Karen Estrella-Ramadan

BOARD REVIEWHEALTH SUPERVISION

Question1:A family in your practice who recently immigrated to this country brings a 7y/o niece, who has come to live with them for the next couple of yrs. She reportedly received OPV as part of a governmental program but otherwise has no reported vaccinations. Her uncle reports she had chickenpox at age 3 and has no reported allergies. He has a letter from the girl’s parents authorizing him to make medical decisions for their daughter.

Of the following which would be appropriate to include in the recommended vaccines for this visit?

1. Dtap2. Hib3. HPV4. MMR5. Varicella

At age 7:Pertussis 1st dose tdap, next “catch-up”: TdHib: NO in children >60mo (5y/o)HPV: NO in children <9y/oAlso include catch-up for polio, HepA and

HepB

Question 2:You are assigned to present information to a group of MS rotating to your service. One of the students is currently in her 2nd trimester of pregnancy and has questions regarding varicella vaccination.

Which of the following is the most accurate statement regarding varicella vaccine?

1. Babies of breastfeeding mothers seroconvert after the mother is immunized

2. Vaccination during pregnancy is strongly associated with congenital varicella

3. Vaccinating a 1y/o child of a pregnant mother is contraindicated

4. Breastfeeding is not a contraindication to varicella vaccination.

DVaricella vaccine during pregnancy is NOT

recommended due to a theorethical risk to the fetusHowever, no marked increase in birth defects

and congenital varicella in this newbornsBF is not a contraindication to varicella

Babies DO NOT seroconvertNo contraindication to immunize the child

of a pregnant woman

Question 3:In the US, a child is most likely to be the victim of a gun accident in which of the following circumstances?

1. In the home of a friend or family member

2. As the victim of a violent crime

3. During a hunting experience

4. During the commision of a crime

Question 4:Upon the review of his immunization records, a 3y/o boy with SS disease is noted to have received PCV7 at 2-4-6-15 months of age. He also continues to receive daily PenVK.

Which of the following represents the most appropriate recommendation for additional vaccination to prevent S. pneumoniae infections in this patient?1. On dose of PPSV232. One dose of PPSV23 followed by a second

dose of 5yrs after the first dose3. One dose of PCV13 followed, at least 8wks

later by one dose of PPSV234. One dose of PCV13 followed at least 8wks

later by one dose of PPSV23, followed by a 2nd dose of PPSV23, 5yrs after the 1st dose

5. One dose of PCV13

QUESTION 5:An 18-year-old exchange student from England who is living in a college dormitory is diagnosed with acute parotitis due to mumps and admitted to the school infirmary. One of the student's roommates calls you to discuss his concerns regarding his risk from this exposure. When you review the calling student's records, you find that he received a single dose of measles, mumps, rubella vaccine at 15 months of age.

Of the following, the MOST appropriate action at this time is to

1. move him into another dormitory room for 18 days from the exposure

2. prescribe a dose of mumps vaccine3. prescribe gamma globulin

intramuscularly4. reassure him that he is likely immune5. screen him for mumps antibodies

Mumps:

Paramyxovirus, transmitted by resp secretions systemic infection Complications: meningitis or encephalitis, orchitis, monoarticular large

joint arthritis, pancreatitis, thyroiditis, myocarditis, and oophoritis. An infected individual is contagious from 1 to 2 days before the

onset of parotid swelling to at least 5 days after the onset of swelling, and the incubation period ranges from 12 to 25 days after exposure. Isolation of an infected individual is recommended for 9 days after the onset of parotid swelling.

Immune globulin is NOT effective for postexposure prophylaxis.

Although a second dose of vaccine may not be effective for the exposure experienced for the young man described in the vignette, it would provide future protection. Infection can occur despite prior vaccination, so reassurance that the young man likely is immune and screening him for mumps antibodies is not appropriate. Because the young man likely already has been exposed and the index case is out of the area, moving into another dormitory room is unlikely to be of value.

QUESTION 6:A 15-year-old boy is brought to the emergency department after a crash involving an all-terrain vehicle. His immunization history is not available. Physical examination reveals an open fracture of his tibia and fibula. You stabilize the fracture and ensure hemodynamic stability.

Of the following, the MOST appropriate tetanus prophylaxis to administer is

1. Td only2. TIG (tetanus immune

globulin) only3. TIG and Tdap4. TIG and DTaP5. TIG and Td

The most appropriate tetanus prophylaxis to administer to the boy in the vignette, who has a heavily contaminated penetrating wound, is tetanus immunoglobulin (TIG) and (Tdap).

TIG is indicated when a patient who has a contaminated wound has not yet completed the initial tetanus immunization series or if the immunization status is unknown, regardless of age.

(Td) or TIG alone is not recommended. (DTaP) or diphtheria toxoid, tetanus toxoid (DT) vaccine should

not be used because DT and DTaP have higher concentrations of diphtheria toxoid and may cause more serious local or systemic vaccine reactions in older children and adults than adult type diphtheria vaccine, which is included in Tdap.

TIG alone is not appropriate because it provides only passive immunity.

Although Td and TIG could be used to protect against tetanus, the increasing prevalence of pertussis in the adolescent age group makes it desirable to administer Tdap instead of Td.

Question 6:Prior to granting permission to immunize her son, the mother of a 15mo old pt inquires about potential side effects associated with the varicella vaccine.

Of the following list of adverse effects, which is most common following administration of this vaccine?

1. A localized varicella-like rash

2. Cerebellar ataxia3. Steven-johnson syndrome4. Arthalagia5. Lymphadenopathy

Adverse effects after varicella vaccine are usually mild.

20% local reaction10-15% fever

3% varicella-like rash-Few: 2-8: maculopapular rather than vesicular

and appear 5-26 days later*mmr/varicella has > risk for febrile sz

Transmission of the vaccine-associated virus from a skin infection is rareA healthy child should receive the vaccine even if

immunodepressed patients share the houseHowever, if pt develops rash, then he/she should

avoid direct contact until all the lesions have crusted over

Varicella

QUESTION 7:Following delivery by stat c/s sec to placental abruption, a 30wk F with a hx of IUGR and bwt: 1.7kg is admitted to the NICU.At what chronological age, can this patient be expected to respond to hepatitis B immunization as would larger term infants?

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20% 20% 20%20%20%1. 1 wk2. 2 wks3. 4 wks4. 6 wks5. 8 wks

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By 1 mo of chronological age: ALL medically stable preterm infants, irrespective of initial bwt or GA, respond with serocoversion rates similar to larger term infants

•Preterm infants of HbsAg negative mothers: who wt <2kg and remained hospitalized at 1 mo of chronological age should receive the 1st dose of hepB prior to discharge or at 1st month bday (whichever comes first)

•ALL preterm infants, with wt < 2kg, whose mothers are HbsAg: positive, should receive HBIG+HBV in <12 hrs from delivery (at different sites)

•In this case this HBV is NOT part of the vaccine schedule and SHOULD NOT be counted as the 1st dose.•At 1 month old, the child should receive his regular HBV•All children born from HbsAg+ mother: check titers at 9-18mo

•No response give additional 3 dose series

QUESTION 8:The foster parents of a previous unimmunized 18wk-old child removed from her home due to medical neglect are disappointed when informed that their foster daughter cannot receive the rotavirus vaccine.

Which of the following best describes current recommendations for administration of the 1st dose of rotavirus?

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1. The 1st dose must be given from ages 6-10wks 6 days2. The 1st dose must be given from ages 4-12wks 6 days3. The 1st dose must be given from ages 6-12wks 6 days4. The 1st dose must be given from ages 4-14wks 6 days5. The 1st dose must be given from ages 6-14wks 6 days

ROTATEQ: 3 DOSES: 2, 4, 6moROTARIX: 2 doses: 2, 4 mo

Do not readminister if child spits it upSeries must be completed before 8months.

0 days of ageDo not give: severely ill, preexisting chronic

intestinal tact disease, hx of intussusception, spina bifida or bladder exstrophy

QUESTION 9A baby girl for whom you provide care has been referred on her newborn hearing screen. Physical examination results are within normal limits. When she is referred on a follow-up hearing screen at 2 weeks of age, you recommend auditory brainstem response testing, which subsequently reveals absent hearing in both ears. A careful family history is negative for any individuals who have deafness. The parents ask you what could have caused deafness in their baby.

Of the following, the likelihood that this infant has a genetic cause for deafness is CLOSEST to

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1. <1%2. 5%3. 25%4. 50%5. 75%

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D Deafness: hearing loss >

90dB see table

Factors associated with hearing loss in neonates1. fhx of sensorineural hearing

loss2. Congenital infection3. Presence of craniofacial

abnormalities4. Bwt <1500gr5. Neonatal jaundice resulting

in exchange transfusion6. Ototoxic meds :

furosemide, aminoglycosides

7. Bacterial meningitis8. Apgar score of <3 at 5 min9. Physical findings consistent

with syndrome associated to hearing loss

How to read an audiometry..quick review

Low pitchLow pitchHigh pitchHigh pitch

VOLUME

louder

Sounds made on normal conversation

Every point on an audiogram represents a different sound

X: LeftO: Right

Conductive

Sensorineural

Management

Below 25dB: nothing25-40dB: can hear almost all, sit child in front 40dB: almost all of the speech sounds are

inaudiblehearing aid is definitely required

50-70 dB: Early and continuous intervention must take place with involvement from the family as well as the teacher, school and other agencies.

70-90 dB: considered deaf A hearing aid may bring his loss into the moderate

range, but communication is still very difficult, and he will still need auxiliary aids to communicate effectively.

Can hear only loud environmental sounds>90dB: profoundly deaf

Lets do a Case…..

A 2y/o boy presents for WCC. He is new to your clinic and arrives with few prior MR. Mom

reports that he has been well his whole life, although his previous doctor mentioned that he was “behind on the things he does”. She does not have any concerns. He started daycare 4mo ago and is starting to attempt toilet training.BM are every other day and can be hard.His diet consists of eating most foods with minimal vegetables,

but limited ‘junk food” and he drinks 4-5 glasses of milk per day. Developmentally he can brush his teeth with help but does not

dress/undress himself.He can build a tower of 6 cubes, climbs steps, but does not kick

a ball. He has 20 word vocabulary and is just starting to combine 2-word phrases.

Fhx: neg for chronic diseasesOn PE: ht: 88cm, wt: 13.2kg, mild pallor on oral mucosa, a

I/VI systolic ejection murmur with good pulses, dry plaques on the antecubital fossa BL and no focal neurological findings. Otherwise his PE is unremarkable

Select the one best answer:What screening test should beordered for this patient?

A. B. C. D. E.

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A. Folate levelB. Lipid panelC. CBCD. PPDE. echocardiogram

A CBC is obtained. The pt has a Hb of 10.3, hct: 30.7 and a MCV of 65. Which of the following is not in your differential?

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20% 20% 20%20%20%1. Iron deficiency anemia2. Thalassemia3. Folate deficiency4. Lead poisoning5. Anemia of chronic

disease

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Which of the following iron studies are consistent with iron deficiency anemia?

A. B. C. D. E.

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A. Low MCV, normal RDW, normal TIBC, high free erythrocyte porphirin (FEP)

B. Low MCV, normal RDW, normal TIBC, normal FEP

C. Low MCV, high RDW, high TIBC, high FEP

D. Low MCV, normal RDW, low TIBC, high FEP

E. None of the above

Based on your history, what other tests might be warranted for this child?

A. B. C. D. E.

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A. Denver II developmental screening

B. Serum lead levelC. Environmental

exposure screenD. A and BE. A, B and C

Which of the following situations would not warrant a risk-based evaluation for lead poisoning?

A. B. C. D. E.

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A. Pt lives in a house built in 1960

B. Pt has a hx of picaC. Pt has a sibling with

hx of lead poisoningD. Pt frequently visits a

house build in 1960 that was renovated 4months ago

E. A and D

The CDC recommends universal screening for lead poisoning for all children between 9-12months?

1 2

50%50%

1. Yes2. No

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CDC recommends universal screening to all high risk areas based on the prevalence of elevated lead levels.

Pts in low-moderate risk areas should be tested ONLY IF RISK FACTORS

Which of the following is not an effect of elevated blood lead levels?

A. B. C. D. E.

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A. ColicB. NephropathyC. Advanced

pubertal development

D. EncephalopathyE. Hemolytic

anemia

The pt’s lead level is 15ug/dL. What is the next step?

A. B. C. D. E.

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A. Begin oral chelation therapy

B. Repeat the lead level in 1 wk

C. Begin nutritional and environmental counseling

D. Stop the supplemental iron therapy

E. None of the above

At what lead level (ug/dL) should chelation be initiated?

A. B. C. D. E.

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A. 25B. 35C. 45D. 55E. 70

Which of the following is true regarding chelation?

A. B. C. D. E.

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A. Dimethylsuccinic acid (DMSA) is initially given for 21 days

B. Hospitalization for therapy is not required until a level is >75ug/dl

C. Parental agents include DMSA and calcium disodium ethylmedianunetraacetic acid (EDTA)

D. Calcium disodium EDTA is toxic when given with iron

E. DMSA side effects include decreased absolute neutrophil counts (ANC) and increased LFT’s.

Which of the following is not a potential side effect of BAL?

A. B. C. D. E.

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A. FeverB. AnaphylaxisC. TachycardiaD. HypotensionE. salivation

Which of the following is a contraindication for BAL therapy?

A. B. C. D. E.

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A. Iron therapyB. Renal

insufficiencyC. Hepatic

insufficiencyD. G6PDE. encephalopathy

Which of the following is not a potential environmental exposure for lead in the US?

A. B. C. D. E.

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A. Old furnitureB. Food cansC. Folk remediesD. Nearby industriesE. Target shooting

According to data from the NHANES II, which of the following are independent risk factors for elevated blood lead levels?

A. B. C. D. E.

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A. PovertyB. Age <6y/oC. African-american

ethnicityD. Dwelling in the cityE. All of the above

Which of the following is a method of prevention for lead intoxication?

A. B. C. D. E.

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A. Frequent mealsB. Meals with high vitamin

C, low calciumC. Use of low-phosphate

detergent for cleansingD. Limit iron intakeE. Increase fat in meals

Chelate lead

All of the following regarding lead toxicity and post-exposure prevention are true except?

A. B. C. D. E.

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A. Painting over existing lead-based paint creates only temporary protection

B. Soil coverage with fabric and ground cover limits ground exposure to lead

C. Use of glass and carbon water filters prevents water transmission

D. Use of high efficiency particulate air (HEPA) vaccum for cleaning is necessary to remove lead from the home

E. Cleaning can temporarily increase the ingestion risk

Which of the following is an indication for cholesterol screening in a child > 2y/o?

A. B. C. D. E.

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A. A GM who died of a myocardial infarction at the age of 60

B. A GF with documented hypercholesterolemia

C. An uncle with an MI at age 45

D. A father with angina at age 45

E. None of the above

AHA recommends: Fasting lipid screening lipid screening to all

kids > 2y/o who: have a (+) PMHX:

parent or grandparent with documented premature CV disease: angina, MI, sudden cardiac death, cerebrovascular disease, coronary bypass, angioplasty or peripheral vascular disease that occurred when younger than 55y/o

A parent with cholesterol >240mg/dlRisk factors: smoking, obesity

For children with LDL >190 (>160 if + pmhx; >130 if DM)Drug therapy should be considered

Which of the following patients should be immediately screened for TB?

A. B. C. D. E.

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A. An international adoptee from Thailand

B. A sibling from an asymptomatic known HIV infected pt

C. The child of a mother with a positive PPD, normal CXR treated with a 9 mo course of isoniazid

D. A and CE. B and C

Which of the following findings would be considered a developmental delay on the Denver II for a 2y/o?

A. B. C. D. E.

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A. Inability to wash and dry hands

B. Inability to combine wordsC. Inability to kick a ball

forwardD. Having half understandable

speechE. Inability to point to 4

pictures