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  #1  
Old 07-19-2016
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Default Help pls CMS Peds Form 4

Please state reasoning of answer and thank you in advance!

1. A previously healthy 17*-year*-old girl is brought to the emergency department 40 minutes after being stabbed in the left side of her chest with a pair of scissors. En route to the hospital, intravenous lactated Ringer solution was administered, and administration of oxygen (3 L/min) via face mask was begun. On arrival, she has severe chest pain. She is agitated and diaphoretic and is not oriented to person, place, or time. Her temperature is
37.2C (99F), pulse is 128/min, respirations are 32/min and labored, and palpable systolic blood pressure is 80 mm Hg. Examination shows jugular venous distention bilaterally. The trachea is deviated to the right. Breath sounds are decreased on the left with hyperresonance to percussion. Which of the following is the most appropriate initial step in management?

A) Chest x*ray
B) Insertion of an oropharyngeal airway (WRONG)
C) Needle decompression
D) Pericardiocentesis
E) Cricothyroidotomy
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Answer is C Needle Decompression. ABCs first, EXCEPT in Respiratory Distress following Chest trauma. Main priority is Breathing and relief of pneumothorax prior to endotracheal intubation.
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A 3*-year-*old boy is brought to the physician for a follow*up examination 2 weeks after being treated for an ear infection. He has had recurrent ear infections, sinusitis, and two episodes of bacterial pneumonia since birth. Over the past year, he has undergone placement of two sets of tympanostomy tubes for otitis media. His mother is HIV negative. He currently takes no medications. He is at the 25th percentile for height and weight. Examination shows no abnormalities except for small anterior cervical lymph nodes. Which of the following is the most likely mechanism of disease?

A) Antibody deficiency
B) Impaired chemotaxis
C) Impaired respiratory burst
D) Splenic dysfunction
E) T-*lymphocyte dysfunction
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3. A 6*-hour-*old female newborn has had cyanosis of her arms and legs since birth. She was born at 38 weeks' gestation following an uncomplicated pregnancy and cesarean delivery for breech presentation. She weighed 3090 g (6 lb 13 oz) at birth. She has been breast-feeding well. She is alert and is not in acute distress. Her rectal temperature is 36.2C (97.2F), pulse is 112/min, respirations are 36/min, and blood pressure is 80/45 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows cyanosis of the upper and lower extremities but no circumoral cyanosis. Cardiopulmonary examination shows no abnormalities. Capillary refill time is mildly delayed. Which of the following is the most appropriate next step in management?

A) Placement of the newborn under warming lights
B) Blood culture
C) Chest x-*ray
D) Echocardiography
E) Intubation and mechanical ventilation
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Old 07-20-2016
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4. An otherwise asymptomatic 4*-week*-old boy is brought to the physician because of increasing jaundice for 1 week. He was born at term following a prolonged labor. One day after birth, he received phototherapy for jaundice and was discharged on the third day. He is exclusively breast*fed. Examination shows no abnormalities except for jaundice. Laboratory studies show a hemoglobin concentration of 12 g/dL with normal red cell morphology, and a total serum bilirubin concentration of 12 mg/dL with a direct component of 8 mg/dL. Which of the following is the most likely underlying mechanism of this patient's jaundice?

A) Decreased biliary excretion
B) Decreased hepatic glucuronosyltransferase activity
C) Decreased hepatic Y and Z protein concentrations
D) Decreased serum bilirubin uptake
E) Increased serum bilirubin production
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  #6  
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Quote:
Originally Posted by doc2530 View Post
A 3*-year-*old boy is brought to the physician for a follow*up examination 2 weeks after being treated for an ear infection. He has had recurrent ear infections, sinusitis, and two episodes of bacterial pneumonia since birth. Over the past year, he has undergone placement of two sets of tympanostomy tubes for otitis media. His mother is HIV negative. He currently takes no medications. He is at the 25th percentile for height and weight. Examination shows no abnormalities except for small anterior cervical lymph nodes. Which of the following is the most likely mechanism of disease?

A) Antibody deficiency
B) Impaired chemotaxis
C) Impaired respiratory burst
D) Splenic dysfunction
E) T-*lymphocyte dysfunction
A. Recurrent bacterial and sinopulmonary infections = defective humoral immunity (low IgA)
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  #7  
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Quote:
Originally Posted by doc2530 View Post
3. A 6*-hour-*old female newborn has had cyanosis of her arms and legs since birth. She was born at 38 weeks' gestation following an uncomplicated pregnancy and cesarean delivery for breech presentation. She weighed 3090 g (6 lb 13 oz) at birth. She has been breast-feeding well. She is alert and is not in acute distress. Her rectal temperature is 36.2C (97.2F), pulse is 112/min, respirations are 36/min, and blood pressure is 80/45 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows cyanosis of the upper and lower extremities but no circumoral cyanosis. Cardiopulmonary examination shows no abnormalities. Capillary refill time is mildly delayed. Which of the following is the most appropriate next step in management?

A) Placement of the newborn under warming lights
B) Blood culture
C) Chest x-*ray
D) Echocardiography
E) Intubation and mechanical ventilation
A. Acrocyanosis is common in newborns
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  #8  
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Originally Posted by doc2530 View Post
4. An otherwise asymptomatic 4*-week*-old boy is brought to the physician because of increasing jaundice for 1 week. He was born at term following a prolonged labor. One day after birth, he received phototherapy for jaundice and was discharged on the third day. He is exclusively breast*fed. Examination shows no abnormalities except for jaundice. Laboratory studies show a hemoglobin concentration of 12 g/dL with normal red cell morphology, and a total serum bilirubin concentration of 12 mg/dL with a direct component of 8 mg/dL. Which of the following is the most likely underlying mechanism of this patient's jaundice?

A) Decreased biliary excretion
B) Decreased hepatic glucuronosyltransferase activity
C) Decreased hepatic Y and Z protein concentrations
D) Decreased serum bilirubin uptake
E) Increased serum bilirubin production
A. Conjugated hyperbilirubinemia = defective clearance of bilirubin
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5. A healthy 9*-month-*old girl is brought to the physician by her parents for a well*-child examination. Her parents are concerned that she is not gaining enough weight. She is breast*feeding six times daily and taking small amounts of baby food from a spoon. She is at the 5th percentile for weight and 25th percentile for length and head circumference. Review of the growth chart shows that this growth pattern has been consistent since birth. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A) Reassurance that this growth pattern is within normal limits
B) Increasing caloric intake by adding more baby food (WRONG)
C) Replacing breast*feeding with soy*based formula
D) Supplementing breast*feeding with whole cow milk
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6. A 5-*year-*old boy is brought to the physician for a well*-child examination. He is active and has been healthy except for an episode of otitis media 3 weeks ago treated with amoxicillin. His parents emigrated from Vietnam. His diet consists mainly of fruits and vegetables; he occasionally eats fish and chicken but no red meat. Examination shows no abnormalities. Laboratory studies show:
Hemoglobin 10 g/dL
Mean corpuscular volume 64 μm3
Leukocyte count 6100/mm3
Platelet count 225,000/mm3
Red cell distribution width 10% (N=13%15%)

A blood smear is shown (http://imgur.com/a/tES3u). Which of the following is the most likely explanation for this patient's anemia?
A) Antibiotic*induced autoimmune hemolysis
B) Decreased synthesis of globin chains
C) Iron deficiency (WRONG)
D) Transient postinfectious bone marrow suppression
E) Vitamin B12 (cobalamin) deficiency
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  #11  
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Originally Posted by doc2530 View Post
6. A 5-*year-*old boy is brought to the physician for a well*-child examination. He is active and has been healthy except for an episode of otitis media 3 weeks ago treated with amoxicillin. His parents emigrated from Vietnam. His diet consists mainly of fruits and vegetables; he occasionally eats fish and chicken but no red meat. Examination shows no abnormalities. Laboratory studies show:
Hemoglobin 10 g/dL
Mean corpuscular volume 64 μm3
Leukocyte count 6100/mm3
Platelet count 225,000/mm3
Red cell distribution width 10% (N=13%15%)

A blood smear is shown (http://imgur.com/a/tES3u). Which of the following is the most likely explanation for this patient's anemia?
A) Antibiotic*induced autoimmune hemolysis
B) Decreased synthesis of globin chains
C) Iron deficiency (WRONG)
D) Transient postinfectious bone marrow suppression
E) Vitamin B12 (cobalamin) deficiency
B. Its not iron deficiency as Fe deficiency is associated with increased RDW. Microcytic anemia with normal RDW and target cells on smear = thalassemia
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  #12  
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Originally Posted by doc2530 View Post
5. A healthy 9*-month-*old girl is brought to the physician by her parents for a well*-child examination. Her parents are concerned that she is not gaining enough weight. She is breast*feeding six times daily and taking small amounts of baby food from a spoon. She is at the 5th percentile for weight and 25th percentile for length and head circumference. Review of the growth chart shows that this growth pattern has been consistent since birth. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A) Reassurance that this growth pattern is within normal limits
B) Increasing caloric intake by adding more baby food (WRONG)
C) Replacing breast*feeding with soy*based formula
D) Supplementing breast*feeding with whole cow milk
C? Not 100% sure but got this by ruling out other options. Cow milk is not started till 1 yr, its certainly not normal growth pattern, increasing caloric intake may be useful in PEM but not something that is going on since birth. Cannot make out the Dx but think its either lactose intolerance or breast mill protein allergy.
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  #13  
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Originally Posted by saxo View Post
C? Not 100% sure but got this by ruling out other options. Cow milk is not started till 1 yr, its certainly not normal growth pattern, increasing caloric intake may be useful in PEM but not something that is going on since birth. Cannot make out the Dx but think its either lactose intolerance or breast mill protein allergy.
@Saxo Uptodate calls Pathologic Failure to Thrive as less then 2nd Percentile for gestation corrected age-sex apparently, so maybe the answer is A?
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A 10-*day*-old male newborn is admitted to the hospital for treatment of indirect hyperbilirubinemia due to isoimmune hemolysis. He is placed in a room with a 2*-month*-old female infant with dehydration secondary to rotavirus gastroenteritis. Two days later, he develops vomiting and diarrhea, and a stool specimen is positive for rotavirus antigen. This nosocomial infection is most likely caused by failure of caregivers to do which of the following?

A) Dispose of diapers and other waste items properly
B) Observe gown and glove precautions (WRONG)
C) Observe hand*washing techniques
D) Place the patients in a reverse airflow room
E) Restrict visitors to the room
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8. An 8*-year*-old girl is brought to the physician because of a 3*day history of fever, progressive cough, and sputum production. Examination at birth showed no abnormalities, but she has a history of respiratory problems since infancy. Her temperature is 37.5C (99.5F), pulse is 100/min, and respirations are 32/min. Pulse oximetry on room air shows an oxygen saturation of 84%. Examination shows clubbing, circumoral cyanosis, and a hyperexpanded chest. There are diffuse rhonchi bilaterally with end*expiratory wheezing. An x*ray of the chest shows hyperinflation, scattered atelectasis, and chronic interstitial changes.

A) Asthma
B) Bronchopulmonary dysplasia
C) Congenital heart disease with right*-to*-left shunt
D) Cystic fibrosis
E) Hypertrophic cardiomyopathy
F) Idiopathic pulmonary hypertension
G) Methemoglobinemia
H) Patent Foramen Ovale
I) Persistent pulmonary hypertension
J) Pneumococcal pneumonia
K) Respiratory distress syndrome
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  #16  
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Originally Posted by doc2530 View Post
@Saxo Uptodate calls Pathologic Failure to Thrive as less then 2nd Percentile for gestation corrected age-sex apparently, so maybe the answer is A?
Maybe. But I don't know. For something that looks like failure to thrive since birth, just reassurance does not seem like a good option.
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  #17  
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D. pneumonia + respiratory problems since infancy + clubbing, cyanosis + hyperinflation = most likely CF
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9. A 13-*year-*old girl with cystic fibrosis is brought to the physician because of a 6-*month history of progressive difficulty breathing. Her mother says that her daughter's hands and feet have appeared swollen during this period. Her temperature is 37C (98.6F), pulse is 98/min, respirations are 30/min, and blood pressure is 124/84 mm Hg. Examination shows dusky nail beds and clubbing of the fingers and toes. There is nasal flaring and moderate intercostal retractions. Bilateral crackles and rhonchi are heard on auscultation. S2 is loud and split in the second left intercostal space. The liver edge is palpated 5 cm below the right costal margin, and the spleen tip is palpated 1 cm below the left costal margin. There is bilateral pitting edema over the dorsum of the hands and feet. Laboratory studies show:
Serum
Na+126 mEq/L
Cl 84 mEq/L
K+ 4.1 mEq/L
HCO336 mEq/L
Albumin 2.8 g/dL

Urine protein 1+

Pulmonary function tests show a decrease in forced vital capacity from 75% to 30% of predicted value over the past year. An x-*ray of the chest shows marked hyperinflation with coarse nodular infiltrates bilaterally. Which of the following is the most likely explanation for this patient's edema?

A) Cirrhosis of the liver
B) Cor pulmonale
C) Inferior vena cava obstruction
D) Lymphedema
E) Nephrotic syndrome
F) Protein*losing enteropathy
G) Vitamin E deficiency
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Quote:
Originally Posted by doc2530 View Post
A 10-*day*-old male newborn is admitted to the hospital for treatment of indirect hyperbilirubinemia due to isoimmune hemolysis. He is placed in a room with a 2*-month*-old female infant with dehydration secondary to rotavirus gastroenteritis. Two days later, he develops vomiting and diarrhea, and a stool specimen is positive for rotavirus antigen. This nosocomial infection is most likely caused by failure of caregivers to do which of the following?

A) Dispose of diapers and other waste items properly
B) Observe gown and glove precautions (WRONG)
C) Observe hand*washing techniques
D) Place the patients in a reverse airflow room
E) Restrict visitors to the room
C. hand washing decreases spread
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  #20  
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Quote:
Originally Posted by doc2530 View Post
9. A 13-*year-*old girl with cystic fibrosis is brought to the physician because of a 6-*month history of progressive difficulty breathing. Her mother says that her daughter's hands and feet have appeared swollen during this period. Her temperature is 37C (98.6F), pulse is 98/min, respirations are 30/min, and blood pressure is 124/84 mm Hg. Examination shows dusky nail beds and clubbing of the fingers and toes. There is nasal flaring and moderate intercostal retractions. Bilateral crackles and rhonchi are heard on auscultation. S2 is loud and split in the second left intercostal space. The liver edge is palpated 5 cm below the right costal margin, and the spleen tip is palpated 1 cm below the left costal margin. There is bilateral pitting edema over the dorsum of the hands and feet. Laboratory studies show:
Serum
Na+126 mEq/L
Cl 84 mEq/L
K+ 4.1 mEq/L
HCO336 mEq/L
Albumin 2.8 g/dL

Urine protein 1+

Pulmonary function tests show a decrease in forced vital capacity from 75% to 30% of predicted value over the past year. An x-*ray of the chest shows marked hyperinflation with coarse nodular infiltrates bilaterally. Which of the following is the most likely explanation for this patient's edema?

A) Cirrhosis of the liver
B) Cor pulmonale
C) Inferior vena cava obstruction
D) Lymphedema
E) Nephrotic syndrome
F) Protein*losing enteropathy
G) Vitamin E deficiency
B. Interstitial lung disease + loud P2 (from pulmonary HTN) + evidence of Rt heart failure = cor pulmonale
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  #21  
Old 09-07-2016
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Correct Answer Answer to 9-month-old girl

Quote:
5. A healthy 9*-month-*old girl is brought to the physician by her parents for a well*-child examination. Her parents are concerned that she is not gaining enough weight. She is breast*feeding six times daily and taking small amounts of baby food from a spoon. She is at the 5th percentile for weight and 25th percentile for length and head circumference. Review of the growth chart shows that this growth pattern has been consistent since birth. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A) Reassurance that this growth pattern is within normal limits
B) Increasing caloric intake by adding more baby food (WRONG)
C) Replacing breast*feeding with soy*based formula
D) Supplementing breast*feeding with whole cow milk
The correct answer is A, reassurance (know for certain b/c it didn't show up on my wrongs). The child has an unusual pattern but it's been the same since birth--shifts in the overall pattern are most concerning in a child. If she's gaining properly and hitting her milestones, she's probably okay.
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