Pediatric Primary Care PNCB 1
Questions with Verified Answers
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. - ANSWERS2 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) - ANSWERS25(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.
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 - ANSWERSCT 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. - ANSWERSfinding an adult
health care provider for transition.
,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 - ANSWERSelbow 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
cigarette smoke exposure
, stressful situations - ANSWERSno 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. - ANSWERSfrequent 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 corneal abrasions heal steadily over the first
24-48 hours. Persistent or increasing pain or discomfort after the first 24 hours indicates
the need for further ophthalmologic evaluation.
Questions with Verified Answers
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. - ANSWERS2 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) - ANSWERS25(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.
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 - ANSWERSCT 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. - ANSWERSfinding an adult
health care provider for transition.
,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 - ANSWERSelbow 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
cigarette smoke exposure
, stressful situations - ANSWERSno 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. - ANSWERSfrequent 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 corneal abrasions heal steadily over the first
24-48 hours. Persistent or increasing pain or discomfort after the first 24 hours indicates
the need for further ophthalmologic evaluation.
