Pediatrics PACKRAT Exam with Complete Solutions
A 10 year-old female experiences fever and polyarthralgia. On examination you note a new early
diastolic murmur. Laboratory results are positive for antistreptolysin O. The patient has no
known drug allergies. Which of the following is the recommended prophylaxis for this
condition?
A. Doxycycline
B. Erythromycin
C. Benzathine penicillin G
D. Trimethoprim/sulfamethoxazole CORRECT ANSWER-(u) A. Doxycycline and Bactrim
are not indicated for the prophylaxis of recurrent rheumatic fever.
(u) B. Erythromycin is considered second line for prophylaxis of recurrent rheumatic fever in a
patient with a penicillin allergy.
(c) C. Recurrences of rheumatic fever are most common in patients who have had carditis
during their initial episode and in children. The preferred method of prophylaxis is Benzathine
penicillin G every four weeks.
A 12 year-old boy presents to the office with pain in his legs with activity gradually becoming
worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his
legs. Examination of the heart reveals an
ejection click and accentuation of the second heart sound. Femoral pulses are weak and
delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated.
Chest x-ray reveals rib notching. Which of the
following is the most likely diagnosis?
A. abdominal aortic aneurysm
B. pheochromocytoma
, Pediatrics PACKRAT Exam with Complete Solutions
C. coarctation of the aorta
D. thoracic outlet syndrome CORRECT ANSWER-(u) A. Abdominal aortic aneurysm is
usually asymptomatic until the patient has dissection or rupture. It is uncommon in a child.
(u) B. Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine
release from the
adrenal medulla, but does not cause variations in blood pressure in the upper and lower
extremities.
(c) C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian
artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the
dilated and pulsatile intercostal arteries and the "3" is due to the coarctation site with proximal
and distal dilations.
(u) D. Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or
subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common
cause of acute arterial occlusion in the upper extremity of adults under 40 years old.
A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical
features?
A. Chest pain
B. Cyanosis
C. Convulsions
D. Palpitations CORRECT ANSWER-(u) A. Chest pain is not a feature of tetralogy of Fallot.
(c) B. Cyanosis is very common in tetralogy of Fallot.
(u) C. Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a
feature of tetralogy of Fallot.
, Pediatrics PACKRAT Exam with Complete Solutions
(u) D. Palpitations are uncommon in tetralogy of Fallot.
An 8-year-old boy is brought to a physician because of palpitation, fatigue, and dyspnea. On
examination, a continuous machinery murmur is heard best in the second left intercostal space
and is widely transmitted over the precordium. The most likely diagnosis is
A. ventricular septal defect.
B. atrial septal defect.
C. congenital aortic stenosis.
D. patent ductus arteriosus. CORRECT ANSWER-(u) A. VSD causes a holosystolic murmur
rather than a continuous machinery-like murmur.
(u) B. ASD causes a fixed split S2 rather than a continuous systolic heart murmur.
(u) C. Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in
the second intercostal space.
(c) D. Patent ductus arteriosus is classically described in children as a continuous machinery-
type murmur that is widely transmitted across the precordium.
A 3-year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the
hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and
erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture
are negative. The most serious systemic complication associated with this disorder is
A. renal.
B. cardiac.
C. pulmonary.
, Pediatrics PACKRAT Exam with Complete Solutions
D. hepatic. CORRECT ANSWER-(c) B. The patient most likely has Kawasaki syndrome. The
major complication with this disorder is
coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology
of this
disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
(u) D. Children with Kawasaki syndrome may have associated hydrops of the gallbladder, but
liver
involvement is not part of this disorder.
A 9 year-old presents with increasing shortness of breath while playing basketball recently. On
examination, radial pulses are exaggerated while femoral pulsations are weak. Chest radiograph
shows rib notching and a mildly enlarged heart. Which of the following is the most likely
diagnosis for this patient?
A. Atrial septal defect
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Tetralogy of Fallot CORRECT ANSWER-(u) A. See B for explanation.
(c) B. In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and a
mildly enlargedheart. Rib notching may also be seen in older children (>8 years old) with large
collaterals.
(u) C. See B for explanation.
(u) D. See B for explanation.
A 10 year-old female experiences fever and polyarthralgia. On examination you note a new early
diastolic murmur. Laboratory results are positive for antistreptolysin O. The patient has no
known drug allergies. Which of the following is the recommended prophylaxis for this
condition?
A. Doxycycline
B. Erythromycin
C. Benzathine penicillin G
D. Trimethoprim/sulfamethoxazole CORRECT ANSWER-(u) A. Doxycycline and Bactrim
are not indicated for the prophylaxis of recurrent rheumatic fever.
(u) B. Erythromycin is considered second line for prophylaxis of recurrent rheumatic fever in a
patient with a penicillin allergy.
(c) C. Recurrences of rheumatic fever are most common in patients who have had carditis
during their initial episode and in children. The preferred method of prophylaxis is Benzathine
penicillin G every four weeks.
A 12 year-old boy presents to the office with pain in his legs with activity gradually becoming
worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his
legs. Examination of the heart reveals an
ejection click and accentuation of the second heart sound. Femoral pulses are weak and
delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated.
Chest x-ray reveals rib notching. Which of the
following is the most likely diagnosis?
A. abdominal aortic aneurysm
B. pheochromocytoma
, Pediatrics PACKRAT Exam with Complete Solutions
C. coarctation of the aorta
D. thoracic outlet syndrome CORRECT ANSWER-(u) A. Abdominal aortic aneurysm is
usually asymptomatic until the patient has dissection or rupture. It is uncommon in a child.
(u) B. Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine
release from the
adrenal medulla, but does not cause variations in blood pressure in the upper and lower
extremities.
(c) C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian
artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the
dilated and pulsatile intercostal arteries and the "3" is due to the coarctation site with proximal
and distal dilations.
(u) D. Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or
subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common
cause of acute arterial occlusion in the upper extremity of adults under 40 years old.
A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical
features?
A. Chest pain
B. Cyanosis
C. Convulsions
D. Palpitations CORRECT ANSWER-(u) A. Chest pain is not a feature of tetralogy of Fallot.
(c) B. Cyanosis is very common in tetralogy of Fallot.
(u) C. Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a
feature of tetralogy of Fallot.
, Pediatrics PACKRAT Exam with Complete Solutions
(u) D. Palpitations are uncommon in tetralogy of Fallot.
An 8-year-old boy is brought to a physician because of palpitation, fatigue, and dyspnea. On
examination, a continuous machinery murmur is heard best in the second left intercostal space
and is widely transmitted over the precordium. The most likely diagnosis is
A. ventricular septal defect.
B. atrial septal defect.
C. congenital aortic stenosis.
D. patent ductus arteriosus. CORRECT ANSWER-(u) A. VSD causes a holosystolic murmur
rather than a continuous machinery-like murmur.
(u) B. ASD causes a fixed split S2 rather than a continuous systolic heart murmur.
(u) C. Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in
the second intercostal space.
(c) D. Patent ductus arteriosus is classically described in children as a continuous machinery-
type murmur that is widely transmitted across the precordium.
A 3-year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the
hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and
erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture
are negative. The most serious systemic complication associated with this disorder is
A. renal.
B. cardiac.
C. pulmonary.
, Pediatrics PACKRAT Exam with Complete Solutions
D. hepatic. CORRECT ANSWER-(c) B. The patient most likely has Kawasaki syndrome. The
major complication with this disorder is
coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology
of this
disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
(u) D. Children with Kawasaki syndrome may have associated hydrops of the gallbladder, but
liver
involvement is not part of this disorder.
A 9 year-old presents with increasing shortness of breath while playing basketball recently. On
examination, radial pulses are exaggerated while femoral pulsations are weak. Chest radiograph
shows rib notching and a mildly enlarged heart. Which of the following is the most likely
diagnosis for this patient?
A. Atrial septal defect
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Tetralogy of Fallot CORRECT ANSWER-(u) A. See B for explanation.
(c) B. In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and a
mildly enlargedheart. Rib notching may also be seen in older children (>8 years old) with large
collaterals.
(u) C. See B for explanation.
(u) D. See B for explanation.
