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Free STEP2 Exam Braindumps (page: 58)

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PDF with 738 Questions

The parents request some treatment for this condition. Which of the following is the most appropriate treatment for a child of this age?

  1. bladder stretching exercises
  2. intranasal DDAVP (desmopressin acetate)
  3. imipramine
  4. conditioning therapy with a bed-wetting alarm
  5. reassurance of the parents and restriction of fluids before bedtime

Answer(s): E

Explanation:

Active treatment should be avoided in children under age 6 years, as nocturnal enuresis is common.
Parents should be reassured that the condition is self-limited. Fluid intake 1 hour before sleep should be restricted. Simple behavioral reinforcement, such as a star or sticker chart to record dry nights, may be helpful. Punitive or humiliating measures should be discouraged. Bladder-stretching exercises and encouraging children to hold urine for longer periods during the day are usually not helpful. Pharmacologic therapy is not curative. DDAVP is a synthetic analog of antidiuretic hormone. It reduces urine production overnight. Hyponatremia has been reported with use of this drug. If used, it should only be for a limited time. Imipramine is a tricyclic antidepressant which was used more often in the past. It is effective in 30- 60% of children, but side effects include anxiety, insomnia, and dry mouth. There is a poisoning risk, especially for younger children. Conditioning therapy may be considered in children older than 6 years.
Success rates range from 30 to 60%. It involves the use of an alarm attached to electrodes in the underwear, which sounds when the child voids. Consistent use of the device is often helpful; it is more effective in older, more motivated children. A common complaint is that the alarm wakes up other family members but not the affected child



A 14-year-old boy complains of breast enlargement on the left side. He denies pain, discharge, or any drug use. He is on no medications and is otherwise healthy. On physical examination, his sexual maturity rating (Tanner) is stage II for both genitalia and pubic hair growth. Initial management should include which of the following?

  1. magnetic resonance imaging of the head
  2. urine drug screen for marijuana
  3. chromosome analysis
  4. reassurance that this is a normal condition
  5. ultrasound imaging of the abdomen and testes

Answer(s): D

Explanation:

Gynecomastia is the enlargement of male breast tissue and occurs in approximately onethird of adolescent males during early- to midpuberty. It usually resolves spontaneously and requires no further evaluation beyond a careful history and physical examination. Features include: breast tissue <4 cm in diameter and resembling female breast budding, and pubertal development between Tanner stage II and IV. Pubertal development signs precede gynecomastia by at least 6 months. It may be more noticeable in obese boys.
A drug and medication history should be obtained; these include estrogens, androgens, human chorionic gonadotropin (hCG), cardiovascular drugs (reserpine, methyldopa, digitalis), cytotoxic agents (busulfan, vincristine), antituberculosis drugs (INH), psychoactive drugs (tricyclic antidepressants, diazepam), ketoconazole, spironolactone, cimetidine, and phenytoin. Illegal drugs include marijuana, heroin, methadone, amphetamines, as well as alcohol. If there is evidence of precocious puberty, hypogonadism or macrogynecomastia (breast tissue >5 cm diameter), laboratory testing should be done including dehydroepiandrosterone sulfate (DHAS), FSH, and LH, hCG, estradiol, and testosterone. Thyroid- stimulating hormone (TSH) may be obtained to rule out hyperthyroidism. Boys with Klinefelter syndrome have hypogonadism (testes <3 cm in diameter), delayed pubertal development, and gynecomastia.
Laboratory tests reveal increased FSH and LH, and decreased testosterone; the diagnosis is confirmed by chromosome analysis. If DHAS, hCG, or estradiol levels are increased, an MRI of the head to exclude a CNS tumor and ultrasound of abdomen and testes to rule out an adrenal, liver, or testicular tumor should be considered.



Amother brings in her 3-year-old girl because she felt a smooth mass on the left side of her belly when she was giving her a bath. Which of the following is the most likely diagnosis?

  1. Wilms tumor
  2. neuroblastoma
  3. acute lymphoblastic leukemia
  4. Hodgkin's disease
  5. hepatoblastoma

Answer(s): A

Explanation:

Wilms tumor is a malignant embryonal neoplasm of the kidney. It is the second most common solid tumor of childhood. Girls are affected more frequently than boys (2:1). The incidence of Wilms tumor peaks at 13 years of age. The classic presentation is a painless abdominal mass that is usually hard, smooth, and unilateral. Hematuria occurs in 1225% of children with Wilms tumor, and hypertension has been reported in up to 60% of patients. Aniridia or hemihypertrophy may be observed in patients with Wilms tumor.



An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no apparent source of infection. She appeared to be 510% dehydrated.

You decide to obtain a urine specimen for analysis and culture. Which of the following is the best method?

  1. Collect a midstream "clean catch" specimen.
  2. Collect a catheterized specimen.
  3. Place an adhesive bag to collect urine.
  4. Obtain urine from a diaper.
  5. Collect urine after she urinates in a potty chair.

Answer(s): B

Explanation:

Urine for urinalysis and culture must be properly obtained. Catheterization is the most reliable method of the choices offered. Suprapubic tap is considered the "gold-standard" but is not always technically feasible, especially in an outpatient office setting. Amidstream, clean catch specimen would be acceptable in an older, toilet-trained child. "Bagged" specimens are not recommended because of possible skin or fecal contamination of the specimen. Similarly, obtaining a sample from a diaper or potty would be unacceptable.
Urinalysis includes dipstick method and microscopic examination. Leukocyte esterase (an enzyme in WBC) and nitrites suggest probable infection. Microscopic analysis of unspun urine for WBC (>10/ highpower field) or bacteria is also predictive of infection. RBCs are often present in a UTI. The patient is vomiting and dehydrated; this may indicate possible pyelonephritis. The most appropriate course would be IV hydration and empiric treatment with antibiotics (ceftriaxone) while awaiting cultures. Children with pyelonephritis are at increased risk of renal scarring, especially younger children, and should be treated early. E. coli is the most common organism cultured; others include Proteus, Klebsiella, S saprophyticus, and Enterococcus. The occurrence of a UTI in a girl under age 35 years and in a boy of any age may be a marker for an underlying congenital anatomic abnormality, in particular, vesicourethral reflux. Radiologic investigation with renal ultrasound and VCUG is recommended






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