has retinal hemorrhages. What are your ethical and legal obligations? To whom would you report your findings? What would you say to the boy's parents? Retinal hemorrhages in the absence of overt trauma or a bleeding disorder is pathognomic of shaken baby syndrome. Ethical and legal obligation is to take a careful history from parents/caretakers to determine series of events that led to findings. Then report findings to CPS. Explain to the parents why an inflicted injury is suspected, that the M.D. is legally obligated to report the findings, that the referral is made to protect the child, that the family will be provided with services and that a CPS worker and law enforcement worker will be involved. 6. A nine-month-old boy has a history of poor weight gain for several months. His weight has fallen from the 50% to the 10% over the past four months. During a hospitalization for poor weight gain, he had a normal physical examination; normal laboratory values, and demonstrated excellent weight gain on an age-appropriate diet. Now one month following discharge from the hospital he has lost weight. What would you do for this child? Discuss the medical, legal, and social implications of your actions. Suspect child neglect. Question parent/caretakers about diet of child at home. Alert CPS. 7. An eighteen-month-old infant presents with scald burns to the buttocks and legs. The parents report the child "turned on the hot water tap while playing in the bathtub." How would you differentiate an accidental burn from an inflicted burn? An inflicted burn leaves a "stocking" appearance on the feet and ankles without splash marks; it spares flexion creases. Depending on the size of the child, the feet and lower legs are burned, the flexed knees are spared, and the buttocks and genitals are burned with distinct lines of demarcation. Another frequent pattern occurs when the submerged skin of the buttocks is spared by coming in contact with the bottom of the tub, giving a "doughnut" pattern. In this case, the groin may be spared if the thighs are held together. Neither of these patterns is consistent with a child accidentally falling into a tub of water or turning on a hot water faucet. "Stocking" and "glove" burns are circumferential injuries to the distal aspect of the extremity that have a clear line of demarcation separating the uniformly burned area; such injuries are pathognomonic of abuse. Child Advocacy 1. A child is seen in the pediatric clinic for vomiting. On further questioning you find that the family is homeless and living in a car. Describe how you would approach helping the family. Discuss how you would treat the child's acute and ongoing medical needs. In order to initiate help for the family I would first interview the parent/adult and try to ascertain information about the circumstances that led to them becoming homeless. I would make sure that the parent/guardian knew that they had the option to enroll their child in the school district that they were living in when they became homeless or in the district where they temporarily reside. Educating the family about the myriad of social services (those providing housing, health care and substance abuse

treatment) available to those who are homeless, from both public and private sources, would be the next step. I would treat the child for dehydration and start him/her on maintenance fluids for treatment of the dehydration likely to be associated with the vomiting. For the childs long term health care needs I would refer the family to a facility that offers affordable or free treatment to homeless citizens. 2. Certain neighborhoods in the city are noted to have high infant mortality rates. If you were the health officer how would you go about addressing this problem? The first thing that I would do is examine the available statistics/data to determine the various causes of infant mortality and address them in order of high to low. Due to the fact that these children are living in a city lead poisoning is a very real possibility. I would test paint and dust from a random sampling of homes in the affected neighborhoods for lead. If these tests revealed higher that acceptable levels I would make the recommendation that expectant mothers should limit their exposure to this environment if at all possible. If a large scale environmental clean up wasnt immediately possible to remove sources of lead I would educate the community about preventive measures such as creating physical barriers between play/living areas and lead sources such as chipping paint. I would also encourage frequent washing of childrens hands and toys as well as frequent mopping of any wood floors and wet wiping of window components to reduce lead exposure from dust. If lead was not the problem I would examine other potential sources of toxins such as the local water supply or any industrial businesses in close proximity to the community. 3. Severe head injuries and death are associated with bicycle riding. How would you go about promoting helmet use by children? At every well child visit I would suggest asking about bicycle riding habits and encourage helmet use in those who dont use the already as well as praising parents and children who use helmets already and encouraging continued use. I would also educate parents to the very real possibility of a serious head injury if helmets are not used on a consistent basis by their children 4. A nine-year old boy with learning disabilities and poor school performance is seen in the clinic. How would you work with the school to increase the likelihood that he gets the services that he needs? I would work with the school and the parents to assess the patients level of disability in various subjects and to identify exactly at which level the patient has developed to. I would compare the teachers assessment with the parental assessment to ascertain if there are social or behavioral issues in addition to the learning disability that were a factor in the poor school performance. I would assess the need for intervention on a subject-by-subject basis in order to allow the child to remain with his classmates as much as possible. In the areas that the child was deficient in, I would have him/her placed in the schools special education or remedial education program 5. You live in a small town and note that many children have dental caries. You find out that the water supply is not fluoridated. How would you proceed? My first step would be to contact the local department of public health and department of water and attempt to convince them that adding fluoride to the local water supply was a very important issue and that it needed to be done immediately. I would also encourage all primary care doctors as well as all local dentists to recommend that all of their patients and patients families use toothpaste that contained fluoride in order to reduce the risk of dental caries 6. You are working in the Emergency Room and note that over a one-month rotation three infants have been injured in baby walkers. What would you do? After treating the infants for their injuries I would discuss with their parents the dangers of using baby walkers before discharge of their child and encourage them to not return to doing so. I would also attempt to educate expectant mothers to the dangers of walkers during their prenatal care in order to hopefully reduce the use of walkers in general 7. The clinic in which you work has a very low immunization rate among the patients. What would you do to improve these immunization rates? In order to improve immunization rates among patients I would implement a patient reminder system. Upon visiting the clinic I would inform all patients or their guardians of the next time that they were scheduled for vaccinations and encourage them to make a follow up appointment before leaving. I would also call the patients one week prior to their appointments to confirm that they are coming and to remind

them of the importance of keeping up with their vaccinations and ensuring that they dont contract a preventable illness