Pediatric Examination and Board Review (208 page)

(C) caput succedaneum

(D) A or B

(E) none of the above

3.
Later on, the mother calls the nurse because the baby has developed a rash. It is red, macular, and papular/pustular and most prominent over the face and trunk. The mother wonders if the baby is allergic to her milk. You explain

(A) “this is erythema toxicum”

(B) “we need to change the baby to a soy formula”

(C) “the baby is allergic to the baby lotion”

(D) “this is a staphylococcal infection”

(E) “I must perform some laboratory tests to determine the cause”

4.
In the above case you decide to do a Wright stain of material from a pustule. You will likely see

(A) sheets of eosinophils

(B) many bacteria

(C) many neutrophils

(D) a dendritic pattern

(E) cellular debris

5.
If there had been shoulder dystocia at delivery and the baby was holding one arm limply at her side, but had a good palmar grasp on the same side, you would diagnose a probable

(A) upper brachial plexus injury (Erb palsy)

(B) lower brachial plexus injury (Klumpke palsy)

(C) fractured clavicle

(D) Werdnig-Hoffman syndrome

(E) fractured humerus

6.
Within the gluteal fold, at the tip of the coccyx, you find a deep dimple. You should

(A) obtain an ultrasound of the spine

(B) obtain an MRI of the spine

(C) order a neurosurgical consult

(D) do nothing

(E) obtain a renal ultrasound

7.
At the anterior margin of the crus of the helix, you note a pinhole opening. The least accurate statement about ear pits is

(A) they commonly run in families

(B) they are an indication for a renal ultrasound

(C) it is important to assess hearing in both ears

(D) they may be associated with branchial cleft fistulae along the neck

(E) they may be associated with Goldenhar syndrome

8.
You find a minor anomaly on your examination of the baby, namely, bilateral single palmer creases. Should you suspect Down syndrome?

(A) yes

(B) no

9.
The mother asks about the red spots on the white of the baby’s eyes. You explain that

(A) they are small hemorrhages from the pressure of labor on the baby

(B) they may represent brain injury and you will order tests

(C) they are from the ointment put in the eyes

(D) you suspect chlamydia

(E) you suspect gonorrhea

10.
The mother expresses concern about a white vaginal discharge. You explain to the mother

(A) this is normal

(B) you will do tests for an infection on the baby

(C) you will obtain an estradiol level on the baby

(D) you will obtain a luteinizing hormone (LH) and follicle-stimulating hormone (FSH) level on the baby

(E) you will need to obtain lab work on the mother

11.
There are multiple tiny yellow papules on the baby’s nose. These are

(A) prominent sebaceous glands

(B) epithelial inclusion cysts (milia)

(C) neonatal acne

(D) dermoid cysts

(E) scabies

12.
You feel a sharp liver edge 2-3 cm below the right costal margin. This represents hepatomegaly

(A) yes

(B) no

13.
On examination of the hips, you find instability on one side with a palpable “clunk” on the Ortolani maneuver. You should

(A) immediately put the baby in a harness

(B) order triple diapers for the baby

(C) repeat the examination (if the clicks are still apparent, an ultrasound examination is the next step)

(D) order an MRI

(E) order a technetium triple-phase bone scan

14.
During your discharge examination on day 2, you hear a grade 2-3 systolic murmur. You tell the parents that

(A) “it is nothing; all babies have murmurs”

(B) “I am going to check an oxygen saturation”

(C) “I am going to order an electrocardiogram (ECG)”

(D) “I am going to call a pediatric cardiologist”

(E) “I am going to transfer your infant to the NICU for further evaluation”

ANSWERS

1.
(C)
Caput succedaneum is a diffuse, sometimes ecchymotic soft tissue swelling of the presenting part in a vertex delivery.

2.
(A)
Cephalhematoma is a subperiosteal hemorrhage. Therefore, it does not cross suture lines but can be bilateral. There is no discoloration of the overlying scalp. Subgaleal hemorrhage occurs as a consequence of subaponeurotic bleeding. It crosses suture lines and is not usually associated with a skull fracture. Because a subgaleal hemorrhage can be large, it can lead to a drop in the hematocrit and resulting hyperbilirubinemia.

3.
(A)
A maculopapular rash on an erythematous base seen 1-3 days after birth is most likely erythema toxicum. It has no known allergic component and requires no laboratory investigation.

4.
(A)
A Wright stain of material from pustules will show eosinophils. Bacteria and neutrophils should be absent.

5.
(A)
Forty-five percent of brachial plexus injuries are associated with shoulder dystocia. Erb palsy is an upper brachial plexus injury involving the 5th and 6th cervical nerves. The arm is adducted and pronated. In Erb palsy, the hand grasp is present. In Klumpke palsy, the 7th and 8th cervical and 1st thoracic nerves are affected and the hand grasp is absent.

6.
(D)
Most dimples that fall within the gluteal fold are normal. Dimples that are large and located above the gluteal fold, such as a sacral dimple, are associated with other midline skin lesions like hemangiomas, lipomas, or skin tags and should be further investigated.

7.
(B)
Preauricular pits may be hereditary and can be commonly found in other family members. Preauricular pits, as a finding in certain syndromes, have been associated with deafness. There is no known association between preauricular pits and renal disease.

8.
(B)
A single palmar crease is a nonspecific finding in an otherwise normal infant. A unilateral single palmar crease is present in 4% of normal people, and bilateral, single palmer creases occur in about 1% of normal people. Down syndrome nearly always has other associated findings.

9.
(A)
Small subconjunctival hemorrhages are common and are of no clinical importance. No further workup is necessary.

10.
(A)
This is a result of maternal estrogen that crossed the placenta and will resolve with time. It takes longer for a baby girl to metabolize and excrete the estrogen. Thus sometimes maternal estrogen can cause some vaginal discharge in the baby.

11.
(B)
Milia are tiny inclusion cysts within the epidermis. Sebaceous hyperplasia occurs in large plaques.

12.
(B)
The liver is usually palpable 2-3 cm below the costal margin in normal neonates without associated disease.

13.
(C)
The diagnosis is most likely laxity of the ligaments, a benign disorder, but investigation for hip dislocation should occur if the finding is consistently present.

14.
(D)
Any murmur grade 2 or greater after the first 24 hours of life warrants a cardiologist’s evaluation to check for the presence of an atrial septal defect, a ventricular septal defect and to evaluate the baby’s hematologic status. If the murmur is greater than grade 2, a follow-up examination suffices as an initial approach because this is most likely a flow or benign murmur.

S
UGGESTED
R
EADING

Martin R, Fanaroff AA, Walsh M.
Fanaroff and Martin’s Neonatal-Perinatal Medicine Diseases of the Fetus and Infant.
8th ed. Chicago, IL: Elsevier Mosby; 2006.

CASE 118: A TERM NEONATE FOUND TO HAVE LOW BIRTHWEIGHT AFTER DELIVERY

A full-term baby is born to a 16-year-old mother. The prenatal course was notable for suspected intrauterine growth retardation. The birthweight is 2325 g.

SELECT THE ONE BEST ANSWER

1.
In the evaluation of a low-birthweight term SGA newborn, which of the following should be considered?