Pediatric Examination and Board Review (48 page)

23.
(E)
100% can schedule daily activities independently

24.
(E)
100% can use a pay telephone

25.
(E)
100% can choose appropriate clothes to wear

26.
(E)
100% can follow a national news event

27.
(E)
100% can act appropriately toward strangers

28.
(E)
100% can sustain a friendship with another person

29.
(E)
100% can anticipate hazards appropriately

As an adult, Max will be able to sustain employment; however, his chances of meeting all current requirements for high school will be compromised.

30.
(B)
He will be able to work many jobs not requiring college experience.

S
UGGESTED
R
EADING

Aylward GP. Overview of school performance problems. In: Aylward GP, ed.
Practitioner’s Guide to Developmental and Psychological Testing
. New York, NY: Plenum Medical; 1994:91-103.

Dixon SD, Stein MT, eds.
Encounters with Children: Pediatric
Behavior and Development.
4th ed. St. Louis, MO: Mosby; 2005.

Illingworth RS. The examination of the older infant and child. In: Illingworth RS, ed.
The Development of the Infant and Young Child: Normal and Abnormal
. Edinburgh, United Kingdom: Churchill Livingstone; 1987:205-230.

Palmer F, Capute A. Mental retardation.
Pediatr Rev.
1994;15:473-479.

Roberts KB. Development and developmental disabilities. In: Roberts KB, ed.
Manual of Clinical Problems in Pediatrics
. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:96-101. Wolraich ML. Disorders of mental development: general issues.

In: Wolraich ML, ed.
Disorders of Development and Learning.
3rd ed. Hamilton, Ontario, Canada: BC Decker; 2003:195-205.

CASE 27: A NEONATE GIRL WITH FLOPPY TONE AND UPWARD-SLANTING EYES

A newborn girl named Amy presents to the evening nurse in the general care nursery with floppy tone and dysmorphic features. She is born full term to a 28-yearold woman who has been pregnant twice and given birth once whose first pregnancy resulted in a healthy daughter. She has delivered a full-term 3-kg girl. Pregnancy, labor, and delivery were all uncomplicated except for a winter flu episode of 48 hours in the first trimester. The obstetrician has told the parents that all went well.

SELECT THE ONE BEST ANSWER

1.
What are the physical examination findings that occur in 50% but not in 90% of individuals with Down syndrome?

(A) midface hypoplasia

(B) excess nuchal skin

(C) small ears

(D) central hypotonia

(E) wide space between first and second toes

2.
Your examination reveals a clustering of craniofacial dysmorphism, central hypotonia, and a strong Moro. When you come in to discuss your concerns with the family, you should

(A) talk to the father alone

(B) tell the nurse what to say to the mother

(C) talk to both parents and describe what the evaluation and follow-up process will involve

(D) talk to both parents and say that you do not know what to do for children with Down syndrome

(E) describe in detail all that children with Down syndrome cannot do

3.
What medical concern listed below is not associated with gastrointestinal (GI) malformations?

(A) oligohydramnios

(B) vomiting after first feed

(C) delayed passage of meconium

(D) choking during feedings

(E) double bubble on abdominal radiograph

4.
Which of the following cardiac malformations does not commonly occur in infants with Down syndrome?

(A) atrioventricular canal

(B) tetralogy of Fallot

(C) hypoplastic left heart syndrome (HLHS)

(D) atrial septal defect (ASD)

(E) ventricular septal defect (VSD)

5.
Atrioventricular canal defect symptoms frequently include all the following except

(A) constipation

(B) feeding difficulties

(C) difficulty gaining weight

(D) congestive heart failure

(E) excessive sweating

6.
The karyotype report is 47XX+21. Cardiology consultation revealed an AV canal defect on echocardiogram. Amy is having difficulty gaining weight. The cardiovascular surgical consultant informed the parents that definitive surgical correction would take place when the child weighs at least 15 pounds. All of the following are acceptable strategies for addressing Amy’s feeding difficulties except

(A) observe breastfeeding and weigh child before and after 20 minutes of feeding

(B) tell mother that children with Down syndrome are difficult to breast-feed

(C) monitor weight using growth charts specific for Down syndrome and have Dad offer pumped breast milk by bottle

(D) add nasogastric feeds at night

(E) none of the above

7.
Amy gained weight slowly, but feeding difficulties continued. At age 2 months, she was hospitalized for respiratory syncytial virus (RSV) pneumonitis with congestive heart failure. At age 4 months, pulmonary artery banding took place. Now, at age 6 months, Amy weighs 10 pounds. She has continuous nasal discharge. It takes her 40 minutes to drink 4 ounces of fortified formula. Significant head lag is noted. In prone, Amy does not roll. She likes to put two hands on her bottle during feeding. Amy is in Early Intervention. What is the primary goal of Early Intervention?

(A) vigorous PT to strengthen Amy’s neck muscles

(B) developmental feeding interventions with regular feedback to physicians

(C) hospitalization so that Mom might get some rest

(D) enrollment in a day-care program outside of home

(E) facilitate starting solid foods to maximize weight gain velocity

8.
At age 2, Amy is status postsurgical repair of her AV canal defect at 18 months. Since surgery, she has made rapid progress in motor skills with attainment of independent ambulation, more fine motor manipulative play, and increased verbal production of single words and jargon use. She awakes at 1:00 AM and 3:00 AM nightly. She returns to sleep if given a bottle of milk or taken into her parents’ bed. Night awakening often occurs in a toddler with any of the following issues except

(A) difficulty self-soothing

(B) nightmares

(C) sleep-onset disorder

(D) circadian rhythm disorder

(E) seizures secondary to open heart surgery

9.
In the daytime, frequent temper tantrums occur, especially during the feeding time of her newborn brother. Temper tantrums should be managed by

(A) discussing in detail what Amy is doing wrong

(B) trying to figure out the exact trigger

(C) putting Amy in her room with the door closed for 30 minutes

(D) giving Amy candy to stop

(E) ignoring them

10.
By age 5, Amy successfully completed 3 years of a special preschool attendance. She speaks in short sentences with 50% intelligibility to strangers. She is toilet trained during the day. She can dress with simple pullovers but cannot handle buttons, snaps, or zippers independently. She cannot do her own Velcro sneakers. She is 10% for height and 75% for weight on the Down syndrome growth charts. Her favorite activity is watching
Sesame Street
and cartoons. All are appropriate goals for mainstreaming in kindergarten except

(A) promoting communication

(B) promoting interaction with typical peers

(C) normalizing IQ

(D) enhancing adaptive skills

(E) providing supports for functional skills

11.
At age 5, Amy pushes and bites her brother’s playmates. What suggestions would you make for behavioral interventions for dealing with Amy’s misbehavior around her brother’s friends?

(A) tell Amy “no” and put her in “time-out”

(B) explain in detail why it is wrong to bite

(C) praise her when she does not bite

(D) teach brother how to bite her back

(E) A and C

12.
At age 5, Amy rips up art work and topples over board games when her older sister is entertaining friends. What is the best approach for dealing with Amy’s problem behaviors with her older sister and older sister’s friends?

(A) loss of television privileges