MAIS CASOS PARA DIAGNÓSTICO...

Case Challenges" From Pediatric Annals
A 16-year-old Boy with Hepatosplenomegaly
Published in Pediatric Annals October 2009
A 16-year-old boy, a new immigrant from Ethiopia, was referred for investigation of hepatosplenomegaly. Past medical history was unremarkable ex... more
A 3-day-old Boy with Acute Flaccid Paralysis
Published in Pediatric Annals September 2009
A 3-day-old male newborn presented to the emergency room with poor sucking, constipation, decreased urination, weak cry, decreased activity, and labor... more
A 5-year-old Girl with Scarring
Published in Pediatric Annals July 2009
A 5-year-old black girl was brought to our pediatric dermatology clinic by her foster mother after referral from the emergency room for the evaluat... more
A 6-week-old Boy with Apnea and Abdominal Distention
Published in Pediatric Annals May 2009
A 6-week-old boy in respiratory distress presented to the Emergency Department via ambulance. Earlier that day, he woke from his nap screaming and ... more
A 14-year-old Boy with Pain in Hands and Feet
Published in Pediatric Annals April 2009
A 14-year-old boy was referred for evaluation of pain in his hands and feet. The pain was intermittent, described as an intense “burning” sensat... more
An 11-year-old Boy with Ankle Trauma
Published in Pediatric Annals March 2009
An 11-year-old boy first presented to his physician following ankle trauma. At that time, radiographs of the ankle revealed no acute osseous inj... more
A 2-month-old Girl with an Enlarging Lesion of the Nasal Root
Published in Pediatric Annals February 2009
A 2-month-old, otherwise healthy white girl presented with an enlarging lesion of the nasal root, slightly to the right of midline. The lesion was fir... more
A 10-year-old Girl with Abdominal Pain
Published in Pediatric Annals January 2009
A 10-year-old girl presented to the emergency department with a 3-day history of intermittent abdominal pain. The pain was initially described as “dul... more
An Unusual Sore Throat
Published in Pediatric Annals December 2008
A previously healthy 15-year-old Hispanic boy presented to the emergency room with a history of fever and sore throat. Both symptoms began 4 days prio... more
A 7-year-old Girl with a Pruritic Facial Eruption
Published in Pediatric Annals November 2008
Editor’s note: Each month, this department features a discussion of an unusual diagnosis in genetics, radiology, or dermatology. A description and ima... more
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QUAL O SEU DIAGNÓSTICO?

http://www.pediatricsupersite.com/section.aspx?sid=190


"Spot the Rash" From Infectious Diseases in Children
13-year-old girl with lesion on scalp
Published in Infectious Diseases in Children September 2009
A 13-year-old girl presents to your clinic stating that the mole behind her ear extending into her scalp is changing. She states the lesion has b... more
12-year-old boy admitted for febrile illness
Published in Infectious Diseases in Children August 2009
A previously healthy 12-year-old boy is admitted to the inpatient ward in mid-July for evaluation of a febrile illness. He had a rapid onset of fev... more
6-week-old girl with a facial rash
Published in Infectious Diseases in Children July 2009
A 6-week-old girl presents to your clinic with a facial rash. Her mother reports that the lesions developed about three weeks ago and appear to be ... more
A 6-year-old boy with black spots
Published in Infectious Diseases in Children June 2009
A 6-year-old boy was referred to rule out melanoma when he developed an asymptomatic “black dot” on the left tragus present for two days.... more
A 5-year-old with rash on extremities and trunk
Published in Infectious Diseases in Children April 2009
A 5-year-old boy presents to your clinic with an asymptomatic rash involving his extremities and trunk for three days (Figure 1). Further history ... more
A 4-year-old with foot laceration
Published in Infectious Diseases in Children March 2009
A previously healthy 4-year-old girl presented to our clinic to be evaluated for a possible infection after injuring herself at the beach. ... more
An 18-month-old boy with erythematous eruption
Published in Infectious Diseases in Children February 2009
An 18-month-old healthy black boy presented to your office with a three-week history of an erythematous, edematous eruption, which began around his el... more
A 2.5-year-old girl with an annular plaque
Published in Infectious Diseases in Children December 2008
A 2.5-year-old girl presented to the clinic complaining of a skin colored annular plaque on her right arm. Her mother reported it had been present f... more
A 34-week-old boy with skin lesions
Published in Infectious Diseases in Children November 2008
A boy, gestational aged 34 weeks and 4 days, was born at an outlying hospital and transferred to the neonatal intensive care unit for evaluation of ex... more
A 9-year-old boy with pruritic lesions
Published in Infectious Diseases in Children October 2008
A 9-year-old healthy boy presented to the clinic complaining of a three-day history of several moderately pruritic lesions on his lower legs. This was... more
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CME Activities
Managing Special Healthcare Needs Pediatric Annals, September 2009Screening and Testing: Genetics Pediatric Annals, August 2009Pediatric Immunization: Meeting the Challenges of the 21ST Century Infectious Diseases in Children, August 2009 Pediatric Annals, October 2008
Allergy
Pediatric Annals, September 2008
School Emergency
Pediatric Annals, August 2008
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Infectious Diseases in Children, July 2008 -->View more CME


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COVER STORY
Respiratory diagnostics tested as pandemic evolves
Rapid diagnostic testing is an evolving area of medicine that enables physicians to diagnose within hours, sometimes minutes, the condition of their patients.Full Story
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Vaccine-Preventable Diseases
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Dermatology
Emerging Diseases
Allergy, Asthma & Immunology
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Developmental and Behavioral Medicine
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Meeting Highlights
In the Journals
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Infectious Diseases in Children
Pediatric Annals
Rotavirus Resource Center
Rotavirus and Red Book 2009: An interview with Larry K. Pickering, MD, editor
Physician supports the processes of the CDC and the AAP that lead to the recommendations in the Red Book for immunization practices in general and for rotavirus in particular.Click here

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IMAGENS PARA DIAGNOSTICO...

"Spot the Rash" From Infectious Diseases in Children
13-year-old girl with lesion on scalp
Published in Infectious Diseases in Children September 2009
A 13-year-old girl presents to your clinic stating that the mole behind her ear extending into her scalp is changing. She states the lesion has b... more
12-year-old boy admitted for febrile illness
Published in Infectious Diseases in Children August 2009
A previously healthy 12-year-old boy is admitted to the inpatient ward in mid-July for evaluation of a febrile illness. He had a rapid onset of fev... more
6-week-old girl with a facial rash
Published in Infectious Diseases in Children July 2009
A 6-week-old girl presents to your clinic with a facial rash. Her mother reports that the lesions developed about three weeks ago and appear to be ... more
A 6-year-old boy with black spots
Published in Infectious Diseases in Children June 2009
A 6-year-old boy was referred to rule out melanoma when he developed an asymptomatic “black dot” on the left tragus present for two days.... more
A 5-year-old with rash on extremities and trunk
Published in Infectious Diseases in Children April 2009
A 5-year-old boy presents to your clinic with an asymptomatic rash involving his extremities and trunk for three days (Figure 1). Further history ... more
A 4-year-old with foot laceration
Published in Infectious Diseases in Children March 2009
A previously healthy 4-year-old girl presented to our clinic to be evaluated for a possible infection after injuring herself at the beach. ... more
An 18-month-old boy with erythematous eruption
Published in Infectious Diseases in Children February 2009
An 18-month-old healthy black boy presented to your office with a three-week history of an erythematous, edematous eruption, which began around his el... more
A 2.5-year-old girl with an annular plaque
Published in Infectious Diseases in Children December 2008
A 2.5-year-old girl presented to the clinic complaining of a skin colored annular plaque on her right arm. Her mother reported it had been present f... more
A 34-week-old boy with skin lesions
Published in Infectious Diseases in Children November 2008
A boy, gestational aged 34 weeks and 4 days, was born at an outlying hospital and transferred to the neonatal intensive care unit for evaluation of ex... more
A 9-year-old boy with pruritic lesions
Published in Infectious Diseases in Children October 2008
A 9-year-old healthy boy presented to the clinic complaining of a three-day history of several moderately pruritic lesions on his lower legs. This was... more
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http://http://www.pediatricsupersite.com/section.aspx?sid=190

LUPUS ERITEMATOSO NEONATAL

6-week-old girl with a facial rash
By Marissa Perman, MD
A 6-week-old girl presents to your clinic with a facial rash.
Her mother reports that the lesions developed about three weeks ago and appear to be expanding. She thought it was “ringworm” and used an antifungal cream twice a day that she had in the home. She has not seen any improvement with this therapy. This is her first child, and her pregnancy was uncomplicated. On exam, you note that the infant is well appearing and alert. Involving the forehead, temples and cheeks are a few ill-defined erythematous annular scaling patches and thin plaques. The rest of her exam is unremarkable.

The patient had a few ill-defined erythematous annular scaling patches and thin plaques on her forehead, temples and cheeks.
Photo courtesy of Anita P. Sheth

What is your diagnosis?
The diagnosis is neonatal lupus erythematosus.
Neonatal lupus erythematosus (NLE) is an uncommon condition usually associated with maternal anti-Ro (anti-SSA) autoantibodies. If the mother has no diagnosis or symptoms, her serologic autoimmunity may be indicative of systemic lupus erythematosis. Sjogren syndrome or other connective tissue disorders are often not detected until after the birth of the child. The disease is believed to be caused by maternal antibodies that pass through the placenta to the fetal circulation. In 95% of cases, the maternal antibodies are anti-Ro autoantibodies, a minority have U1-RNP autoantibodies.These antibodies gradually disappear in the child in the second half of the first year of life.

Marissa L. Perman
Cutaneous lesions typically present within the first several weeks of life but may be present at birth. They may be precipitated by exposure to small amounts of sunlight and are one of the most common manifestations of NLE. Annular erythematous, finely scaling macules, patches, papules and plaques are often found on the scalp and face. These lesions can often be confused with tinea corporis due to the scale and annular configuration. In addition, many infants may have confluent erythema in a periorbital distribution leading to an “eye mask” appearance. Other skin findings that can be seen include scaly atrophic patches, telangiectasias and discoid plaques. Sunlight is well known to exacerbate established or trigger new lesions, consistent with other types of cutaneous lupus.
The histopathology of cutaneous lesions in NLE is consistent with subacute cutaneous lupus seen in older patients and includes a lymphocytic infiltrate at the dermal-epidermal junction associated with damaged keratinocytes throughout the epidermis. There is also a mild to moderate perivascular lymphocytic infiltrate in the papillary dermis.
About one-third of children have extracutaneous manifestations of NLE. Several organ systems can be involved, although single organ involvement is the most likely finding. Cardiac involvement is the most severe and includes third-degree heart block and cardiomyopathy. Third-degree heart block usually develops during the second trimester and once established is irreversible leading to cardiomyopathy in some cases. Pacemaker placement is often required. The mortality rate of cardiac neonatal lupus is approximately 20%. This is due to anti-Ro autoantibodies binding to fetal, but not adult, cardiac myoctes and injuring the conducting system.
In addition, hepatobiliary and hematologic manifestations may be seen. Roughly 10% of children have hepatobiliary disease, along with cutaneous and cardiac manifestations. The three most common findings include liver failure consistent with neonatal hemochromatosis, cholestasis with conjugated hyperbilirubinemia and/or transient, mild to moderate transaminase elevations all typically occurring within the first several weeks after birth. Hematologic findings include most commonly thrombocytopenia followed by neutropenia, anemia or pancytopenia.
The workup in a patient with lesions suggesting NLE includes a complete physical exam, CBC with differential, liver enzymes, anti-nuclear antibody (ANA), anti-Ro (anti-SSA), anti-La (anti-SSB) and anti-U1RNP autoantibodies. If the infant has bradycardia or a murmur, an electrocardiogram and echocardiogram are indicated. The mother should also have ANA, anti-Ro, anti-La and anti-U1RNP autoantibodies evaluated. If these studies are positive, the mother should be referred for further autoimmune workup.
The course of the cutaneous lesions is usually complete spontaneous resolution by 6-12 months of age, although telangectasias may persist. The lesions may also resolve with atrophy, dyspigmentation or scarring. Sunlight exposure should be avoided, and sun protection with sun blocks and protective clothing should be used when UV exposure is unavoidable. Topical anti-inflammatory agents such as steroids have not been shown to change the course of the skin lesions of NLE.
There is some evidence that children exposed to anti-Ro autoantibodies in utero may be at risk later in childhood or adult life for developing systemic lupus, but the level of that risk is unclear. There is also a genetic risk. Asymptomatic mothers of children with NLE tend to develop signs and symptoms of autoimmunity with time. They should be counseled regarding the risk of NLE with subsequent pregnancies: The risk for future children developing NLE born to mothers with one affected child is 22%. Prevention of NLE in anti-Ro positive mothers is being studied. Treatment during pregnancy using betamethasone or dexamethasone has not been definitively shown to change outcome. IVIG therapy is now being reviewed.
Marissa L. Perman is a first-year dermatolology resident at the University of Cincinnati.
For more information:
Izmirly PM, Rivera TL, Buyon JP. Neonatal lupus syndromes. Rheum Dis Clin North Am. 2007 May;33(2):267-85, vi.
Lee LA. The clinical spectrum of neonatal lupus. Arch Dermatol Res. 2009 Jan;301(1):107-10.
Paller, Amy S, and Mancini, Anthony J. Hurwitz. Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence. Philadelphia: Elsevier, 2006; pp 581-3.
Weston WL, Morelli JG, Lee LA. The clinical spectrum of anti-Ro-positive cutaneous neonatal lupus erythematosus. J Am Acad Dermatol. 1999;40 (5 Pt 1): 675-681.

RESPOSTAS DOS TESTES DE CONHECIMENTOS...

Módulo I -1-b, 2-b, 3-d, 4-a
Módulo II- 1-c, 2-a, 3-d, 4-c
Módulo III- 1-a, 2-d, 3-a, 4-c
Módulo IV- 1-b,2-c,3-d, 4-b
Módulo V - 1-c, 2-d,3-a, 4-c
Módulo VI- 1-c, 2-a, 3-d, 4-c
Módulo VII- 1-b, 2-b, 3-d, 4-c
Módulo VIII- 1-a, 2-c, 3-b, 4-b
Módulo IX - 1-b, 2-d, 3-c, 4-e
Módulo X - 1-d, 2-a, 3-c, 4-b
Módulo XI- 1-c, 2-c, 3-d, 4-d
Módulo XII- 1-a, 2-c, 3-d, 4-b
Módulo XIII- 1-c, 2-c,3-d, 4-d
Módulo XIV- 1-d, 2-d, 3-a, 4-a
Módulo XV- 1-b, 2-e, 3-d, 4-a
Módulo XVI- 1-e, 2-?, 3-d,4-d
Módulo XVII- 1-d, 2-e, 3-a, 4-e
Módulo XVIII- 1-d, 2-c, 3-c,4-c
Módulo XIX- 1-d, 2-a, 3-a, 4-d
Módulo XX- 1-a, 2-a, 3-e,4-e
Módulo XXI- 1-a, 2-a, 3-a,4-e
Módulo XXII- 1-d, 2-c, 3-a,4-e

TESTE SEUS CONHECIMENTOS DE APLS ON LINE

CME Questions -modulo I

1: A 2-month-old presents to the ED with a temperature of 40°C. He is irritable but in no obvious distress. The triage nurse should consider this patient to be which of the following?
A: Level II triage, and place in an examination room to see the physicianB: Level II triage, and requires immediate medical attentionC: Level III triage, and place in the waiting roomD: Level IV triage, and place in the waiting room
2: Which of the following statements regarding a child-friendly examination room is correct?
A: Is generally not necessary in a busy EDB: Involves both décor and safety-proofing the roomC: Means having toys in the roomD: Requires placing children in a separate part of the ED
3: All EDs in the United States:
A: Admit children to pediatric wardsB: Have appropriate equipment and supplies for pediatricsC: Transfer all pediatric patients when necessary for higher levels of careD: None of the above
4: A 2-year-old girl has choked on a small rubber ball. When the paramedics arrive, she has no pulse and is not breathing. Hospital A has an ED and a small inpatient pediatric ward and is 2 minutes away. Hospital B has an ED, a large inpatient pediatric ward, and a neonatal ICU and is 6 minutes away. The child should be transported to:
A: A tertiary pediatric hospital by helicopterB: Hospital AC: Hospital BD: The hospital that the parents choose

CME Questions -modulo II

1: All of the following are components of the PAT except:
A: AppearanceB: Circulation to the skinC: Heart rateD: Work of breathing
2: Abnormalities in which of the following components of the PAT indicate a decompensated shock state?
A: Appearance and circulation to the skinB: Appearance and work of breathingC: Circulation to skinD: Work of breathing and circulation to skin
3: All of the following are signs to assess for shock except:
A: Effortless tachypnea, hyperpneaB: InteractivenessC: Pulse qualityD: Work of breathing
4: You are about to assess an 8-month-old boy. Based on his developmental level, which of the following techniques would be helpful?
A: Do your assessment from a standing positionB: Examine head to toeC: Offer distractionsD: Separate infant and mother

CME Questions -modulo III

1: Which newborn anatomic structure closes at birth or shortly thereafter to help with the transition from the intrauterine to the extrauterine environment?
A: Coronary sinusB: Ductus arteriosusC: Pulmonary arteryD: Ventricular septum
2: Which of the following statements regarding shock is correct?
A: Decompensated shock, by definition, exists when the blood pressure is elevatedB: First determined by the evaluation of capillary refill timeC: Fluid resuscitation is a priority in managementD: Most commonly manifests as cardiogenic–type shock in pediatric patients
3: Which of the following drugs can be a lifesaver in a newborn with congestive heart failure secondary to closure of the ductus arteriosus?
A: DigoxinB: DopamineC: FurosemideD: Prostaglandin E1
4: All of the following are reversible causes of dysrhythmia except:
A: Calcium channel blocker overdoseB: HypochloremiaC: HypovolemiaD: Hypoxemia

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© American Academy of Pediatrics, American

CME Questions -modulo IV

1: A child presents to the ED with lethargy after consuming 3 oz of his mother’s perfume. Which of the following is the most helpful bedside test for the evaluation of this patient’s altered mental status?
A: HemoglobinB: Serum electrolytesC: Serum glucoseD: Toxicology screen
2: Of the following options, which is the best method for acutely lowering increased intracranial pressure?
A: HyperoxygenationB: Intravenous steroidsC: Midline positioning of the neckD: Mild hyperventilation
3: All of the following are common complications of bacterial meningitis except:
A: Acute renal failureB: SeizuresC: SIADHD: Subdural effusion
4: All of the following are criteria of simple febrile seizures except:
A: Age 6 months to 5 yearsB: Associated with no neurologic deficitC: Fever greater than 40°CD: Last less than 15 minutes

CME Questions-modulo V

1: All of the following are associated with increased risk of cerebral edema in a child with diabetic ketoacidosis (DKA) except:
A: High BUN concentration at presentationB: High serum glucose concentration at presentationC: Low PCO2 at presentation D: Treatment with sodium bicarbonate
2: All of the following are clues to the presence of adrenal insufficiency except:
A: Acanthosis nigricansB: Ambiguous genitaliaC: HyperpigmentationD: Midline facial defects and microphallus
3: Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) should be treated with which of the following?
A: Administration of 3% saline if the sodium concentration is <130 mEq/LB: Administration of hydrocortisoneC: Administration of oral sodium and/or normal salineD: Fluid restriction unless the patient is seizing or severely lethargic/comatose 4: Which of the following statements regarding hypernatremia in patients with diabetes insipidis (DI) is correct? A: Never occurs in infants with DI because of high fluid intakeB: Occurs in all patients with DIC: Rare in older children with DI and normal thirst mechanismsD: Should be treated with 3% sodium chloride solution
CME Questions -modulo VI

1: The diagnosis of hypothermia is dependent on: A: Absence of an underlying metabolic conditionB: Core temperature less than 35°CC: Documented drop in basal metabolismD: Presence of J wave on ECG 2: Paramedics bring a 15-year-old girl to the ED. She had fallen into a frozen lake during an ice skating party and was in the water for an unknown period of time. CPR was administered on scene. On arrival to the ED, she is unresponsive. Which of the following is the best indicator that she is likely to survive? A: She has a high blood alcohol levelB: She has return of spontaneous circulation after 10 minutes of ACLS interventionsC: She is found to be mildly hypothermicD: Survival cannot be predicted 3: An 8-month-old is found abandoned in a dumpster on a cool fall evening. He is brought by police to the ED. On examination, the infant is lethargic with poor tone. The pulse is 60, the respiratory rate is 10, and the temperature is 30°C. There are no signs of trauma. Which of the following methods is the best way to rewarm this patient? A: Forced air rewarming deviceB: Warm blankets plus heat lampsC: Warm humidified O2 by ET tubeD: Warmed oxygen by ET tube plus IV fluids heated to 40°C 4: Which of the following differentiates coral snake envenomations from pit viper envenomations? A: Degree of pain and edemaB: Response to antivenin therapyC: Signs of neurologic involvementD: Small number of patients who require antivenin therapy var valid = new Validation('aspnetForm');
CME Questions-modulo VII
1: Activated charcoal will adsorb all of the following medications except: A: Ferrous sulfateB: PhenobarbitalC: SalicylatesD: TheophyllineE: Verapamil 2: A high anion gap metabolic acidosis would be anticipated in all of the following toxic ingestions except: A: Ethylene glycolB: IronC: IsopropanolD: MethanolE: Salicylates 3: A comatose adolescent patient with an acute exposure to an unknown toxin should receive all of the following therapeutic interventions except: A: DextroseB: FlumazenilC: Intravenous normal saline solutionD: NaloxoneE: Oxygen 4: A mother brings her 2-month-old daughter to the ED to be checked for carbon monoxide poisoning because their detector had sounded. The infant has normal vital signs and is sleeping. The mother complains of a headache. While waiting for the blood gas results, you place both mom and infant on 100% oxygen. Assuming the levels are slightly elevated (10), an appropriate amount of time on 100% oxygen for treatment would be: A: 15 to 30 minutesB: 60 to 90 minutesC: 180 minutesD: 240 minutes
CME Questions -modulo VIII
1: Which of the following would preclude clinical clearance of the cervical spine in a child or adolescent? A: Age of 9 yearsB: Altered level of consciousnessC: Asymptomatic and nontender abdomen with 10 RBCs/hpf on urinalysisD: Low-speed bicycle crashE: Superficial abrasions on both lower extremities 2: You are resuscitating a 3-year-old girl who was rescued from a burning house. She has singed nasal hairs and eyebrows, a history of impaired mentation when first discovered, and has had a dry cough since transport to your ED. You arrange transfer to the nearest burn center, which is 45 minutes away. The child is now awake, alert, and irritable and has an O2 saturation of 90% on a 40% FIO2 nonrebreather mask. She is hoarse, and the initial carboxyhemoglobin is 15%. You should: A: Administer 100% oxygen en routeB: Alert the transport crew to the possible need for intubation during transportC: Ask the local otolaryngologist to perform a bronchoscopy prior to transportD: Intubate the patient using RSI technique before transportE: Sedate the patient, and perform laryngoscopy to evaluate the vocal cords 3: The target PaCO2 for initial management of pediatric traumatic brain injury is: A: 15 torrB: 25 torrC: 35 torrD: 45 torrE: Does not matter 4: Surgical evaluation is necessary for which of the following trauma patients? A: Child who has evidence of visceral disruptionB: Child who is not hemodynamically stableC: Child who needs surgical managementD: Child whose injury mechanism or initial clinical findings suggest internal organ system derangementE: All of the above
CME Questions-modulo IX
1: When assessing the history of a traumatic injury, which of the following factors should raise concern about inflicted trauma? A: History is inconsistent with the development level of the childB: Injury is alleged to have been inflicted by a young siblingC: Minor mishap has resulted in a major injuryD: All of the above 2: Which of the following etiologies is the most common cause of death from inflicted trauma? A: Abusive head injuryB: BurnsC: Inflicted abdominal traumaD: Suffocation/strangulation 3: An infant with environmental failure to thrive will manifest any of the following findings except: A: Growth impairmentB: Impaired mother-infant interactionC: Skeletal dysplasiaD: Watchful, wary gaze 4: Which of the following presentations is consistent with Münchausen syndrome by proxy? A: Mother who administers Echinacea and goldenseal to her child for upper respiratory symptomsB: Mother who administers ipecac to her healthy child and complains about intractable vomitingC: Parents who refuse a blood transfusion for their hemorrhaging child because of their religious beliefsD: Parents who refuse to administer insulin to their child with diabetes because of their religious beliefs var valid = new Validation('aspnetForm'); CME Questions -módulo X
1: All of the following are classic findings and symptoms of intussusception except: A: Crampy, intermittent abdominal painB: “Currant jelly” stoolsC: HematemesisD: Vomiting 2: Pneumatosis intestinalis and portal vein gas can be viewed on all of the following imaging studies except: A: Abdominal CTB: Magnetic resonance imagingC: Nuclear medicine scanD: Plain film radiographsE: Ultrasonography 3: Which of the following complications of malrotation is the most serious? A: Bowel obstruction from compressing Ladd bandsB: Hypochloremic metabolic alkalosisC: Intermittent volvulusD: Midgut volvulusE: Sigmoid volvulus 4: All of the following are complications of Meckel diverticulum except: A: Diverticulum inflammation (diverticulitis)B: Ectopic gastritis and hemorrhageC: IntussusceptionD: Malrotation var valid = new Validation('aspnetForm');
CME Questions -modulo XI

1: Which of the following statements regarding Legg-Calvé-Perthes disease is correct?
A: Can be bilateralB: Classically presents in toddlersC: Generally seen in large, obese childrenD: Has no findings on x-ray
2: Which of the following statements regarding slipped capital femoral epiphysis (SCFE) is correct?
A: Most common in the early 20sB: Occurs when the femoral head slips anterior and superior relative to the femoral neckC: Often presents as knee painD: Treated nonsurgically
3: Which of the following statements regarding septic arthritis is correct?
A: Always yields bacterial growth from the synovial fluidB: Most common in teenagersC: Most commonly caused by N meningitidisD: Treated with joint drainage and intravenous antibiotics
4: Which of the following statements regarding children with Osgood-Schlatter disease is correct?
A: All have knee effusionsB: Have increased pain when they squat with the knee in full flexionC: Have increased pain when they squat with the knee in full flexionD: Usually play a lot of video games


CME Questions -modulo XII

1: Which of the following pathogens has been associated with aplastic crises in sickle cell disease?
A: E ColiB: KlebsiellaC: Parvovirus B19D: Salmonella typhimurium
2: Which of the following statements is correct?
A: Even when a patient has significant scrotal swelling, it is easy to differentiate between acute testicular torsion and epididymitisB: Patients with epididymitis rarely have normal urinalysis resultsC: Relief of pain with scrotal elevation is not a reliable sign in differentiating between testicular torsion and epididymitisD: Urethral discharge rarely indicates that a sexually transmitted disease is most likely responsible
3: An 8-month-old child is brought to the ED for evaluation of fever, vomiting, and listlessness. On examination, the infant is lethargic with a temperature of 103°F, a weak pulse of 160/min, a respiratory rate of 44/min, and cool, mottled extremities with a capillary refill time of 6 seconds. After evaluation of the ABCs, which of the following is the next step in management?
A: Attempt oral fluids with a rehydration solutionB: Give an intravenous normal saline bolus; if the WBC count is elevated, give parenteral antibioticsC: Obtain a blood culture, attempt a lumbar puncture, and then give parenteral antibioticsD: Obtain a blood culture, and then give an intravenous normal saline bolus and intravenous antibiotics
4: A 13-year-old girl is brought to the ED on hot summer morning after she passed out in church. According to bystanders, she was standing when she fainted. By the time the ambulance arrived, she was awake. She has no significant past medical history, and her physical exam is normal. Which of the following is the most likely etiology of her syncope?
A: Breath-holding spellB: DysrhythmiaC: SeizureD: Vasovagal



CME Questions -modulo XIII

1: A mother arrives at triage with a newly born infant that is wrapped in a blanket. He is mottled, limp, and has a heart rate of 80/min. Your first step should be:
A: Chest compressionsB: Intravenous accessC: Narcan administration IMD: Position the head and clear the airwayE: Positive pressure ventilation
2: A 15-year-old girl delivers a 34-week infant stained with meconium in the ED. The newly born infant is cyanotic with poor respiratory effort, and the pulse rate is 80/min. What is the first management priority?
A: Begin bag-mask ventilationB: Begin chest compressionsC: Insert umbilical vein catheterD: Suction the nose and mouth, and perform endotracheal suctioning
3: All of the following questions are part of the resuscitation-oriented history for a woman in labor except:
A: Do you abuse alcohol?B: Do you have twins?C: What color was the amniotic fluid?D: What is your due date?
4: A 3-day-old girl is brought to the ED by her mother with a complaint of constipation; she has not passed a stool since birth. All of the following diagnoses should be considered except:
A: Biliary atresiaB: Hirschsprung diseaseC: Hypoplastic left colonD: HypothyroidismE: Meconium plug syndrome


CME Questions-modulo XIV

1: What is the ASA classification for a 7-year-old child with occasional asthma relieved with PRN albuterol MDI puffs?
A: Class IB: Class IIC: Class IIID: Class IV
2: Which of the following agents would be a good choice for sedation of an alert and normally acting obese 9-month-old who rolled off a changing table and requires a CT scan for a possible head injury?
A: Chloral hydrate POB: Ketamine IMC: Methohexital PRD: Midazolam POE: All of the above
3: Discharge criteria following procedural sedation include:
A: 2 hours of observation after conclusion of procedureB: Return to baseline ambulation statusC: Return to baseline level of alertnessD: Return to baseline respiratory status
4: Which of the following is an advantage of the IM route of administering procedural sedation and analgesia?
A: Does not adversely affect NPO statusB: Facilitates patient-controlled analgesiaC: Facilitates titration of medicationsD: Lower probability of allergic reaction


CME Questions -modulo XV

1: All of the following definitions related to EMS are correct except:
A: Direct medical oversight—medical direction provided to paramedics by radio or telephone by a physician or nurseB: EMSC continuum of care—begins with prevention, moves through access, care, rehabilitation, and return to communityC: Indirect medical oversight—medical direction provided by written protocolD: Primary transport—transport from the scene to the EDE: Secondary transport—transport from the scene to an ICU
2: Which of the following statements regarding prehospital providers’ care of children is correct?
A: They are comfortable managing critically ill childrenB: They frequently provide assisted ventilation for childrenC: They frequently transport seriously ill or injured childrenD: They require frequent refreshing of pediatric knowledge and skills
3: All of the following treatments or services can be provided by an EMT-B except:
A: Assisted ventilationB: Cardiac compressionsC: ImmobilizationD: Manual defibrillationE: Patient transport
4: The role of the physician in EMS includes all of the following except:
A: Becoming familiar with local prehospital care providers, EDs, and transport servicesB: Emphasizing safety and injury preventionC: Maintaining office emergency preparedness and ED preparedness for childrenD: Providing funding for issues pertaining to EMSCE: Serving as a medical advisor to local EMS systems



CME Questions -modulo XVI

1: After a disaster, families should plan to be self-sufficient for:
A: 12 hoursB: 24 hoursC: 48 hoursD: 72 hours
2: Which of the following factors can precipitate problems for children with special health care needs after a disaster?
A: Inability to avoid allergensB: Lack of electricityC: Lack of refrigeration/cooling capabilitiesD: Stress and disruption in daily routinesE: All of the above
3: Which of the following statements regarding multicasualty triage is correct?
A: An objective triage system helps to optimize patient classification and resource allocationB: Children should automatically be given the highest triage prioritiesC: Responders should attempt to resuscitate all children in full cardiopulmonary arrest in a mass casualty incident settingD: Triage personnel should go to the most critical patients firstE: All of the above
4: Which of the following issues should be included in hospital disaster planning?
A: Command structure, such as Hospital Emergency Incident Command SystemB: Critical incident stress monitoring and servicesC: External disastersD: Internal disastersE: All of the above

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CME Questions -modulo XVII

1: A biological weapons attack would most likely resemble which of the following mass casualty emergencies?
A: EarthquakeB: Large bomb blastC: Release of chlorine from a train wreckD: Severe influenza epidemicE: Tornado
2: Which of the following syndromes is common to most of the high-threat biological agents?
A: Characteristic rashB: EncephalopathyC: Febrile prodromeD: PneumoniaE: Renal failure
3: Which of the following distinguishes botulism from other causes of paralysis?
A: HallucinationsB: High feverC: Intact sensationD: Normal bulbar functionE: Severe paresthesias
4: Which of the following patients poses the least potential hazard to health care providers?
A: Adolescent with untreated pneumonic plagueB: Asymptomatic adolescent with mustard agent on skinC: Child exposed to high doses of ionizing radiationD: Child with fever and extensive lesions of smallpoxE: Infant with nerve agent on clothing


CME Questions -modulo XVIII

1: What is the first step in managing a child with a tracheostomy tube and respiratory distress?
A: Assess colorB: Auscultate chestC: Remove trachesotomy tubeD: Suction tracheostomy tube
2: Which of the following can be used to clear a clogged gastrostomy tube?
A: Coca-Cola®B: Ginger aleC: Hydrogen peroxideD: PancreaseE: Pressure
3: All of the following statements regarding a central line are correct except:
A: A regular needle can be used to access an implanted portB: Commonly used tunneled central venous catheters in children include Broviac and Hickman; the distal ends rests outside the chest and can have 1 to 3 portsC: Implanted central vascular access ports have a distal end of the catheter, which consists of a reservoir covered with a self-healing rubber septumD: Tunneled central venous catheters are inserted surgically into a central vein, most commonly the subclavian, cephalic, or external jugular
4: Which of the following conditions is most likely to require a patient to have a tracheostomy?
A: BronchiolitisB: CroupC: Cystic fibrosisD: Tracheal stenosis


CME Questions-modulo XIX

1: All of the following are characteristics of an emancipated minor except:
A: College graduationB: High school graduationC: MarriedD: Military serviceE: Pregnancy
2: All of the following are valid reasons to transfer a child from Hospital A to Hospital B except:
A: Parents do not have insurance, and Hospital B is a county hospitalB: Parents request the transfer to be closer to their homeC: Parents request the transfer to obtain care from the child's pediatricianD: Required CT scan is available at Hospital B but not at Hospital AE: Required specialist is available at Hospital B but not at Hospital A
3: Which of the following statements regarding consent and confidentiality is correct?
A: Consent from a grandparent is always as legally valid as consent from a parentB: Court order is required to treat a child if a parent or guardian is not available for consentC: Filing a claim under a parent's medical insurance provides insufficient clinical detail to be considered a breach of confidentialityD: Parent or guardian consent is required before emergency care can be providedE: Under some circumstances, minors are able to consent for their own care
4: All of the following are considered to be routinely appropriate responsibilities for a physician after the death of a patient in the ED except:
A: Call in hospital social servicesB: Complete the death certificateC: Notify the medical examiner as required by lawD: Notify the organ donation service if required by lawE: Order complete postmortem imaging studies (body CT scan or skeletal survey) and additional blood tests

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CME Questions -modulo XX

1: Which of the following statements regarding a paronychia is correct?
A: Can be treated in the physician’s office or EDB: Deep space infection of the hands and feetC: Usually painlessD: Usually requires removal of the nail on the affected digit
2: Which of the following statements regarding paraphimosis is correct?
A: Associated with a phimotic ring of the foreskinB: Can be reduced electivelyC: PainlessD: Should be reduced only by a urologistE: Usually seen as part of a febrile illness
3: As a guide for estimating burn size, a child’s palm is approximately what percentage of the total body surface area?
A: 1%B: 3%C: 5%D: 7%
4: Correct application of tissue adhesive includes which of the following?
A: Complete hemostasisB: Debridement of foreign bodies or materialsC: ImmobilizationD: Thorough wound cleansing and irrigationE: All of the above



CME Questions -modulo XXI

1: All of the following statements regarding impedance pneumography are correct except:
A: Display can be affected by patient movementB: Measures chest wall movementC: Measures respiratory effortD: Measures ventilationE: Uses the ECG monitor leads
2: Which of the following statements regarding basic airway management is correct?
A: Chin-lift maneuver is acceptable for most trauma victimsB: Chin-lift maneuver is acceptable for unconscious trauma victims as long as cervical spine films are normalC: Jaw-thrust maneuver is preferred for trauma victimsD: Nasal airways can only be used in conscious patientsE: Oral airways work best in conscious patients
3: Which of the following statements regarding RSI in pediatric patients is correct?
A: Involves administration of a sedative agent and a neuromuscular blocking agentB: Preoxygenation is of little benefitC: Should almost always be conducted as quickly as possible; equipment can be gathered while the procedure is being performedD: Tachycardia is a common side effect of succinylcholine E: There is almost no indication for the use of atropine
4: Cannulation of which of the following venous sites has the highest risk of complications?
A: Brachial veinB: Distal saphenous veinC: External jugular veinD: Femoral veinE: Subclavian vein

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