The only antidepressant approved by the Food and Drug Administration for the treatment of depression in children 8-17 years of age is:
Correct Answer E:
Fluoxetine is the only SSRI approved by the FDA for the treatment of depression in children 8-17 years of age. Tricyclic antidepressants are ineffective in children and have limited effectiveness in adolescents, with safety concerns in both groups. In children and adolescents, there is limited or no evidence evaluating the use of lithium, monoamine oxidase inhibitors, St. John’s wort, or venlafaxine.
A 3-year-old male is brought to your office because of ear pain. On examination you find a round, plastic bead in the lower third of the ear canal close to the tympanic membrane. You restrain the child and unsuccessfully attempt to remove the object despite several attempts, first using water irrigation and then fast-acting glue on an applicator.
Which one of the following is the best option for removal?
Correct Answer B:
After several unsuccessful attempts to remove an object deep in the ear canal of an uncooperative child, it is best to refer the patient to an otolaryngologist for removal under anesthesia. Additional attempts are very unlikely to succeed, especially with the techniques listed. A loop curette cannot be safely placed behind a foreign body that is close to the tympanic membrane. A round, hard object cannot be grasped with forceps. Acetone can be used to dissolve Styrofoam foreign bodies, but it would not dissolve a plastic bead.
You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with the cosmetic appearance and possible future disability, and request that she be treated.
You recommend which one of the following?
Correct Answer A:
There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8-10 years of age who still have cosmetically unacceptable, dysfunctional gaits. Major complications of surgery occur in approximately 15% of cases, and can include residual in-toeing, out-toeing, avascular necrosis of the femoral head, osteomyelitis, fracture, valgus deformity, and loss of position. Thus, observation alone is appropriate treatment for a 5-year-old with uncomplicated anteversion.
A 16-year-old high-school football player plants his left foot to make a cut and feels his left leg give way. He feels a pop in the knee, followed by acute pain. He is evaluated on the field, and examination with the knee flexed 20° reveals that the tibia can be displaced farther anteriorly than with the uninvolved knee.
Which one of the following conditions is most likely?
Correct Answer C:
Anterior cruciate ligament (ACL) tears are the most common ligament injury requiring surgery. Females have a significantly higher rate of ACL tears, with the majority of tears in both men and women occurring without physical contact. In addition to the immediate problems, there is a significant increase in premature osteoarthritis of the knee.
Approximately 50% of patients with this injury develop osteoarthritis in 10-20 years. Findings that help make the diagnosis of ACL tear include a non-contact mechanism of injury, an audible popping sound, early swelling of the joint, and the inability to participate in the game after the injury. Many patients can walk normally and can perform such straight-plane activities as climbing stairs, biking, or jogging. Physical examination using the Lachman test or pivot shift test can be used to further assess whether the ligament is torn. MRI can be used to confirm the diagnosis, although it is not needed if the diagnosis is clear from the history and examination.
The other conditions listed are also sports-related knee injuries, but have different mechanisms of injury or physical findings. Patients with patellar tendon rupture are unable to fully extend their knee and examination shows a palpable defect in the patellar ligament and a high-riding patella. While the mechanism of injury in patients with posterior cruciate ligament tears may be similar to that of ACL injury, the examination would show posterior rather than anterior displacement of the tibia when the knee is flexed at 90° (the posterior drawer sign).
The mechanism of injury of tibial plateau fractures in a healthy young male generally involves a high- energy collision causing a valgus force with axial loading. Patients with patellar dislocations have symptoms similar to those of an ACL injury, including an audible crack or pop and the feeling of the knee giving way after a twisting motion. Immediately following the injury, however, examination would show an obvious deformity, but the patella may spontaneously relocate prior to the on-field exam. There would be no instability on the Lachman maneuver.
You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September, and he tells you that he has severe symptoms every autumn that impair his academic performance. He has a strongly positive family history of atopic dermatitis.
Which one of the following medications is considered optimal treatment for this condition?
Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety.
→ Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms.
→ Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.
→ Azelastine, an intranasal antihistamine, is effective for controlling symptoms but can cause somnolence and a bitter taste.
→ Oral antihistamines are not as useful for congestion as for sneezing, pruritus, and rhinorrhea. Overall, they are not as effective as topical glucocorticoids.
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