A 6-year-old boy presents to the clinic because of monosymptomatic enuresis for the past month. Urinalysis, detailed patient history, and fluid intake, stool, and voiding diary from a previous visit all show no abnormalities. The parent and child are referred for education and behavioral therapy. Enuresis decreases but persists. Both the patient and his mother express concern and want this issue to resolve as soon as possible. Which of the following is the most appropriate next step in management?
Q192
A 12-month-old boy is brought to the physician for a well-child examination. He was born at 38 weeks' gestation and was 48 cm (19 in) in length and weighed 3061 g (6 lb 12 oz); he is currently 60 cm (24 in) in length and weighs 7,910 g (17 lb 7 oz). He can walk with one hand held and can throw a small ball. He can pick up an object between his thumb and index finger. He can wave 'bye-bye'. He can say 'mama', 'dada' and 'uh-oh'. He cries if left to play with a stranger alone. Physical examination shows no abnormalities. Which of the following is most likely delayed in this child?
Q193
A 7-year-old boy is brought to the physician for recurrent 3–4 minutes episodes of facial grimacing and staring over the past month. He is nonresponsive during these episodes and does not remember them afterward. He recalls a muddy taste in his mouth before the onset of symptoms. One week ago, his brother witnessed an episode where he woke up, stared, and made hand gestures. After the incident, he felt lethargic and confused. Examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q194
A 19-year-old African female refugee has been granted asylum in Stockholm, Sweden and has been living there for the past month. She arrived in Sweden with her 2-month-old infant, whom she exclusively breast feeds. Which of the following deficiencies is the infant most likely to develop?
Q195
A previously healthy 10-year-old boy is brought to the emergency room by his mother 5 hours after the onset of abdominal pain and nausea. Over the past 2 weeks, he has also had progressive abdominal pain and a 4-kg (8.8-lb) weight loss. The mother reports that her son has been drinking more water than usual during this period. Last week he wet his bed three times despite being completely toilet-trained since 3 years of age. His temperature is 37.8°C (100°F), pulse is 128/min, respirations are 35/min, and blood pressure is 95/55 mm Hg. He appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Serum laboratory studies show:
Na+ 133 mEq/L
K+ 5.9 mEq/L
Cl- 95 mEq/L
HCO3- 13 mEq/L
Urea nitrogen 25 mg/dL
Creatinine 1.0 mg/dL
Urine dipstick is positive for ketones and glucose. Further evaluation is most likely to reveal which of the following?
Growth/Development US Medical PG Practice Questions and MCQs
Question 191: A 6-year-old boy presents to the clinic because of monosymptomatic enuresis for the past month. Urinalysis, detailed patient history, and fluid intake, stool, and voiding diary from a previous visit all show no abnormalities. The parent and child are referred for education and behavioral therapy. Enuresis decreases but persists. Both the patient and his mother express concern and want this issue to resolve as soon as possible. Which of the following is the most appropriate next step in management?
A. Reassurance
B. Behavioral therapy
C. DDAVP
D. Oxybutynin
E. Enuresis alarm (Correct Answer)
Explanation: ***Enuresis alarm***
- Enuresis alarms have a **90% success rate** and are considered the **most effective long-term treatment** for monosymptomatic enuresis.
- While it may take time, an enuresis alarm helps condition the child's brain to recognize a full bladder and wake up to void, establishing a **physiological response**.
*Reassurance*
- Reassurance alone is insufficient in this case, as enuresis is **persisting despite initial interventions** and causing distress to both the child and mother.
- While important for psychological support, it does not address the underlying issue or provide a **definitive treatment strategy**.
*Behavioral therapy*
- Behavioral therapy has already been attempted, and although it led to some decrease, the **enuresis persists**, indicating a need for a more intensive or different approach.
- While foundational, it may not be adequate as a **standalone next step** when basic behavioral interventions have not fully resolved the issue.
*DDAVP*
- **Desmopressin (DDAVP)** is an antidiuretic hormone analogue that reduces urine production and is effective for short-term control of enuresis.
- However, it has a **high relapse rate** (up to 90%) after discontinuation and is generally reserved for situations requiring temporary dryness, such as sleepovers, or as an adjunct therapy.
*Oxybutynin*
- **Oxybutynin** is an anticholinergic medication used to treat overactive bladder by reducing bladder muscle contractions.
- It is typically considered only if there is evidence of **detrusor overactivity** (e.g., urgency, frequent voiding during the day), which is not indicated by the patient's history and normal voiding diary.
Question 192: A 12-month-old boy is brought to the physician for a well-child examination. He was born at 38 weeks' gestation and was 48 cm (19 in) in length and weighed 3061 g (6 lb 12 oz); he is currently 60 cm (24 in) in length and weighs 7,910 g (17 lb 7 oz). He can walk with one hand held and can throw a small ball. He can pick up an object between his thumb and index finger. He can wave 'bye-bye'. He can say 'mama', 'dada' and 'uh-oh'. He cries if left to play with a stranger alone. Physical examination shows no abnormalities. Which of the following is most likely delayed in this child?
A. Fine motor skills
B. Language skills
C. Growth (Correct Answer)
D. Gross motor skills
E. Social skills
Explanation: ***Growth***
- At 1 year of age, a child's **birth weight should triple**, and their **birth length should increase by 50%**.
- This child's birth weight was 3061 g (6 lb 12 oz), meaning his expected weight at 1 year should be around **9183 g (20 lb 4 oz)**, but he only weighs **7910 g (17 lb 7 oz)**, indicating **inadequate weight gain** (~1273 g below expected).
- This child's birth length was 48 cm (19 in), meaning his expected length at 1 year should be around **72 cm (28 in)**, but he is only **60 cm (24 in)**, indicating **poor linear growth** (12 cm below expected).
- Both **weight-for-age and length-for-age are delayed**, making growth the most likely delayed parameter.
*Fine motor skills*
- The child can **pick up an object between his thumb and index finger**, demonstrating a **pincer grasp**, which is an appropriate fine motor skill for a 12-month-old.
- He can also **throw a small ball**, further indicating age-appropriate fine motor development.
*Language skills*
- The child can say **'mama', 'dada'**, and **'uh-oh'**, which are appropriate first words for a 12-month-old.
- He also **waves 'bye-bye'**, showing appropriate receptive and expressive communication.
*Gross motor skills*
- The child can **walk with one hand held**, which is an expected gross motor milestone for a 12-month-old.
- Many 12-month-olds are just beginning to cruise or take their first independent steps.
*Social skills*
- The child **waves 'bye-bye'** and **cries if left with a stranger alone**, which are age-appropriate demonstrations of **social interaction** and **stranger anxiety**, respectively, for a 12-month-old.
- These behaviors indicate typical social and emotional development.
Question 193: A 7-year-old boy is brought to the physician for recurrent 3–4 minutes episodes of facial grimacing and staring over the past month. He is nonresponsive during these episodes and does not remember them afterward. He recalls a muddy taste in his mouth before the onset of symptoms. One week ago, his brother witnessed an episode where he woke up, stared, and made hand gestures. After the incident, he felt lethargic and confused. Examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Focal seizure with impaired awareness (Correct Answer)
B. Absence seizures
C. Myoclonic seizure
D. Focal aware seizure
E. Breath-holding spell
Explanation: ***Focal seizure with impaired awareness***
- The symptoms, including **facial grimacing**, staring, **nonresponsiveness**, and subsequent **amnesia** with a **postictal state**, are characteristic of a focal seizure with impaired awareness.
- The preceding "muddy taste" is an **aura**, often indicative of a focal onset seizure involving the **temporal lobe**.
- These seizures typically last 1-2 minutes (can extend to 3-4 minutes) and are associated with **automatisms** (repetitive, purposeless movements like hand gestures).
*Absence seizures*
- Typically involve **brief staring spells** (5-20 seconds) without postictal confusion, and the child usually **does not recall** the episode.
- They lack the **complex motor automatisms** (facial grimacing, hand gestures) and significant postictal lethargy seen in this case.
- Absence seizures have abrupt onset and termination without an aura.
*Myoclonic seizure*
- Characterized by **sudden, brief, jerking movements** of a muscle or muscle group, often occurring shortly after waking.
- They do not typically involve prolonged staring, nonresponsiveness, **automatisms**, or a postictal state as described.
*Focal aware seizure*
- Involves focal symptoms without **impairment of consciousness**. The patient would **remain aware** during the episode.
- Although an aura (muddy taste) can precede a focal aware seizure, the patient's nonresponsiveness and amnesia indicate impaired awareness, making this diagnosis incorrect.
*Breath-holding spell*
- Usually occur in response to **pain, fear, or frustration** in young children (6 months to 6 years) and involve a period of breath-holding, often leading to cyanosis or pallor and brief loss of consciousness.
- They are not associated with complex motor behaviors, automatisms, auras, or **postictal confusion** like seizures.
Question 194: A 19-year-old African female refugee has been granted asylum in Stockholm, Sweden and has been living there for the past month. She arrived in Sweden with her 2-month-old infant, whom she exclusively breast feeds. Which of the following deficiencies is the infant most likely to develop?
A. Vitamin E
B. Vitamin A
C. Vitamin C
D. Vitamin B1
E. Vitamin D (Correct Answer)
Explanation: ***Vitamin D***
- The combination of exclusive breastfeeding, a 2-month-old infant, being of African heritage (darker skin), and living in a high-latitude region like Stockholm, Sweden, significantly increases the risk of **vitamin D deficiency**. Darker skin pigmentation reduces the efficiency of **cutaneous vitamin D synthesis** from sunlight, and insufficient sun exposure in northern latitudes further exacerbates this.
- Breast milk is a relatively poor source of **vitamin D**, and infants specifically require supplementation, especially when they have risk factors for deficiency such as being of African descent and living in an area with limited sunshine.
*Vitamin E*
- **Vitamin E deficiency** in infants is rare and typically seen in premature infants or those with severe malabsorption, neither of which is indicated in this scenario.
- While breast milk contains vitamin E, deficiency is not directly linked to geographic location, skin color, or a 2-month-old infant.
*Vitamin A*
- **Vitamin A deficiency** can be a concern in developing countries, but it is less likely to be the primary concern under these specific circumstances in a 2-month-old exclusively breastfed infant unless the mother herself is severely deficient.
- Breast milk usually provides adequate **vitamin A** if the mother's nutritional status is sufficient.
*Vitamin C*
- **Vitamin C deficiency** (scurvy) is rare in breastfed infants because breast milk typically contains adequate vitamin C if the mother has adequate dietary intake.
- Scurvy would be more likely in infants fed with improperly prepared formula or after 6 months if complementary foods lack vitamin C.
*Vitamin B1*
- **Vitamin B1 (thiamine) deficiency** is uncommon in exclusively breastfed infants in developed countries.
- It is often associated with maternal malnutrition in endemic areas or specific genetic disorders, which are not suggested here.
Question 195: A previously healthy 10-year-old boy is brought to the emergency room by his mother 5 hours after the onset of abdominal pain and nausea. Over the past 2 weeks, he has also had progressive abdominal pain and a 4-kg (8.8-lb) weight loss. The mother reports that her son has been drinking more water than usual during this period. Last week he wet his bed three times despite being completely toilet-trained since 3 years of age. His temperature is 37.8°C (100°F), pulse is 128/min, respirations are 35/min, and blood pressure is 95/55 mm Hg. He appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Serum laboratory studies show:
Na+ 133 mEq/L
K+ 5.9 mEq/L
Cl- 95 mEq/L
HCO3- 13 mEq/L
Urea nitrogen 25 mg/dL
Creatinine 1.0 mg/dL
Urine dipstick is positive for ketones and glucose. Further evaluation is most likely to reveal which of the following?
A. Serum glucose concentration > 600 mg/dL
B. Increased total body sodium
C. Increased arterial pCO2
D. Hypervolemia
E. Decreased total body potassium (Correct Answer)
Explanation: **Decreased total body potassium**
- Despite **hyperkalemia** on serum labs, patients with **diabetic ketoacidosis (DKA)** often have a **total body potassium deficit** due to increased renal losses and intracellular-to-extracellular shifts.
- The combination of polyuria, vomiting, and acidemia all contribute to significant potassium disturbances.
*Serum glucose concentration > 600 mg/dL*
- A glucose level of **over 600 mg/dL** is more characteristic of **hyperglycemic hyperosmolar state (HHS)**, not typically seen in pediatric DKA.
- While DKA involves hyperglycemia, severe dehydration and altered mentation typically occur at lower glucose thresholds in DKA.
*Increased total body sodium*
- Patients with DKA are typically **hypovolemic and hyponatremic** (even if serum sodium appears normal due to pseudohyponatremia) due to osmotic diuresis caused by hyperglycemia.
- There is no mechanism in DKA that would lead to an increase in total body sodium.
*Increased arterial pCO2*
- The patient's **deep and labored breathing (Kussmaul respirations)** is a compensatory mechanism to **blow off CO2** and correct the metabolic acidosis.
- Therefore, arterial pCO2 would be **decreased**, not increased.
*Hypervolemia*
- **Polyuria** (increased urination) due to osmotic diuresis and poor oral intake typically leads to **hypovolemia and dehydration** in DKA patients.
- The patient exhibits signs of dehydration such as dry mucous membranes, increased pulse, and low blood pressure.
