Stu Silverstein, MD, Attending Physician, Department of Pediatric Emergency Medicine, Nyack Hospital, Nyack, NY
1. A 17-year-old boy has been despondent and withdrawn ever since he was turned down during an audition for "American Idol," when he was told that the "only thing he should entertain was getting out of entertainment" by a smug judge with a brush-cut dark shirt and matching hairstyle. In taking a history, which of the following would be the least important factor to consider when assessing his risk for suicide?
A. Access to his father's .38 caliber revolver
C. His being black
E. Media coverage of a recent suicide
2. Which of the following statements is true regarding varicella-zoster immune globulin (VZIG)?
A. From 70% to 90% of adults who do not have a reliable (ie, documented) history of varicella (also known as chicken pox) are not immune to varicella and are at high risk if exposed to the disease
B. VZIG is effective in preventing varicella infection if given within 7 days of exposure to the virusC. VZIG should be given to newborns when the mother develops varicella 2 days before or 5 days after delivery
E. Bone marrow transplant patients should be given VZIG after exposure if they have no history of varicella
3. A patient presents with a rash that you diagnose as erythema migrans. It would be very embarrassing to fall into the "cephalosporin-generation gap." What would be the best-generation cephalosporin to treat the cause of this rash?
4. Which of the following conditions is an absolute contraindication for the use of an oral contraceptive pill?
A. Migraine headaches with focal neurologic signs
C. Sexually transmitted infection
E. Thyroid disorders
5. What would be the best first-line approach to management in preventing exacerbations in patients with chronic asthma?
A. Repeated visits to the emergency department at 3 AM
C. Anti-immunoglobulin (Ig) E
E. Cromolyn sodium (Intal)
6. A 13-year-old girl appears at your office at 5:05 PM for a 3:30 PM appointment scheduled for the day before. Her mother tells you that the girl has been limping for a couple of weeks and has much knee pain. She has been afebrile, does not recall being hit in the knee or leg, and has not had any illnesses recently. She has difficulty "moving her leg inward." Given the late hour and that the workup will be done in the emergency department, you impress the pediatric emergency department staff by telling them that the most likely diagnosis is one of the following:
A. She twisted the leg trying to be on time for the appointment yesterday
C. Septic arthritis of the knee
E. Slipped capital femoral epiphysis
7. A 3-year-old girl presents with a temperature of 100.2?F and severe ear pain. "She gets these all the time," the parents tell you, "and Dr Treetemall always gives us the pink medicine and sometimes the white fruity one." The child is alert, with some discomfort, nasal congestion, and slight cough. Her tympanic membranes are red, with positive movement on insufflation. The tympanogram does show a peaked curve. What would be the most appropriate treatment?
A. Myringotomy for positive identification and treatment
E. Amoxicillin/potassium clavulanate (Augmentin)
8. A 16-week-old afebrile infant presents with a runny nose and cough for the past 2 to 3 days. Physical examination shows that the infant has intercostal retractions and bilateral rales, with a respiratory rate of 52 breaths/min and a heart rate of 128 beats/min. You order a chest x-ray, which shows diffuse infiltrates. The delivery was normal and spontaneous at full term. How did the infant most likely acquire this infection?
A. In your office during the routine 2-week visit
C. During the birth process
E. By airborne infection
9. A 9-year-old boy in your practice has demonstrated the following pattern on the growth curve:
Age (yr) Height percentile 6 60th7 40th
The parents are of average height, and the physical examination is otherwise unremarkable. You are concerned that hyperthyroidism could be the underlying cause. What would be the most helpful test(s) to order?
C. Thyroid technetium scan
E. T4 and free triiodothyronine
10. You are in your office late one cold winter evening, seeing a pair of siblings who have a cold and cough. The mother and paternal grandmother are there. The grandmother notes that the best way to prevent the spread of colds is by wearing a wool hat at all times. What should you say?
A. Agree and pull out a cartoon with the trademarked hats promoting your practice
C. Limiting exposure to other children to once weekly would help
E. Isolating all children with colds is the best method ANSWERS 1 - C. Black youngsters have lower suicide rates than whites, and the lowest rate for adolescents is in black girls. The highest rates are in Native American adolescent boys. Access to firearms is considered an important risk factor for suicide. Firearms are seen more frequently in the homes of suicide victims than in the general population. Restricting a depressed teenager's access to firearms in the home is important. The same would apply to access to prescription medications, especially sedatives, such as benzodiazepines. The risk for suicide as well as for depression and anxiety is increased when a teenager is exposed to or hears about a suicide. Therefore, media coverage of a suicide would indeed increase risk. References American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 1998; 37(suppl):63S-83S; 2001; 40(suppl):24S-51S.
Laughing Your Way to Passing the Pediatric Boards
2 - D. Preterm infants younger than 28 weeks should be given VZIG if exposed, regardless of the mother's immune status. Likewise, bone marrow transplant patients should receive VZIG, regardless of their immune status. VZIG is effective when given within 4 days, not 7 days, of exposure, and 70% to 90% of adults with no reliable history of varicella actually are immune.1 They either had a mild case, or the scars that are typically seen on the skin were eclipsed by other scars. Choice C is actually reversed; VZIG should be given to newborns when the mother develops varicella 5 days before or 2 days after delivery. As pointed out in ,2 this can easily be remembered by the mnemonic, "varicella," with the Roman numeral V being first and "ll" coming later in the word. Now you will never be confused when given these 2 choices.
1. English R. Varicella. 2003;24:372-379.
Laughing Your Way to Passing the Pediatric Boards.
2. Silverstein S. Stamford, Conn: Medhumor Medical Publications; 2005.
3 - C. Erythema migrans is associated with Lyme disease, and the best treatment would be ceftriaxone sodium (Rocephin), which is a third-generation cephalosporin. Ceftriaxone is effective against the offending agent, Borrelia burgdorferi, which I believe might also be the name of an offensive cheap cologne. Ceftriaxone treats the carditis, meningitis, encephalitis, and recurrent arthritis associated with Lyme disease. Reference Klein NC, Cunha BA. Third-generation cephalosporins. Med Clin North Am. 1995;79:705-719.
4 - A. Migraine headache with focal neurologic signs is the only absolute contraindication for the use of oral contraceptive pills. Epilepsy, sexually transmitted infection, and an undiagnosed breast mass are not considered absolute contraindications. However, breast cancer is a contraindication. One often-overlooked contraindication is pregnancy. Therefore, oral contraceptives cannot be started until pregnancy is ruled out. This could result in you getting a question wrong if you overlook this obvious fact.
ACOG Practice Bulletin No. 18.
American College of Obstetricians and Gynecologists. The use of hormonal contraception in women with coexisting medical conditions. July 2000:1-14.
5 - D. Inhaled corticosteroids are the most effective agents for managing chronic asthma. Because of fears of chronic steroid use among patients as well as among physicians, these agents are probably not used enough. This makes for a classic board examination question capitalizing on misconceptions. Inhaled corticosteroids are more effective than leukotriene inhibitors and cromolyn sodium. Anti-IgE is in the domain of researchers with pen protectors in their pockets and will not likely be included on any board examination soon. Although repeated visits to the emergency department at 3 AM is the treatment of choice of many unfortunate patients, it is not the best choice. Reference National Asthma Education and Prevention Program Expert Panel. Guidelines for the Diagnosis and Management of Asthma - Update on Selected Topics 2002. Available at www.nhlbi.nih.gov/guidelines/asthma/index.htm. Accessed March 30, 2005.
6 - E. Slipped capital femoral epiphysis typically presents in girls aged 11 to 13 years and boys aged 13 to 15 years who are obese. It is most common in blacks. Although a slipped capital femoral epiphysis can produce pain localized to the groin area, it often presents as knee pain, especially on the board examination. Internal rotation is difficult. If you were to suggest an x-ray, anteroposterior and frog lateral x-rays of the pelvis would be the way to go.
J Bone Joint Surg Am
Loder RT, Richards BS, Shapiro PS, et al. Acute slipped capital epiphysis: the importance of physeal stability. . 1993;75A:1134-1140.
7 - C. The clinical vignette described is typical of myringitis, or inflammation of the tympanic membrane, but not of otitis media (OM). Therefore, antibiotic treatment would not be indicated. In OM, there would be blunting of the curve on tympanogram, and insufflation would reveal decreased mobility. In addition, with OM we would expect a more toxic-looking child. Decongestants or antihistamines have no proven value in treating myringitis or OM. Acetaminophen will help alleviate the pain. Reference Siegel RM, Kiely M, Bien JP, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. 2003;112:527-531.
8 - C. To answer this question correctly, you must first make the correct diagnosis: . The keys to diagnosis are that this young infant is afebrile, with bilateral rales, and diffuse infiltrates. In addition, the age of 16 weeks is the classic period for to present in the newborn. If you spell "sixteen" as "cixteen" to remember that "C" is for chlamydia, it might serve you well on the examination. Also note that, on the board examination, you will be provided with vital signs and laboratory values. When you note a respiratory rate of 54 breaths/min, it is important to write the word "tachypnea" in the margin to help jog your memory. Once you make the correct diagnosis you can answer the question correctly. This infection is acquired during passage in the birth canal.
Chlamydia (Chlamydophila) pneumoniae
Red Book: 2003 Report of the Committee on Infectious Diseases
American Academy of Pediatrics. . In: Pickering LK, ed. . 26th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2003:235-237.
9 - D. An elevated TSH level would suggest a diagnosis of hypothyroidism. The addition of a free (ie, unbound, biologically active) T4 determination would provide definitive results on which treatment should be based. Total T4 levels can be influenced by factors that can affect thyroxine-binding protein levels. For example, inherited thyroxine-binding globulin deficiency or excess can cause high or low T4 values, when in actuality the biologically active free T4 level may be normal.
10 - D. Hand washing and cleaning toys that are shared by children are the most effective means of preventing the spread of colds and upper respiratory tract infections during winter. If wearing a hat during cold weather prevented the spread of colds, then children in warm climates, such as south Florida, would never get sick.