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Free STEP3 Exam Braindumps (page: 89)

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PDF with 804 Questions

While in the emergency department you see a 3-week-old infant. The mother says that the child felt warm earlier in the day and has not been eating very well. The infant has a temperature of 100.9°F and has mildly decreased tone. What is the most appropriate initial management?

  1. Give acetaminophen and reassess in a few hours.
  2. Draw a blood culture, recommend increased fluid intake, and follow-up for re-examination in 24 hours in the primary pediatrician's office.
  3. Admit to the hospital and perform a full "sepsis workup."
  4. Draw a blood culture, give a shot of ceftriaxone (Rocephin) to cover for any infections and follow- up in 2448 hours.
  5. Get a urine culture and begin trimethoprim/sulfamethoxazole (Septra).

Answer(s): C

Explanation:

A fever in the first 46 weeks of life needs to be treated very aggressively. There are no reliable clinical or laboratory findings currently available that can discriminate between a nominal viral illness and a serious bacterial infection. In the newborn period, fever may be the only indicator of bacteremia or meningitis. Any rectal temperature greater than 100.5°F should trig ger a full sepsis workup. This should include cultures of the blood, urine, and spinal fluid. In this age range, empiric antimicrobials should be initiated that should cover for GBS, E. coli, and Listeria monocytogenes. A commonly used regimen is ampicillin and gentamicin. Many would also include empiric acyclovir in this age range. In infants, the routine use of antipyretics should be discouraged. A blood culture alone is not an adequate screening tool for meningitis. While a urinary tract infection (UTI) is a common cause of infection in infants, a more complete evaluation would be warranted.



You see a 2-month-old infant in the emergency department for vomiting. The mother says that the baby has been spitting up more over the past few days and has become more irritable. She denies any fever, diarrhea, or change in formula. The mother tells you that there is a family history of "heartburn" and that her other children have all spit up. The infant has some emesis in the emergency department that seems to be formula mixed with some bile. The infant is intermittently irritable and sleepy.

What is the most concerning diagnosis that this could be?

  1. biliary atresia
  2. malrotation
  3. pyloric stenosis
  4. imperforate anus
  5. diaphragmatic hernia

Answer(s): B

Explanation:

Bilious emesis in an infant is malrotation until proven otherwise. Malrotation can lead to a midgut volvulus. The volvulus can result in bowel ischemia and necrosis. This makes bilious emesis in a newborn a concerning finding. Pyloric stenosis would cause nonbilious emesis. Imperforate anus would present with the failure of stool passage. Diaphragmatic hernia will present with poor feeding, drooling, and respiratory embarrassment The best radiographic test in the diagnosis of malrotation is an UGI contrast study with small bowel follow through. This will identify the duodenum and its location relative to the ligament of Treitz. The characteristic finding in a midgut volvulus is the "corkscrew" sign, which is seen as contrast media traverses the kinked intestine. An abdominal CT may show malrotation but is less specific for it. Barium enema and radionuclide scans have no role in the diagnosis of malrotation.



You see a 2-month-old infant in the emergency department for vomiting. The mother says that the baby has been spitting up more over the past few days and has become more irritable. She denies any fever, diarrhea, or change in formula. The mother tells you that there is a family history of "heartburn" and that her other children have all spit up. The infant has some emesis in the emergency department that seems to be formula mixed with some bile. The infant is intermittently irritable and sleepy.

Which of the following would be the most appropriate initial test?

  1. abdominal computed tomography (CT)
  2. barium enema
  3. abdominal ultrasound
  4. UGI series with small bowel follow through
  5. radionuclide scan

Answer(s): D

Explanation:

Bilious emesis in an infant is malrotation until proven otherwise. Malrotation can lead to a midgut volvulus. The volvulus can result in bowel ischemia and necrosis. This makes bilious emesis in a newborn a concerning finding. Pyloric stenosis would cause nonbilious emesis. Imperforate anus would present with the failure of stool passage. Diaphragmatic hernia will present with poor feeding, drooling, and respiratory embarrassment The best radiographic test in the diagnosis of malrotation is an UGI contrast study with small bowel follow through. This will identify the duodenum and its location relative to the ligament of Treitz. The characteristic finding in a midgut volvulus is the "corkscrew" sign, which is seen as contrast media traverses the kinked intestine. An abdominal CT may show malrotation but is less specific for it. Barium enema and radionuclide scans have no role in the diagnosis of malrotation



An 8-year-old male presents to your office complaining of a 1-week history of painful knee and elbow joints. On examination, you find a painful, hot, and swollen knee. He also has multiple erythematous macules with pale centers on his trunk and extremities. The laboratory work you order reveals elevated antistreptococcal antibodies.
What is the most likely diagnosis?

  1. JRA
  2. septic arthritis
  3. acute rheumatic fever (ARF)
  4. child abuse
  5. SLE

Answer(s): C

Explanation:

ARF is clinically diagnosed by using the Jones criteria. The Jones criteria are separated into major and minor findings. The major criteria are arthritis (not simply arthralgia), carditis, Sydenham chorea, erythema marginatum, and subcutaneous nodules. The minor criteria include the presence of a fever, arthralgias, documentation of a GAS infection (either currently or in the past), or laboratory evidence of inflammation (increased ESR). Two major criteria, or one major and two minors, are required for the diagnosis of ARF. The only exception to this rule is that the presence of Sydenham chorea alone will make the diagnosis. While the documentation of a prior, or current, GAS infection is compelling, it is not a requirement for the diagnosis of ARF. Children with rheumatic fever are not considered contagious.






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