Asclepius1
12-02-2004, 11:33 AM
PEDIATRIC CLINICAL PROBLEM SET
The Clinical Problem set describes common pediatric scenarios with which you should become familiar. Read about the diseases, situations, diagnoses, differential diagnoses, and management issues raised by the problems. The clinical problems set and the problem list form the basis of the multiple-choice exam at the end of the clerkship and appear verbatim on the final exam as selected essay questions. Three of four case questions from the problem set will be answered as part of the exam.
The clinical problem set is designed to focus your reading on common pediatric problems and situations. It does not relieve you from the need to read in preparation for your patient care experiences in the clinics or on the inpatient services or your need to read in preparation for the USMLE Step 2 exam.
In addition to preparing for the essay questions and topics, all students should be able to plot and interpret growth data.
1. A mother brings her 18-month-old boy for a scheduled well baby visit. She is concerned because her neighbor's 18-month-old can do more than her own child. By history he sat alone at nine months, started pulling up at 14 months, but does not yet walk. He says Dada, Mama and dog, but no other words. Outline your initial differential diagnoses, your approach and your response to this mother's concerns including any additional history, physical examination and laboratory information you would like to obtain. Contrast this to your approach and response to the mother if the child walked well, but said no words.
2. A newborn infant presents with canthal folds, Brushfield spots, small ears, a prominent tongue, and loose nuchal skin. What is the likely diagnosis in this case? In view of the above, what additional historical information such as prenatal or family history might be useful in the further evaluation of this infant? How is this information relevant to the evaluation? What additional physical findings might support the clinical diagnosis? How will initially approach the family to tell them of your clinical impressions? What information could you give the family concerning prognosis and recurrence risk in a future pregnancy?
If a karyotype discloses a normal 46,XX, female chromosome constitution, what etiologic considerations might one consider as possible causes of this infant's problems?
3. It is 3:00 A.M. Saturday morning. The mother of a 1-month-old infant calls you at home and tells you that her baby has a temperature of 39.3o C. Describe your management of this child in detail, and how it would vary depending on the results of information you would seek including history, physical examination, if done, and laboratory data, if any.
One year later (assuming that you managed the patient properly) the same mother calls with the same complaint that her 13-month-old child has a temperature of 39.3EC. Describe your management of this child, specifically contrasting the differences in management and reasons for these differences between this age and one year earlier.
4. A 2250-gram infant male is delivered to a mother who has received no prenatal care and who has uncertain dates. In your assessment you must distinguish whether the child is term, small for gestational age (SGA) as opposed to preterm but appropriate for gestational age (AGA). What additional history would you require to evaluate this patient including the known etiological factors contributing to the pathogenesis of the term SGA and preterm AGA infant? What physical criteria distinguish between these entities? With each entity, what problems must you anticipate in the first few days of life?
5. A full-term infant is noted to be jaundiced at 48 hours of age. The total bilirubin is 13.0 mg/dL with a direct bilirubin of 1.0 mg/dL. Discuss your approach to this infant's hyperbilirubinemia and any additional information you would require including history, physical examination and laboratory data. What are the most common causes of jaundice in this setting? How would you explain this infant's jaundice to the parents?
6. An inquisitive first-time mother has just given birth to a healthy term infant. She asks you to be her baby's doctor. She wants to know the schedule for the next two years for routine visits and immunizations you plan as well as the "real truth" about the problems and risks involved with the immunizations. Outline an appropriate response to her questions.
7. A 10-month-old child with recurrent respiratory and enteric infections and failure to thrive presents with tachypnea and cough for 1 month. The mother of the child is 20 years old and admits to having used IV drugs when she was 18 years old. How would you evaluate this child, including any history, physical examination and laboratory data you would require? What is the differential diagnosis? How would you discuss your concerns about this child with the mother?
8. A pregnant woman presents in your office for a pre-delivery visit; she wants you to be her child's physician. This is her first pregnancy, and she expresses concern about her ability to care for a newborn infant. She has read about breast-feeding her infant, and inquires about the advantages and disadvantages of both breast-feeding and formula feeding. She also asks about vitamin and fluoride supplementation for her infant and how and when to proceed with solid foods. Outline what you would tell her during this session, including answers to her specific questions.
9. A mother brings her 2-year-old son to clinic with complaints of temperature elevation to 39.1o C, irritability and pulling at the right ear. She gives you a history of two previous ear infections, and suggests that the child probably has another ear infection. Described the specific information you would seek to make a diagnosis of otitis media in this patient, and to exclude other diagnoses. Describe the sequence of pathophysiological and clinical events which led to the problem. Assuming the diagnosis of otitis media is made, outline an appropriate treatment plan, the expected clinical course and possible complications which you should anticipate. How would you explain otitis media to this parent?
10. You see an 8-year-old girl in the office with complaint of sore throat, abdominal pain and temperature elevation (38.4EC) for two days. On examination the patient has normal ears, a slight clear nasal discharge, moderate exudate over tonsillar crypts, tonsils 3+ enlarged, anterior cervical lymph nodes 2 x 3 cm bilaterally and mildly tender. The remainder of the physical exam is normal. What additional information or data would you obtain for management of this patient? List the diagnostic entities which you consider most likely or important to consider, and give the general treatment approach to each. How would you discuss this problem with the child?...with the parents?
11. A previously well 14-month-old child presents to your Emergency Room with a history of acute onset of high fever followed by what sounds like sudden unconsciousness with symmetrical convulsive activity that lasted approximately three minutes. She has been somnolent on the way to the hospital. Upon arrival to the Emergency Room, she is alert and playful with a temperature of 38.7EC. Physical examination is remarkable only for rhinorrhea; there is no nuchal rigidity. Discuss your approach to this patient including the most important diagnostic entities. What additional information is needed in the areas of history, physical examination and diagnostic tests? How would you manage this patient in the Emergency Room and during subsequent follow up? How would you explain this problem to the parents?
While you are explaining the problem to the parents, the child begins to have another generalized seizure. What would be your response to this seizure in the Emergency Room? How would your approach be different if the original seizure had been asymmetric and the patient remained somnolent and irritable?
12. An obese 8-year-old boy is seen in the office for a routine visit. His mother is concerned because of all the junk food that her son eats and the long hours of television he watches. She describes her son as a worrier. The mother has been a one pack per day cigarette smoker for many years. The boy's father had a history of elevated cholesterol and died of a heart attack at the age of 39 years. Construct a problem list for this patient. What additional history, physical examination and laboratory data do you require to properly evaluate each of this patient's problems? For each of the problems you have listed, what are the immediate and long range health risks to this boy? What would your initial management be for each of the problems you listed? How would you discuss your concerns with this mother and her son?
13. You are called to the nursery following the birth of a term infant who has a lumbar myelomeningocele. This is the couple's first baby. On your exam this child, a female, has a head circumference of 37 cm (greater than the 90%ile), and a normal length and weight. She has a 4 cm open spine defect with exposure of the meninges and spinal cord. She has limited hip flexor function and bilateral talipes equinovarus deformaties. Describe how you will assess this child. The parents ask you about her prognosis, and about possible future complications and treatments. What will you tell them? They also ask about the causes of neural tube defects and possible ways to detect them prenatally, as well as possible prevention. What will you tell them?
14. A mother brings her 2-year-old into clinic and states that he has been having diarrhea for one month. The child appears to be thin.
For this problem construct a differential diagnosis of the most common and/or important possibilities and give historical questions, physical findings, and laboratory tests (if any) which you would seek to support each diagnosis.
15. A 4-week-old infant is reported to have forcefully vomited several feedings. Construct a differential diagnosis including the most important possible etiologies for this problem. Outline your approach to this problem including historical and physical findings as well as laboratory tests or other procedures (if needed) which would confirm each diagnosis. How does this differential diagnosis and approach differ from those for the same symptoms in a newborn infant?
16. A 3-year-old female is being evaluated for an acute onset of dysuria and urinary frequency. Construct a differential diagnosis for this problem and describe your diagnostic approach including any additional history, physical examination and laboratory data you would require. How would you explain your diagnostic concerns to the mother? What guidelines for long-term management, if any, would you use if the diagnosis of a urinary tract infection were made? How would your approach to diagnosis and management differ if the patient were male?
17. At his routine screening, a 13-month-old black male infant is found to have a hemoglobin of 9.6 g/dl, hematocrit of 31% and MCV of 67. Outline a logical approach to the diagnostic and therapeutic evaluation of this patient including relevant history, physical examination and laboratory features of the entities under consideration. How would you explain you concerns and approach to the parents?
18. A 13-year-old boy comes to your office with both of his parents for a physical examination before enrolling in a private day school; the school requires this examination. He informs you that he thinks that this examination is unnecessary, since he has been healthy. He last saw you 3 years ago for a camp physical. He tells you that he has decided to become a strict vegetarian (vegan), and will no longer consume any animal products as food. His parents are not vegetarian and seem quite concerned about this. His mother is an internist, and his father is a public high school science teacher. On exam, his height and weight are at the 10 percentile. He has mild facial acne, a few axillary hairs, and Tanner stage 2 genitalia. He has two "non-professional" tattoos on his buttocks. There are no abnormal physical findings. Describe how you will interact with this patient and his parents. How will you counsel him about his prospective dietary change? What lab studies, if any, will you order?
19. A 3-year-old is brought to the clinic with a history of cough for the past week. The cough has been getting progressively worse. The child appears comfortable. Bilateral wheezing with forced expiration is noted on physical examination. What are the diagnostic possibilities for this patient? What additional history, physical examination and laboratory data would be useful to evaluate this patient? Outline an appropriate management plan should the diagnosis of asthma be made. How would you explain the pathophysiology and management of asthma to the child and parents?
How would your approach to this patient differ if the child was in moderate respiratory distress, with 2+ retractions, poor aeration and bilateral wheezing? How would your approach to diagnosis and management differ if the wheezing were unilateral?
20. A 4-year-old child presents to you with the acute onset of limp and inability to bear weight. Construct a differential diagnosis of disorders which you consider most important (common and/or serious). For each diagnostic possibility, what would be your approach to reach a diagnosis including any additional history, physical examination and laboratory data?
21. While you are in the Emergency Room, a 15-year-old girl is brought in by her mother with a history of taking 6 aspirin tablets 2 hours ago. She appears alternatively agitated and sullen, but is otherwise alert and in no distress. After stabilization and initial management of possible poisoning describe your approach to the evaluation and management of the patient's behavior. What diagnostic entities are most important to consider? What other historical, physical, or lab data would you require? How would you discuss this problem with the girl?...with her parents?
22. A 3-year-old child is brought into the hospital Emergency Room at 2:00 A.M. with a history of stridor and "barky" cough of 6 hours duration. He is febrile to 38.5EC, anxious and drooling slightly. What diagnostic possibilities are most important to consider? What additional history, physical examination and laboratory data do you require to evaluate this patient? What is your plan for the immediate evaluation and management of this patient? How would you explain this problem to the parents? How would you explain your concerns to the child?
23. A 2-year-old is found to have an asymptomatic abdominal mass in the right upper quadrant and flank. What are the likely benign and malignant considerations? Outline the diagnostic steps required for the evaluation of this child. How would you explain your approach and concerns to the parents?
24. A 1-year-old child is brought to the Emergency Room because she "rolled off the couch" two days ago. On examination, you find a depressed skull fracture, a fractured right femur, and black and blue marks on the left buttock.
Given this presentation, what are the principal diagnostic considerations? What additional questions would you ask of the parents to further define the problem? Give the significance of each question. How would you explain your concerns to the parents? How would you proceed with the management of this case?
25. A 2-year-old boy is brought to the Emergency Room because the child's 9-year-old sister said she saw her brother "playing with the grandfather's heart medicine"; the bottle is now empty. The boy is alert and active. What additional history, physical examination and laboratory data would you require to evaluate this patient? How would you discuss this problem with the parents? What, if anything, would you say to this child? List ways that parents can prevent poisonings in the home.
26. A 3-year-old is brought to the clinic with "sores" on the skin of one week's duration. The lesions are over the upper lip, chin, hands, and arms, and are pruritic, shallow, 1/2 to 2 cm in size, and are covered with a yellowish crust, surrounded by a small area of erythema. There are no vesicles. Several other children in the patient's preschool have a similar rash. What is the most likely diagnostic entity? Outline a plan for evaluation and management of this patient. What complications could result from this problem?
27. A 15-year-old female is seen in the office for a routine physical examination for working papers. She is accompanied by her 8-year-old sister and her mother. What are the most significant differences in your approach to this teenager with regard to taking the history, performing the physical exam and providing anticipatory guidance as compared to your interactions with her 8-year-old sister?
28. A 6-pound baby is born to a 26-year-old mother who has one previous child. At 2 hours of age, the baby's respiratory rate is noted to be 80 breaths per minute. Construct a differential diagnosis for this problem. Discuss your approach to this baby's problem including any additional history, physical examination or laboratory data you would require. How would you explain your concerns to the parents? What would be your initial management? How would your differential diagnosisand management vary if the infant were cyanotic?
29. A 5-year-old girl is being evaluated for II/IV systolic heart murmur. What additional history, physical exam and laboratory data are required to evaluate this child's murmur? What are the basic criteria which one may use to differentiate an "innocent" or functional heart murmur from a pathologic heart murmur? What are the most common causes of a heart murmur in this age group? How would you explain this problem to the child?...to the parent?
30. A mother brings her 8-month-old child into the Emergency Room and states that he has been vomiting and having diarrhea for the past two days. The child appears well hydrated and in no acute distress. Discuss the most common causes for this problem including any additional history, physical examination or laboratory data you would require. What would be your management for this patient? How would you explain this problem to the child's mother?
Two days later, this same patient is again brought to the Emergency Room. His mother reports that the vomiting and diarrhea have gotten worse. The child is now refusing to drink from his bottle. His last urination was 12 hours ago. On exam, he appears lethargic and weak. His weight is 9.9 kg and height is 71 cm. He has dry mucous membranes, a sunken fontanelle, decreased skin turgor and no tears. What is your assessment of this patient now? What additional data from the history, physical examination and laboratory do you now require? What orders would you write for the initial fluid management for this patient?
An hour later, your patient has urinated and the initial serum electrolytes are reported as:
Na-126 mEq/L, K-4.1 mEq/L, Cl-89 mEq/L, CO2-19 mEq/L, Glucose-80 mEq/L
Outline your approach to the fluid management for this child. What is your estimate of the deficits of volume, sodium and potassium? After the stooling has ceased and the deficits have been repaired, what maintenance fluids would be needed if oral intake is not tolerated?
31. A mother and her 14 year old daughter present to your office because the daughter has not yet had menarche. On physical exam, her height is 151 cm, and weight 41 kg. She is a quiet and obviously nervous white female. Findings include scant axillary hair, and a moderate amount of dark, curled pubic hair. There is palpable breast tissue, and the areolae are separate from the breast contour, with prominence of the nipples. The legs are shaved. The patient seems uncomfortable answering your questions about her medical history, school performance, etc. How will you proceed in your evaluation of this patient? What lab or radiographic tests, if any, would you order?
32. You are called to the newborn nursery to see an infant with ambiguous genitalia. The infant was born 2 hours ago, and seems stable at this time. The external physical exam is normal with the exception of the genitalia. There is a 1.5 cm bowed phallus with an opening at the base. The labioscrotal folds are slightly pigmented and rugated, and no gonads are palpable. What is your differential diagnosis, and how will you proceed with the evaluation and management of this patient? What will you tell the parents about your concerns?
How will you advise the parents?
33. The parents of a 15 year old boy bring him to your office because they "can't do anything with him anymore". He was formerly an A/B student, but he is currently failing several subjects. He complains of frequent headaches, sometimes of sufficient severity to cause him to leave school or stay home from school. Describe your approach to the evaluation and management of this patient, including pertinent questions you would ask, lab tests (if any), and other diagnostic studies (if any).
34. A young couple brings their children to see you for their first visit after moving to your town. The parents have 3 children, ages 1 year, 3 years, and five years. The children are all healthy. The parents have moved into a new residential area near an elementary school, and have a swimming pool in their back yard. The 5 year old announces that "Granddaddy is going to give me a motor scooter for my birthday". Describe the well-child care issues that should be discussed with this family.
35. A 13-year-old boy presents to your office for a pre-camp physical. On physical exam, you note that he has a low-grade fever, and that he has several large bruises on his thighs, shins, upper arms and lower back, as well as some petechiae. What is your differential diagnosis, and what historical and physical findings will help you in arriving at a final diagnosis? What lab tests will you order (if any)?
36. The mother of a newborn infant asks to see you to discuss the newborn screening tests about to be performed on her child; she is unhappy and does not want her child to "get stuck". In your state, the usual mandated tests are for PKU, maple syrup urine disease, galactosemia, homocystinuria, congenital hypothyroidism, biotinidase deficiency, and sickling hemoglobinopathies. What will you tell her about these tests, and how will you respond to her concerns about testing her child?
37. A 24 month old black male infant presents to the emergency room with lethargy, tachypnea, and tachycardia. On physical exam, his height is 84 cm and weight 25 kg. His temperature is 39.9oC. You obtain a CBC; his hematocrit is 12%, with hemoglobin 3.8 gm/dl; his wbc is 2,000. How will you proceed in your evaluation and management of this patient? Include pertinent medical history, physical findings you would look for, and additional lab tests (if any), and your initial management. How would your diagnosis and management differ if there was a recent history of mothball ingestion?
38. A 6-year-old child is referred to you because of poor school performance. The family recently moved to your community when the father was discharged from the army; they had been living in a relatively old apartment building near the base which had been "stripped" and repainted several times while they were there. The father asks you about the possibility of lead poisoning. What historical features, physical findings, laboratory data, and other studies might be useful in evaluating this child for lead poisoning? If you confirm the diagnosis of lead poisoning, how will you treat this child? Describe the epidemiology of lead poisoning in the United States.
39. A 7-year old boy is referred to you for evaluation of poor school performance. He is losing his friends and the parents are concerned about behavior outbursts. He has always been active and inquisitive, but since entering school, has been oppositional and in increasing trouble with the teacher and his parents. What is the differential diagnosis for this boy? What are the possible interventions? What are the next steps in his work-up?
40. You are called from the emergency room because a patient of yours, age 3 months, has been brought to the hospital by ambulance and could not be resuscitated. He was previously well, and his immunizations were up to date. The parents state that he had a runny nose the night before but acted normally and did not seem to have a fever. He went to bed at the normal time, but was found dead the next morning when the mother went in to check on him. The parents called 911 and attempted CPR, but he did not respond. As this child's primary care physician, how will you approach this situation and family? What studies, if any, will you order or suggest, and why? What agencies, if any, will you involve, and why?
The Clinical Problem set describes common pediatric scenarios with which you should become familiar. Read about the diseases, situations, diagnoses, differential diagnoses, and management issues raised by the problems. The clinical problems set and the problem list form the basis of the multiple-choice exam at the end of the clerkship and appear verbatim on the final exam as selected essay questions. Three of four case questions from the problem set will be answered as part of the exam.
The clinical problem set is designed to focus your reading on common pediatric problems and situations. It does not relieve you from the need to read in preparation for your patient care experiences in the clinics or on the inpatient services or your need to read in preparation for the USMLE Step 2 exam.
In addition to preparing for the essay questions and topics, all students should be able to plot and interpret growth data.
1. A mother brings her 18-month-old boy for a scheduled well baby visit. She is concerned because her neighbor's 18-month-old can do more than her own child. By history he sat alone at nine months, started pulling up at 14 months, but does not yet walk. He says Dada, Mama and dog, but no other words. Outline your initial differential diagnoses, your approach and your response to this mother's concerns including any additional history, physical examination and laboratory information you would like to obtain. Contrast this to your approach and response to the mother if the child walked well, but said no words.
2. A newborn infant presents with canthal folds, Brushfield spots, small ears, a prominent tongue, and loose nuchal skin. What is the likely diagnosis in this case? In view of the above, what additional historical information such as prenatal or family history might be useful in the further evaluation of this infant? How is this information relevant to the evaluation? What additional physical findings might support the clinical diagnosis? How will initially approach the family to tell them of your clinical impressions? What information could you give the family concerning prognosis and recurrence risk in a future pregnancy?
If a karyotype discloses a normal 46,XX, female chromosome constitution, what etiologic considerations might one consider as possible causes of this infant's problems?
3. It is 3:00 A.M. Saturday morning. The mother of a 1-month-old infant calls you at home and tells you that her baby has a temperature of 39.3o C. Describe your management of this child in detail, and how it would vary depending on the results of information you would seek including history, physical examination, if done, and laboratory data, if any.
One year later (assuming that you managed the patient properly) the same mother calls with the same complaint that her 13-month-old child has a temperature of 39.3EC. Describe your management of this child, specifically contrasting the differences in management and reasons for these differences between this age and one year earlier.
4. A 2250-gram infant male is delivered to a mother who has received no prenatal care and who has uncertain dates. In your assessment you must distinguish whether the child is term, small for gestational age (SGA) as opposed to preterm but appropriate for gestational age (AGA). What additional history would you require to evaluate this patient including the known etiological factors contributing to the pathogenesis of the term SGA and preterm AGA infant? What physical criteria distinguish between these entities? With each entity, what problems must you anticipate in the first few days of life?
5. A full-term infant is noted to be jaundiced at 48 hours of age. The total bilirubin is 13.0 mg/dL with a direct bilirubin of 1.0 mg/dL. Discuss your approach to this infant's hyperbilirubinemia and any additional information you would require including history, physical examination and laboratory data. What are the most common causes of jaundice in this setting? How would you explain this infant's jaundice to the parents?
6. An inquisitive first-time mother has just given birth to a healthy term infant. She asks you to be her baby's doctor. She wants to know the schedule for the next two years for routine visits and immunizations you plan as well as the "real truth" about the problems and risks involved with the immunizations. Outline an appropriate response to her questions.
7. A 10-month-old child with recurrent respiratory and enteric infections and failure to thrive presents with tachypnea and cough for 1 month. The mother of the child is 20 years old and admits to having used IV drugs when she was 18 years old. How would you evaluate this child, including any history, physical examination and laboratory data you would require? What is the differential diagnosis? How would you discuss your concerns about this child with the mother?
8. A pregnant woman presents in your office for a pre-delivery visit; she wants you to be her child's physician. This is her first pregnancy, and she expresses concern about her ability to care for a newborn infant. She has read about breast-feeding her infant, and inquires about the advantages and disadvantages of both breast-feeding and formula feeding. She also asks about vitamin and fluoride supplementation for her infant and how and when to proceed with solid foods. Outline what you would tell her during this session, including answers to her specific questions.
9. A mother brings her 2-year-old son to clinic with complaints of temperature elevation to 39.1o C, irritability and pulling at the right ear. She gives you a history of two previous ear infections, and suggests that the child probably has another ear infection. Described the specific information you would seek to make a diagnosis of otitis media in this patient, and to exclude other diagnoses. Describe the sequence of pathophysiological and clinical events which led to the problem. Assuming the diagnosis of otitis media is made, outline an appropriate treatment plan, the expected clinical course and possible complications which you should anticipate. How would you explain otitis media to this parent?
10. You see an 8-year-old girl in the office with complaint of sore throat, abdominal pain and temperature elevation (38.4EC) for two days. On examination the patient has normal ears, a slight clear nasal discharge, moderate exudate over tonsillar crypts, tonsils 3+ enlarged, anterior cervical lymph nodes 2 x 3 cm bilaterally and mildly tender. The remainder of the physical exam is normal. What additional information or data would you obtain for management of this patient? List the diagnostic entities which you consider most likely or important to consider, and give the general treatment approach to each. How would you discuss this problem with the child?...with the parents?
11. A previously well 14-month-old child presents to your Emergency Room with a history of acute onset of high fever followed by what sounds like sudden unconsciousness with symmetrical convulsive activity that lasted approximately three minutes. She has been somnolent on the way to the hospital. Upon arrival to the Emergency Room, she is alert and playful with a temperature of 38.7EC. Physical examination is remarkable only for rhinorrhea; there is no nuchal rigidity. Discuss your approach to this patient including the most important diagnostic entities. What additional information is needed in the areas of history, physical examination and diagnostic tests? How would you manage this patient in the Emergency Room and during subsequent follow up? How would you explain this problem to the parents?
While you are explaining the problem to the parents, the child begins to have another generalized seizure. What would be your response to this seizure in the Emergency Room? How would your approach be different if the original seizure had been asymmetric and the patient remained somnolent and irritable?
12. An obese 8-year-old boy is seen in the office for a routine visit. His mother is concerned because of all the junk food that her son eats and the long hours of television he watches. She describes her son as a worrier. The mother has been a one pack per day cigarette smoker for many years. The boy's father had a history of elevated cholesterol and died of a heart attack at the age of 39 years. Construct a problem list for this patient. What additional history, physical examination and laboratory data do you require to properly evaluate each of this patient's problems? For each of the problems you have listed, what are the immediate and long range health risks to this boy? What would your initial management be for each of the problems you listed? How would you discuss your concerns with this mother and her son?
13. You are called to the nursery following the birth of a term infant who has a lumbar myelomeningocele. This is the couple's first baby. On your exam this child, a female, has a head circumference of 37 cm (greater than the 90%ile), and a normal length and weight. She has a 4 cm open spine defect with exposure of the meninges and spinal cord. She has limited hip flexor function and bilateral talipes equinovarus deformaties. Describe how you will assess this child. The parents ask you about her prognosis, and about possible future complications and treatments. What will you tell them? They also ask about the causes of neural tube defects and possible ways to detect them prenatally, as well as possible prevention. What will you tell them?
14. A mother brings her 2-year-old into clinic and states that he has been having diarrhea for one month. The child appears to be thin.
For this problem construct a differential diagnosis of the most common and/or important possibilities and give historical questions, physical findings, and laboratory tests (if any) which you would seek to support each diagnosis.
15. A 4-week-old infant is reported to have forcefully vomited several feedings. Construct a differential diagnosis including the most important possible etiologies for this problem. Outline your approach to this problem including historical and physical findings as well as laboratory tests or other procedures (if needed) which would confirm each diagnosis. How does this differential diagnosis and approach differ from those for the same symptoms in a newborn infant?
16. A 3-year-old female is being evaluated for an acute onset of dysuria and urinary frequency. Construct a differential diagnosis for this problem and describe your diagnostic approach including any additional history, physical examination and laboratory data you would require. How would you explain your diagnostic concerns to the mother? What guidelines for long-term management, if any, would you use if the diagnosis of a urinary tract infection were made? How would your approach to diagnosis and management differ if the patient were male?
17. At his routine screening, a 13-month-old black male infant is found to have a hemoglobin of 9.6 g/dl, hematocrit of 31% and MCV of 67. Outline a logical approach to the diagnostic and therapeutic evaluation of this patient including relevant history, physical examination and laboratory features of the entities under consideration. How would you explain you concerns and approach to the parents?
18. A 13-year-old boy comes to your office with both of his parents for a physical examination before enrolling in a private day school; the school requires this examination. He informs you that he thinks that this examination is unnecessary, since he has been healthy. He last saw you 3 years ago for a camp physical. He tells you that he has decided to become a strict vegetarian (vegan), and will no longer consume any animal products as food. His parents are not vegetarian and seem quite concerned about this. His mother is an internist, and his father is a public high school science teacher. On exam, his height and weight are at the 10 percentile. He has mild facial acne, a few axillary hairs, and Tanner stage 2 genitalia. He has two "non-professional" tattoos on his buttocks. There are no abnormal physical findings. Describe how you will interact with this patient and his parents. How will you counsel him about his prospective dietary change? What lab studies, if any, will you order?
19. A 3-year-old is brought to the clinic with a history of cough for the past week. The cough has been getting progressively worse. The child appears comfortable. Bilateral wheezing with forced expiration is noted on physical examination. What are the diagnostic possibilities for this patient? What additional history, physical examination and laboratory data would be useful to evaluate this patient? Outline an appropriate management plan should the diagnosis of asthma be made. How would you explain the pathophysiology and management of asthma to the child and parents?
How would your approach to this patient differ if the child was in moderate respiratory distress, with 2+ retractions, poor aeration and bilateral wheezing? How would your approach to diagnosis and management differ if the wheezing were unilateral?
20. A 4-year-old child presents to you with the acute onset of limp and inability to bear weight. Construct a differential diagnosis of disorders which you consider most important (common and/or serious). For each diagnostic possibility, what would be your approach to reach a diagnosis including any additional history, physical examination and laboratory data?
21. While you are in the Emergency Room, a 15-year-old girl is brought in by her mother with a history of taking 6 aspirin tablets 2 hours ago. She appears alternatively agitated and sullen, but is otherwise alert and in no distress. After stabilization and initial management of possible poisoning describe your approach to the evaluation and management of the patient's behavior. What diagnostic entities are most important to consider? What other historical, physical, or lab data would you require? How would you discuss this problem with the girl?...with her parents?
22. A 3-year-old child is brought into the hospital Emergency Room at 2:00 A.M. with a history of stridor and "barky" cough of 6 hours duration. He is febrile to 38.5EC, anxious and drooling slightly. What diagnostic possibilities are most important to consider? What additional history, physical examination and laboratory data do you require to evaluate this patient? What is your plan for the immediate evaluation and management of this patient? How would you explain this problem to the parents? How would you explain your concerns to the child?
23. A 2-year-old is found to have an asymptomatic abdominal mass in the right upper quadrant and flank. What are the likely benign and malignant considerations? Outline the diagnostic steps required for the evaluation of this child. How would you explain your approach and concerns to the parents?
24. A 1-year-old child is brought to the Emergency Room because she "rolled off the couch" two days ago. On examination, you find a depressed skull fracture, a fractured right femur, and black and blue marks on the left buttock.
Given this presentation, what are the principal diagnostic considerations? What additional questions would you ask of the parents to further define the problem? Give the significance of each question. How would you explain your concerns to the parents? How would you proceed with the management of this case?
25. A 2-year-old boy is brought to the Emergency Room because the child's 9-year-old sister said she saw her brother "playing with the grandfather's heart medicine"; the bottle is now empty. The boy is alert and active. What additional history, physical examination and laboratory data would you require to evaluate this patient? How would you discuss this problem with the parents? What, if anything, would you say to this child? List ways that parents can prevent poisonings in the home.
26. A 3-year-old is brought to the clinic with "sores" on the skin of one week's duration. The lesions are over the upper lip, chin, hands, and arms, and are pruritic, shallow, 1/2 to 2 cm in size, and are covered with a yellowish crust, surrounded by a small area of erythema. There are no vesicles. Several other children in the patient's preschool have a similar rash. What is the most likely diagnostic entity? Outline a plan for evaluation and management of this patient. What complications could result from this problem?
27. A 15-year-old female is seen in the office for a routine physical examination for working papers. She is accompanied by her 8-year-old sister and her mother. What are the most significant differences in your approach to this teenager with regard to taking the history, performing the physical exam and providing anticipatory guidance as compared to your interactions with her 8-year-old sister?
28. A 6-pound baby is born to a 26-year-old mother who has one previous child. At 2 hours of age, the baby's respiratory rate is noted to be 80 breaths per minute. Construct a differential diagnosis for this problem. Discuss your approach to this baby's problem including any additional history, physical examination or laboratory data you would require. How would you explain your concerns to the parents? What would be your initial management? How would your differential diagnosisand management vary if the infant were cyanotic?
29. A 5-year-old girl is being evaluated for II/IV systolic heart murmur. What additional history, physical exam and laboratory data are required to evaluate this child's murmur? What are the basic criteria which one may use to differentiate an "innocent" or functional heart murmur from a pathologic heart murmur? What are the most common causes of a heart murmur in this age group? How would you explain this problem to the child?...to the parent?
30. A mother brings her 8-month-old child into the Emergency Room and states that he has been vomiting and having diarrhea for the past two days. The child appears well hydrated and in no acute distress. Discuss the most common causes for this problem including any additional history, physical examination or laboratory data you would require. What would be your management for this patient? How would you explain this problem to the child's mother?
Two days later, this same patient is again brought to the Emergency Room. His mother reports that the vomiting and diarrhea have gotten worse. The child is now refusing to drink from his bottle. His last urination was 12 hours ago. On exam, he appears lethargic and weak. His weight is 9.9 kg and height is 71 cm. He has dry mucous membranes, a sunken fontanelle, decreased skin turgor and no tears. What is your assessment of this patient now? What additional data from the history, physical examination and laboratory do you now require? What orders would you write for the initial fluid management for this patient?
An hour later, your patient has urinated and the initial serum electrolytes are reported as:
Na-126 mEq/L, K-4.1 mEq/L, Cl-89 mEq/L, CO2-19 mEq/L, Glucose-80 mEq/L
Outline your approach to the fluid management for this child. What is your estimate of the deficits of volume, sodium and potassium? After the stooling has ceased and the deficits have been repaired, what maintenance fluids would be needed if oral intake is not tolerated?
31. A mother and her 14 year old daughter present to your office because the daughter has not yet had menarche. On physical exam, her height is 151 cm, and weight 41 kg. She is a quiet and obviously nervous white female. Findings include scant axillary hair, and a moderate amount of dark, curled pubic hair. There is palpable breast tissue, and the areolae are separate from the breast contour, with prominence of the nipples. The legs are shaved. The patient seems uncomfortable answering your questions about her medical history, school performance, etc. How will you proceed in your evaluation of this patient? What lab or radiographic tests, if any, would you order?
32. You are called to the newborn nursery to see an infant with ambiguous genitalia. The infant was born 2 hours ago, and seems stable at this time. The external physical exam is normal with the exception of the genitalia. There is a 1.5 cm bowed phallus with an opening at the base. The labioscrotal folds are slightly pigmented and rugated, and no gonads are palpable. What is your differential diagnosis, and how will you proceed with the evaluation and management of this patient? What will you tell the parents about your concerns?
How will you advise the parents?
33. The parents of a 15 year old boy bring him to your office because they "can't do anything with him anymore". He was formerly an A/B student, but he is currently failing several subjects. He complains of frequent headaches, sometimes of sufficient severity to cause him to leave school or stay home from school. Describe your approach to the evaluation and management of this patient, including pertinent questions you would ask, lab tests (if any), and other diagnostic studies (if any).
34. A young couple brings their children to see you for their first visit after moving to your town. The parents have 3 children, ages 1 year, 3 years, and five years. The children are all healthy. The parents have moved into a new residential area near an elementary school, and have a swimming pool in their back yard. The 5 year old announces that "Granddaddy is going to give me a motor scooter for my birthday". Describe the well-child care issues that should be discussed with this family.
35. A 13-year-old boy presents to your office for a pre-camp physical. On physical exam, you note that he has a low-grade fever, and that he has several large bruises on his thighs, shins, upper arms and lower back, as well as some petechiae. What is your differential diagnosis, and what historical and physical findings will help you in arriving at a final diagnosis? What lab tests will you order (if any)?
36. The mother of a newborn infant asks to see you to discuss the newborn screening tests about to be performed on her child; she is unhappy and does not want her child to "get stuck". In your state, the usual mandated tests are for PKU, maple syrup urine disease, galactosemia, homocystinuria, congenital hypothyroidism, biotinidase deficiency, and sickling hemoglobinopathies. What will you tell her about these tests, and how will you respond to her concerns about testing her child?
37. A 24 month old black male infant presents to the emergency room with lethargy, tachypnea, and tachycardia. On physical exam, his height is 84 cm and weight 25 kg. His temperature is 39.9oC. You obtain a CBC; his hematocrit is 12%, with hemoglobin 3.8 gm/dl; his wbc is 2,000. How will you proceed in your evaluation and management of this patient? Include pertinent medical history, physical findings you would look for, and additional lab tests (if any), and your initial management. How would your diagnosis and management differ if there was a recent history of mothball ingestion?
38. A 6-year-old child is referred to you because of poor school performance. The family recently moved to your community when the father was discharged from the army; they had been living in a relatively old apartment building near the base which had been "stripped" and repainted several times while they were there. The father asks you about the possibility of lead poisoning. What historical features, physical findings, laboratory data, and other studies might be useful in evaluating this child for lead poisoning? If you confirm the diagnosis of lead poisoning, how will you treat this child? Describe the epidemiology of lead poisoning in the United States.
39. A 7-year old boy is referred to you for evaluation of poor school performance. He is losing his friends and the parents are concerned about behavior outbursts. He has always been active and inquisitive, but since entering school, has been oppositional and in increasing trouble with the teacher and his parents. What is the differential diagnosis for this boy? What are the possible interventions? What are the next steps in his work-up?
40. You are called from the emergency room because a patient of yours, age 3 months, has been brought to the hospital by ambulance and could not be resuscitated. He was previously well, and his immunizations were up to date. The parents state that he had a runny nose the night before but acted normally and did not seem to have a fever. He went to bed at the normal time, but was found dead the next morning when the mother went in to check on him. The parents called 911 and attempted CPR, but he did not respond. As this child's primary care physician, how will you approach this situation and family? What studies, if any, will you order or suggest, and why? What agencies, if any, will you involve, and why?