PNCB 1 Pediatric Primary Care / Questions and
applicable solutions
The child at highest risk for having an elevated blood lead level is a:
3 month old exclusively breastfed infant
6 month old who lives in a home built after 1970
2 year old with iron deficiency anemia
2 year old who is a picky eater
D. - (ANSWERS)2 year old with iron deficiency anemia
The amount of lead absorbed from the gut is increased in children with nutritional deficiencies
such as iron deficiency anemia (IDA). Iron deficiency anemia is often a comorbidity of lead
poisoning. The hand-to-mouth behavior of infants and young children increases their lead
exposure. However, living in a home built after 1970 reduces the risk since residential paint
used in that era should not have been lead based. Infants more than 4 months of age exclusively
breast fed without supplemental iron are at increased risk of IDA. A child who is a picky eater
may or may not be at high risk for IDA, depending on foods actually eaten.Which laboratory
assessment is the BEST indicator of vitamin D deficiency?
Which laboratory assessment is the BEST indicator of vitamin D deficiency?
25(OH)-D (cholecalciferol)
1,25(OH)2-D (calcitriol)
PTH (parathyroid hormone)
25(OH)-D (cholecalciferol) - (ANSWERS)25(OH)-D (cholecalciferol)
The best diagnostic study of vitamin D deficiency is the level of 25(OH)-D (cholecalciferol).
1,25(OH)2-D (calcitriol) is the active metabolite of 25(OH)-D, but due to its short half-life it is
not a good indicator of vitamin D sufficiency. The parathyroid hormone releases calcium from
bone. Rachitic changes can be seen at growth plates and decreased calcification leads to
thickening of the growth plate. Serum calcium and phosphorous are initial screening tests but
not the best indicator of vitamin D deficiency.
,PNCB 1 Pediatric Primary Care / Questions and
applicable solutions
In a 2 month old with visible rib fractures on radiograph, the NEXT most critical evaluation to
obtain is a:
CT scan of the head
Long bone series
Coagulation profile
Retinal ophthalmologic exam - (ANSWERS)CT scan of the head
Posterior rib fractures associated with accidental trauma are rare. Posterior fractures can be
seen in infants who have been shaken as the perpetrator hands are typically wrapped around
the infant's thorax during the shaking, with the vertebrae acting as a fulcrum. These findings
should alert the provider to consider shaken baby syndrome (SBS). Subdural and subarachnoid
hemorrhages are the most common acute intracranial injuries seen in SBS and are associated
with high rates of morbidity and mortality. Thus, the most important study to do next is a CT
scan. Studies have shown that nearly one third of confirmed abusive head trauma cases were
missed on initial presentation, and many infants then sustain additional brain injury along with
poorer neurologic outcomes because of the delay in diagnosis. Long bone studies will be
needed as part of a thorough work-up of non-accidental trauma, but the skull would be the
most critical area to image first. Coagulation studies are done to rule out any coagulation
problem associated with injury to the brain and are important for medico-legal reasons, but
again, brain studies take precedence. A thorough ophthalmologic exam is needed in suspected
cases of SBS—preferably done by a pediatric ophthalmologist.
The MOST common barrier related to transitioning health care for an adolescent with special
needs or chronic illness is
Finding an adult health care provider for transition.
Resistance of the family and adolescent to transition of care.
Lack of health care provider time to plan for transition of care.
Difficulty in talking with patients about transitioning care. - (ANSWERS)finding an adult health
care provider for transition.
,PNCB 1 Pediatric Primary Care / Questions and
applicable solutions
Finding an adult health care provider, one who is qualified to care for young adults with special
health care needs, is the most commonly perceived barrier to the successful transition of
health care as identified by family and young adults, pediatric health care providers, and adult
internists. Transitioning of care requires time and communication with the parents and
adolescents involved. Many families may be hesitant to leave the nurturing environment of
pediatric care, and may perceive differences in adult practices as a difficult adjustment.
Internists may lack the training and qualifications to address many of the complicated health
care needs of adolescents with chronic illnesses. Because of the delicate nature of such
conversations, some pediatric providers may not be comfortable in dealing with the
complexities of transitioning care.
A toddler is unable to use the right arm normally after the caregiver pulled her arm to prevent
the child from falling. Which finding would confirm the diagnosis of subluxation of the radial
head?
Severe swelling and bruising of the elbow
Elbow flexed with pronated forearm
Point tenderness at ulnar aspect of elbow
Obvious deformity of the forearm - (ANSWERS)elbow flexed with pronated forearm
Subluxation of the radial head, also called nursemaid's elbow, must be differentiated from a
fracture prior to reducing the annular ligament of the elbow. Radiographic examination is not
necessary if the child's physical findings and history are consistent with subluxation. The
typical presentation of this injury includes the following: age 2-5 years; history of a longitudinal
traction injury, possible "pop" and immediate pain, inability to use the arm normally, and arm
splinted against the side. On examination the elbow appears normal, is flexed with a pronated
forearm against the body, is tender laterally over the radial head, and has limited flexion with no
supination. If the child fell on his/her elbow or there is no history of a traction injury, suspect a
fracture and order the appropriate radiograp
Education for caregivers whose child has sickle cell disease should include that the majority of
pain crises are triggered by which of the following?
No identifying cause
Temperature changes
, PNCB 1 Pediatric Primary Care / Questions and
applicable solutions
Cigarette smoke exposure
Stressful situations - (ANSWERS)no identifying cause
Sickle cell disease is a common genetic hematologic disorder. Pain is the most common and
disabling symptom of sickle cell disease. Environmental temperature and second-hand smoke
exposure have been studied as possible precipitating factors, but have not been supported by
the research. Negative emotions can facilitate the pain cycle. In general, pain episodes are
erratic and unpredictable and occur for various, unknown reasons.
A 5 year old complains of a painful left eye after being accidentally scratched by a sibling two
hours ago. Fluorescein exam shows a small central corneal abrasion. The MOST appropriate
management during the first 24 hours is
Frequent application of topical antibiotic.
Observation of the injured eye.
Frequent application of topical nonsteroidal anti-inflammatory drops.
Occlusive patching of the injured eye. - (ANSWERS)frequent application of topical antibiotic.
Accidental abrasion of the corneal epithelium causes pain, tearing, and photophobia and is a
common eye injury in children. An abrasion can be detected by examining the eye with a Wood's
lamp after instillation of fluorescein dye. The one time use of a topical ophthalmic anesthetic
may be useful in gaining cooperation for an adequate eye exam. The goal of treatment is rapid
healing of the abrasion. Until such healing occurs, the eye should be protected from infection
by the use of a topical ophthalmic antibiotic every 4-6 hours for a few days. The repeated use
of a topical anesthetic is not recommended, as these medications can cause corneal toxicity
and inhibit the blinking reflex. Topical steroids are not recommended as they lower the eye's
resistance to infection. Oral acetaminophen or ibuprofen and intermittent cool compresses
may manage discomfort. Narcotics are not recommended because of frequent side effects.
The use of topical nonsteroidal anti-inflammatory drops is being studied in the treatment of
some sterile corneal abrasions, such as those acquired during laser treatment of refractive
errors in adults, but are not recommended in management of traumatic corneal abrasions in
children. Patching is no longer recommended for most corneal abrasions, as it does not reduce
discomfort or speed healing and makes instillation of antibiotic medication more difficult. Most
applicable solutions
The child at highest risk for having an elevated blood lead level is a:
3 month old exclusively breastfed infant
6 month old who lives in a home built after 1970
2 year old with iron deficiency anemia
2 year old who is a picky eater
D. - (ANSWERS)2 year old with iron deficiency anemia
The amount of lead absorbed from the gut is increased in children with nutritional deficiencies
such as iron deficiency anemia (IDA). Iron deficiency anemia is often a comorbidity of lead
poisoning. The hand-to-mouth behavior of infants and young children increases their lead
exposure. However, living in a home built after 1970 reduces the risk since residential paint
used in that era should not have been lead based. Infants more than 4 months of age exclusively
breast fed without supplemental iron are at increased risk of IDA. A child who is a picky eater
may or may not be at high risk for IDA, depending on foods actually eaten.Which laboratory
assessment is the BEST indicator of vitamin D deficiency?
Which laboratory assessment is the BEST indicator of vitamin D deficiency?
25(OH)-D (cholecalciferol)
1,25(OH)2-D (calcitriol)
PTH (parathyroid hormone)
25(OH)-D (cholecalciferol) - (ANSWERS)25(OH)-D (cholecalciferol)
The best diagnostic study of vitamin D deficiency is the level of 25(OH)-D (cholecalciferol).
1,25(OH)2-D (calcitriol) is the active metabolite of 25(OH)-D, but due to its short half-life it is
not a good indicator of vitamin D sufficiency. The parathyroid hormone releases calcium from
bone. Rachitic changes can be seen at growth plates and decreased calcification leads to
thickening of the growth plate. Serum calcium and phosphorous are initial screening tests but
not the best indicator of vitamin D deficiency.
,PNCB 1 Pediatric Primary Care / Questions and
applicable solutions
In a 2 month old with visible rib fractures on radiograph, the NEXT most critical evaluation to
obtain is a:
CT scan of the head
Long bone series
Coagulation profile
Retinal ophthalmologic exam - (ANSWERS)CT scan of the head
Posterior rib fractures associated with accidental trauma are rare. Posterior fractures can be
seen in infants who have been shaken as the perpetrator hands are typically wrapped around
the infant's thorax during the shaking, with the vertebrae acting as a fulcrum. These findings
should alert the provider to consider shaken baby syndrome (SBS). Subdural and subarachnoid
hemorrhages are the most common acute intracranial injuries seen in SBS and are associated
with high rates of morbidity and mortality. Thus, the most important study to do next is a CT
scan. Studies have shown that nearly one third of confirmed abusive head trauma cases were
missed on initial presentation, and many infants then sustain additional brain injury along with
poorer neurologic outcomes because of the delay in diagnosis. Long bone studies will be
needed as part of a thorough work-up of non-accidental trauma, but the skull would be the
most critical area to image first. Coagulation studies are done to rule out any coagulation
problem associated with injury to the brain and are important for medico-legal reasons, but
again, brain studies take precedence. A thorough ophthalmologic exam is needed in suspected
cases of SBS—preferably done by a pediatric ophthalmologist.
The MOST common barrier related to transitioning health care for an adolescent with special
needs or chronic illness is
Finding an adult health care provider for transition.
Resistance of the family and adolescent to transition of care.
Lack of health care provider time to plan for transition of care.
Difficulty in talking with patients about transitioning care. - (ANSWERS)finding an adult health
care provider for transition.
,PNCB 1 Pediatric Primary Care / Questions and
applicable solutions
Finding an adult health care provider, one who is qualified to care for young adults with special
health care needs, is the most commonly perceived barrier to the successful transition of
health care as identified by family and young adults, pediatric health care providers, and adult
internists. Transitioning of care requires time and communication with the parents and
adolescents involved. Many families may be hesitant to leave the nurturing environment of
pediatric care, and may perceive differences in adult practices as a difficult adjustment.
Internists may lack the training and qualifications to address many of the complicated health
care needs of adolescents with chronic illnesses. Because of the delicate nature of such
conversations, some pediatric providers may not be comfortable in dealing with the
complexities of transitioning care.
A toddler is unable to use the right arm normally after the caregiver pulled her arm to prevent
the child from falling. Which finding would confirm the diagnosis of subluxation of the radial
head?
Severe swelling and bruising of the elbow
Elbow flexed with pronated forearm
Point tenderness at ulnar aspect of elbow
Obvious deformity of the forearm - (ANSWERS)elbow flexed with pronated forearm
Subluxation of the radial head, also called nursemaid's elbow, must be differentiated from a
fracture prior to reducing the annular ligament of the elbow. Radiographic examination is not
necessary if the child's physical findings and history are consistent with subluxation. The
typical presentation of this injury includes the following: age 2-5 years; history of a longitudinal
traction injury, possible "pop" and immediate pain, inability to use the arm normally, and arm
splinted against the side. On examination the elbow appears normal, is flexed with a pronated
forearm against the body, is tender laterally over the radial head, and has limited flexion with no
supination. If the child fell on his/her elbow or there is no history of a traction injury, suspect a
fracture and order the appropriate radiograp
Education for caregivers whose child has sickle cell disease should include that the majority of
pain crises are triggered by which of the following?
No identifying cause
Temperature changes
, PNCB 1 Pediatric Primary Care / Questions and
applicable solutions
Cigarette smoke exposure
Stressful situations - (ANSWERS)no identifying cause
Sickle cell disease is a common genetic hematologic disorder. Pain is the most common and
disabling symptom of sickle cell disease. Environmental temperature and second-hand smoke
exposure have been studied as possible precipitating factors, but have not been supported by
the research. Negative emotions can facilitate the pain cycle. In general, pain episodes are
erratic and unpredictable and occur for various, unknown reasons.
A 5 year old complains of a painful left eye after being accidentally scratched by a sibling two
hours ago. Fluorescein exam shows a small central corneal abrasion. The MOST appropriate
management during the first 24 hours is
Frequent application of topical antibiotic.
Observation of the injured eye.
Frequent application of topical nonsteroidal anti-inflammatory drops.
Occlusive patching of the injured eye. - (ANSWERS)frequent application of topical antibiotic.
Accidental abrasion of the corneal epithelium causes pain, tearing, and photophobia and is a
common eye injury in children. An abrasion can be detected by examining the eye with a Wood's
lamp after instillation of fluorescein dye. The one time use of a topical ophthalmic anesthetic
may be useful in gaining cooperation for an adequate eye exam. The goal of treatment is rapid
healing of the abrasion. Until such healing occurs, the eye should be protected from infection
by the use of a topical ophthalmic antibiotic every 4-6 hours for a few days. The repeated use
of a topical anesthetic is not recommended, as these medications can cause corneal toxicity
and inhibit the blinking reflex. Topical steroids are not recommended as they lower the eye's
resistance to infection. Oral acetaminophen or ibuprofen and intermittent cool compresses
may manage discomfort. Narcotics are not recommended because of frequent side effects.
The use of topical nonsteroidal anti-inflammatory drops is being studied in the treatment of
some sterile corneal abrasions, such as those acquired during laser treatment of refractive
errors in adults, but are not recommended in management of traumatic corneal abrasions in
children. Patching is no longer recommended for most corneal abrasions, as it does not reduce
discomfort or speed healing and makes instillation of antibiotic medication more difficult. Most
