An infant is delivered at full term by a spontaneous vaginal delivery to a 30-year-old primigravida. At delivery, the infant is noted to have subcostal retractions and cyanosis despite good respiratory effort. The abdomen is scaphoid. On bag and mask ventilation, auscultation of the lungs reveals decreased breath sounds on the left, with heart sounds louder on the right.
Which of the following is the most likely diagnosis?
Correct Answer B:
Congenital diaphragmatic hernia is often seen on prenatal ultrasound. A diaphragmatic hernia is a defect in the hemidiaphragm that allows the abdominal contents into the thorax. It has the findings of respiratory distress, cyanosis, and scaphoid abdomen. Auscultation will show decreased breath sounds on the affected side. It occurs more often on the left side than the right.
What is the most frequent etiologic agent of occult bacteremia in children?
Correct Answer C:
With widespread immunization against Haemophilus influenzae infection, Streptococcus pneumoniae has become the predominant cause of serious bacterial infection in infants and young children. In a study of about 9000 well-appearing older infants and young children, 149 (1.7%) had positive blood cultures, 92% of which were S. pneumoniae.
A 6-year-old boy is brought to the office by his mother because of the gradual onset of abdominal pain. Today, on physical examination, the child does not appear to be in acute distress. Abdominal examination shows normal bowel sounds, no tenderness, and is otherwise inconclusive.
Which of the following is the most appropriate next step?
Correct Answer A:
It is important to differentiate whether the patient’s abdominal pain is due to an underlying organic, psychogenic, or functional cause. A full history must be taken to determine the nature and characteristics of the pain and any associated symptoms. The initial interview should be performed with the entire family together; however, the patient and parents should then be interviewed separately. At this point, the physician may be able to discern if the abdominal pain is a manifestation of a stress in the home or school environment. The patient may also be more forthcoming when interviewed alone, and may verbalize any fears or complaints more easily.
A 12-year-old girl, who has been undergoing treatment for chronic juvenile rheumatoid arthritis for the past three years, is brought to the office because of painful swelling of the right knee. She has had three episodes of painless swelling of her left knee and ankle, which have subsided spontaneously with rest and aspirin therapy. On physical examination today there is pronounced redness and warmth around the right knee, and a large effusion is present. Attempts at active and passive motion cause severe pain.
Which of the following is the most appropriate step at this time?
Aspiration of the joint (choice B) should be done in this patient because she has clinical findings suspicious for septic arthritis. These clinical findings include redness and warmth around the knee, large effusion, and pain upon movement of the joint. Diagnostic arthrocentesis should be performed in all patients in whom the diagnosis of septic arthritis is considered.
→ Obtaining a 99mm technetium bone scan (choice A) may aid in the diagnosis of a septic joint by demonstrating increased soft tissue uptake in the region of the joint. However, this is an aid to diagnosis; the “gold standard” is the joint aspirate.
→ Obtaining an antinuclear antibody titer (choice C) would not be helpful, as we already know that this patient has juvenile rheumatoid arthritis (JRA), and an ANA (choice D) depending on the type of JRA may or may not be positive. The focus should be on determining if the knee is septic, only the joint aspirate will give us this information.
Which of the following investigations is most helpful in the assessment of a child presenting with an acute asthma attack?
Correct Answer D:
Known asthmatics with an acute exacerbation should have pulse oximetry and either PEF or FEV1 measurement (choice D). All 3 measures help establish the severity of an exacerbation and document treatment response. PEF values are interpreted in light of the patient's personal best, which may vary widely among patients who are equally well controlled. A 15 to 20% reduction from this baseline indicates a significant exacerbation. When baseline values are not known, the percent predicted value gives a general idea of airflow limitation but not the individual patient's degree of worsening.
→ ABG (choice B) measurements should be obtained in patients with marked respiratory distress or signs and symptoms of impending respiratory failure.
→ Chest x-ray (choice C) is not necessary for most exacerbations but should be obtained in patients with symptoms suggestive of pneumonia or pneumothorax.
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