Question 1

A 3-year-old boy is brought to the office by his mother because of a large head contusion and altered mental status. At first, the mother says her son got injured when a “pot fell from a shelf onto his head.” Later, she changes the story and says that he hit his head after “tripping over a football.” Physical examination shows cracks in the suture lines of the skull, and there is a flattened appearance to the bone. The patient’s father arrives to inquire on how his son is “recovering from his fall down the stairs.” Upon request to interview the patient alone, the parents refuse, complaining loudly about the request. Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Child abuse. ***Child abuse***
- The multiple, **inconsistent histories** of injury provided by both parents, ranging from a falling pot to tripping over a football and falling down stairs, are a major red flag for **non-accidental trauma**.
- The physical findings of **cracks in the suture lines** and a **flattened skull bone**, combined with **altered mental status**, are concerning for severe head injury. The parents' refusal to allow a private interview further raises suspicion of child abuse.

*Rickets*
- **Rickets** is characterized by defective bone mineralization leading to soft and weakened bones, often presenting as bowed legs or delayed fontanelle closure.
- It does not typically present with acute **skull cracks** or a flattened skull due to trauma, nor does it involve inconsistent histories of injury which points away from child abuse.

*Cranioschisis*
- **Cranioschisis** is a severe congenital anomaly where the skull fails to close completely, leading to extrusion of brain tissue.
- This condition is a **birth defect** apparent at or shortly after birth and is not an acquired injury in a 3-year-old child due to trauma.

*Osteogenesis imperfecta*
- **Osteogenesis imperfecta** (brittle bone disease) is a genetic disorder causing fragile bones that fracture easily. While this condition might involve bone fragility, there would be a **pattern of recurrent fractures** and often other features like blue sclera.
- However, the inconsistencies in the parents' stories and the specific skull findings are more indicative of physical trauma rather than an underlying genetic condition.

*Paget disease of bone*
- **Paget disease of bone** is a chronic disorder of abnormal bone remodeling, typically affecting older adults, causing localized areas of enlarged and weakened bone.
- It is extremely **rare in children** and would not present with acute traumatic skull fractures or inconsistent injury narratives. [Practice more Pediatrics questions on OnCourse]

Question 2

A 4-month-old boy is brought to the physician for a well-child examination. He was born at 39 weeks gestation via spontaneous vaginal delivery and is exclusively breastfed. He weighed 3,400 g (7 lb 8 oz) at birth. At the physician's office, he appears well. His pulse is 146/min, the respirations are 39/min, and the blood pressure is 78/44 mm Hg. He weighs 7.5 kg (16 lb 9 oz) and measures 65 cm (25.6 in) in length. The remainder of the physical examination is normal. Which of the following developmental milestones has this patient most likely met?

Accepted Answer

Intentionally rolls over. ***Intentionally rolls over***
  - Rolling over is a common developmental milestone achieved between **4 to 6 months** of age.
  - At 4 months, an infant typically has sufficient **head control** and **trunk strength** to intentionally roll from tummy to back or back to tummy.

*Sits with support of pelvis*
  - Sitting with **pelvic support** (tripod sitting) is generally achieved around **6 to 7 months** of age.
  - A 4-month-old typically lacks the necessary **trunk stability** and strength for this milestone.

*Grasps small objects between thumb and finger*
  - This describes a **pincer grasp**, which is a fine motor skill usually developed around **9-12 months** of age.
  - At 4 months, infants primarily use a **palmar grasp** (raking motion) to pick up objects.

*Transfers objects from hand to hand*
  - Transferring objects from hand to hand is a fine motor milestone typically achieved between **5 and 7 months** of age.
  - A 4-month-old is beginning to reach for objects but usually has difficulty with **smooth transfers** between hands.

*Bounces actively when held in standing position*
  - Active bouncing when held in a standing position is typically seen around **6 months** when infants start putting more weight on their legs.
  - At 4 months, while an infant might bear some weight, **active bouncing** is usually more rudimentary or absent. [Practice more Pediatrics questions on OnCourse]

Question 3

A 6-month-old girl presents to an outpatient office for a routine physical. She can sit momentarily propped on her hands, babbles with consonants, and transfers objects hand to hand. The pediatrician assures the parents that their daughter has reached appropriate developmental milestones. Which additional milestone would be expected at this stage in development?

Accepted Answer

Stranger anxiety. ***Stranger anxiety***
  - **Stranger anxiety** typically develops around **6–9 months** of age, peaking at **9–12 months**.
  - This milestone aligns with the infant's increasing ability to distinguish familiar caregivers from unfamiliar individuals.

*Separation anxiety*
  - **Separation anxiety** typically develops later, usually around **9–12 months** of age.
  - It involves distress when a primary caregiver leaves, which is distinct from fear of strangers.

*Showing an object to her parents to share her interest in that object*
  - **Joint attention**, where a child actively gestures or shows objects to share interest, typically emerges around **9–12 months**.
  - This milestone requires more advanced social and cognitive development than expected at 6 months.

*Starts to share*
  - The concept of **sharing** and reciprocal play develops later in toddlerhood, typically around **18 months to 2 years**.
  - This involves understanding social give-and-take, which is too complex for a 6-month-old.

*Engaging in pretend play*
  - **Pretend play** or symbolic play typically begins around **12–18 months** of age.
  - It involves using objects or actions to represent something else and requires more advanced cognitive and imaginative skills. [Practice more Pediatrics questions on OnCourse]

Question 4

A 4-year-old boy is brought to the physician by his parents for bedwetting. He went 3 months without wetting the bed but then started again 6 weeks ago. He has been wetting the bed about 1–2 times per week. He has not had daytime urinary incontinence or dysuria. His teachers report that he is attentive in preschool and plays well with his peers. He is able to name 5 colors, follow three-step commands, and recite his address. He can do a somersault, use scissors, and copy a square. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Accepted Answer

Reassurance. ***Reassurance***
  - This 4-year-old boy presents with secondary enuresis, which is common and often **resolves spontaneously with time**. Given his age and lack of other concerning symptoms (daytime incontinence, dysuria, developmental delays), initial management should focus on **reassurance** and education for the parents.
  - At this age, the **prevalence of enuresis is still high (around 20%)**, and many children have not yet achieved consistent nighttime bladder control. There is **no evidence of organic pathology** or significant psychological distress based on the provided information.

*Enuresis alarm*
  - While effective for enuresis, enuresis alarms are generally considered for children **over 5-7 years old** or older with persistent enuresis, after initial conservative measures and observation.
  - For a 4-year-old, the primary approach is often to **wait and monitor**, as developmental maturation plays a significant role.

*IQ testing*
  - The boy's developmental milestones (naming colors, following commands, gross and fine motor skills) are **appropriate for his age**, and his teachers report no concerns.
  - There is **no indication of global developmental delay** or cognitive impairment that would necessitate IQ testing.

*Bladder ultrasound*
  - This child exhibits no signs or symptoms suggesting an underlying urological abnormality, such as **daytime incontinence, frequent urinary tract infections, dysuria, or abnormal voiding patterns**.
  - A bladder ultrasound would be considered in cases with **red flag symptoms** or if initial conservative management of enuresis fails in older children to rule out structural issues.

*Oxybutynin therapy*
  - Oxybutynin is an **anticholinergic medication** used to treat overactive bladder symptoms or severe enuresis, typically in older children when other treatments have failed.
  - It is **not a first-line therapy** for a 4-year-old with secondary enuresis without other symptoms, as the condition is likely developmental. [Practice more Pediatrics questions on OnCourse]

Question 5

A 3-year-old boy is brought for general developmental evaluation. According to his parents he is playing alongside other children but not in a cooperative manner. He has also recently begun to ride a tricycle. Upon questioning you also find that he is toilet trained and can stack 9 blocks. Upon examination you find that he can copy a circle though he cannot yet copy a triangle or draw stick figures. In addition he is currently speaking in two word phrases but cannot yet use simple sentences. Based on these findings you tell the parents that their child's development is consistent with which of the following?

Accepted Answer

Normal social, normal motor, delayed language. ***Normal social, normal motor, delayed language***
  - The child's ability to play alongside other children without direct cooperation is typical for a 3-year-old, indicating **normal social development**.
  - His motor skills (riding a tricycle, stacking 9 blocks, copying a circle) are largely age-appropriate, but his language (two-word phrases instead of simple sentences) is mildly **delayed for a 3-year-old**.

*Normal social, delayed motor, delayed language*
  - This option is incorrect because the child's **motor skills** (riding a tricycle, stacking 9 blocks, copying a circle) are generally on track for a 3-year-old.
  - While language is delayed, the motor development is not, making this option inconsistent with the overall clinical picture.

*Delayed social, normal motor, delayed language*
  - This is incorrect because playing alongside peers (parallel play) is a **normal social behavior** for a 3-year-old, not a sign of delayed social development.
  - The motor skills are normal, and language is indeed delayed, but the social assessment is inaccurate.

*Delayed social, normal motor, normal language*
  - This option is incorrect due to an inaccurate assessment of both **social and language development**. Playing alongside peers is normal, not delayed social.
  - The child's language use of only two-word phrases is considered delayed for a 3-year-old, not normal.

*Normal social, normal motor, normal language*
  - This option is incorrect because the child's **language development** is not normal; 3-year-olds are typically using simple sentences, not just two-word phrases.
  - While social and motor development appears normal, the language delay makes "normal language" an incorrect assessment. [Practice more Pediatrics questions on OnCourse]

Pediatrics Questions

Topics

Milestones

Congenital defects

Vaccines

Growth/Development

Neonatal infections

Kawasaki disease

Infectious Disease

Genetic disorders

Pediatric emergency management

Nutritional requirements and disorders

Common pediatric cancers