NMS Q&A Family Medicine

Care and Prevention, Ages 1 to 5 Years 261Examination Answers1. The answer is C. Erythema infectiosum or fifth disease.The “slapped cheek” look is like none of the otherchoices. Rubella has a much shorter course, a typical morbilliformrash and suboccipital and post auricular adenopathy.Rubeola manifest a seriously toxic illness, theharder and more severe morbilliform rash and the buccalmucosal Koplik spots opposite the lower second molar;roseola is the well-known rash that appears as a prolongedhighly febrile phase abates.2. The answer is D. A macrolide. The description is classicfor pertussis, which has been making a comeback, duein great part to hysteria over vaccine side effects. The typicalaspects mentioned, besides the “whoop” of inspiratorystridor are the prolonged prodromal catarrhal stage; thewhoop (which if untreated, may last for another 4–6weeks); the absolute lymphocytosis and the “shaggy heartborder” on x-ray. An acceptable application of a macrolideantibiotic would include the standard dosages of erythromycinfor 7–14 days.3. The answer is E. No action is needed at this time; reassurethe parent that the child is growing normally.Although babies should double the birth weight by6 months and many babies triple their birth weights bythe age of 1 year, growth rate decelerates rapidly after thefirst year. The average boy gains about 5 lb (2.26 kg) duringthe period from 1 year to 2 years of age. In this situation,there is neither indication for endocrinologicaltesting nor any need for force feeding.4. The answer is C. Varicella vaccine requires only onedose, when the child is between 12 and 25 months of age.It may be given at any time through the years of youth toanyone who has not received it. The child receives DTaP at2, 4, 6, and 12 to 15 months, and then a booster at 4 to6 years. PCV is given at 2, 4, 6, and 12 to 15 months. Hibvaccine is given at 2, 4, 6, and 12 to 15 months. IPV isgiven at 2, 4, and 6 to 15 months and at 4 to 6 years.5. The answer is D. All persons older than 6 months ofage should receive the influenza vaccine on an annualbasis. The AAP and AAFP agree that all children betweenthe ages of 6 months and 18 years should receive the vaccine,and the ACIP states that all adults should receiveinfluenza vaccine yearly.6. The answer is D. Reassure the parents that the child isdeveloping within normal limits. A fair rule of thumb inevaluating language development is two-word sentencesat age 2; four-word sentences at age 3; five-word sentencesat age 4; and six- or seven-word sentences at age 5. Reviewof growth and development milestones is not a matterreserved for addressing a genuine concern. It is somethingthat should take place at each well child visit.7. The answer is D, high (4 ft or 1.8 m) fences with selflatchinggates around swimming pools. Each of the otherchoices merits attention and would be an effective supplementto fencing the swimming pools, but the choices areunproven in effectiveness to prevent drowning. Choice E,outlawing private swimming pools, has not been triedand tested; such a law would not likely be passed in anycommunity. Blood lead level should be 10 mcg/dL. Evenexposures to levels in the 10–15 mcg/dL range if prolongedcan produce behavioral and cognitive effects.Ongoing studies have resulted in steady reduction of leadlevel cutoff points over the past 30 years. All the otherchoices are appropriate periodically but not annually ifthe child is healthy. The child need not be screened forthalassemia despite the half Italian parentage. Both and thalassemias would be picked up on a CBC with attentionto the MCV that would show microcytosis out ofproportion to an anemia.8. The answer is A. Lead-based paint was used in housesbuilt before 1960. Nearby industry that places children athigh risk includes lead smelting and battery manufacturing.Routine screening starts when the child reaches theage of 1 year, with checks at 6 months only for those childrenat high risk. Some physicians apply a written questionnairefor risk factors instead of automatic level checksin neighborhoods where lead toxicity is rare. Childrenshould be checked with serum lead levels at any age if theyhave symptoms of lead poisoning or exhibit a lot of handto-mouthactivity.9. The answer is A, motor vehicle accidents. Motor vehicleaccidents (with children as a vehicle occupant or pedestrian)account for about 47% of injury deaths in children.In 1998, 57% of children 15 years of age and younger whodied in motor vehicle accidents were unrestrained.10. The answer is D, Klinefelter syndrome. Klinefelter syndromeis associated with tall stature with disproportionalincreases in long bones. All the other mentioned diseasesresult in growth retardation of a child. Parental deprivationleads to starvation, sometimes through anorexia; intrauterinegrowth retardation, by definition, is characterized bythe child’s starting life in a growth-retarded state; HIV