Pediatrics
Certification Exam Review Online

Educational Objective:

Plan the appropriate initial evaluation and management of acute central nervous system trauma.

Explanation:

Children younger than 2 years of age with any alteration of mental status; have a Glasgow Coma Scale score of less than 15; or those with palpable skull fracture require neuroimaging (see Figure).

References:

Atabaki SM, Hoyle JD Jr, Schunk JE, et al. Comparison of prediction rules and clinician suspicion for identifying children with clinically important brain injuries after blunt head trauma.

Acad Emerg Med. 2016;23(5):566-575.

Bressan S, Romanato S, Mion T, Zanconato S, Da Dalt L. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Mihindu E, Bhullar I, Tepas J, Kerwin A. Computed tomography of the head in children with mild traumatic brain injury. Am Surg. 2014;80(9):841-843.

Educational Objective:

Describe the appropriate treatment for an immunosuppressed child experiencing symptoms of herpes simplex virus infection.

Key Point:

Acyclovir is the treatment of choice for symptomatic herpes simplex virus infection in an immunosuppressed child.

Explanation:

Gingivostomatitis is the most common clinical manifestation of herpes simplex virus (HSV) infection during childhood. Immunocompromised children are more at risk for severe local lesions or disseminated disease.

First-line of therapy for mucocutaneous lesions in immunocompromised children is intravenous acyclovir. Foscarnet is the recommended drug for acyclovir-resistant disease and more severe infections.

Pain control with ibuprofen or acetaminophen would also be important; however, pain relief alone is not appropriate. Amphotericin B is an antifungal medicine, and sulfamethoxazole/trimethoprim is an antibiotic for bacterial infections; thus, neither of these medications would be appropriate for HSV infection.

References:

American Academy of Pediatrics. Red Book: Report of the Committee on Infectious Diseases. 31st ed., 2018.

Michaels MG, Green M. Infections in immunocompromised persons. In: Kliegman RM, et al. Nelson Textbook of Pediatrics. 20th ed., 2016:1287-1295.

Educational Objective:

List signs, symptoms, causes, and complications of hydronephrosis in infants.

Key Point:

Hydronephrosis is the most common characteristic of urinary tract obstruction and can be diagnosed on renal ultrasonography.

Explanation:

This neonate has an abdominal mass and weak urinary stream indicating urinary tract obstruction. Hydronephrosis is the most common characteristic of urinary tract obstruction and may be diagnosed prenatally by ultrasonography, but it may be asymptomatic until its severe stages.

Hydronephrosis should be included in the differential diagnosis for an infant with an abdominal mass. Other causes of abdominal masses in a neonate may include a multicystic dysplastic kidney. Upper urinary tract dilation is not necessarily an indication of obstruction on renal ultrasonography. This may occur if there is abnormal development of the urinary tract outside of urinary obstruction.

VUR may be associated with hydronephrosis, but it cannot be diagnosed by ultrasonography. Voiding cystourethrography is required for diagnosis. An infant with an abdominal mass and weak urinary stream is not likely to have normal findings on renal ultrasonography.

Complications of untreated urinary obstruction and hydronephrosis include postrenal azotemia, increased risk for urinary tract infections and pyelonephritis, upper urinary tract stones, weak urinary stream, incontinence, failure to thrive, flank pain, and nausea/vomiting.

Reference:

Elder J. Obstruction of the urinary tract (chapter 540). In: Kliegman, R ed. Nelson Textbook of Pediatrics. 20th ed., 2016:2567-2575.

Educational Objective:

Identify the most common congenital heart lesions found in full term infants.

Key Point:

VSD is the most common congenital heart lesion found in full-term infants.

Explanation:

VSD makes up 25% of congenital heart disease. Clinical findings vary based on size, pulmonary blood flow. and pressure. When the VSD is small and left-to-right shunting is trivial, a patient may be asymptomatic and only discovered during a routine physical examination. A large VSD with high pulmonary blood flow and pulmonary hypertension may cause dyspnea, feeding difficulties, and cardiac failure in a infant.

A patient with PDA may have a machinery-like continuous murmur on the left sternal border. An infant born with tetralogy of Fallot will usually have a loud harsh murmur. COA may cause a short systolic murmur heard on the left sternal border as well as a systolic ejection click.

Reference:

Kliegman RM, et al. Acyanotic congenital heart disease: left-to-right shunt lesions (chapter 426). In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016:2189-2199.