Pediatric Board Recertification Review

554 Pages·2008·3.519 MB·English

by  Katie S. Fine MD

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Pediatric Board
Recertification
KATIE S. FINE, MD
Private Pediatrician
Charlotte, NC
Co-author of Blueprints Pediatrics
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Dedicated to Lucy Carpenter Butler, PhD, who gave me
life and showed me how to live it.
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©2008 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business
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All rights reserved. This book is protected by copyright. No part of this book may be reproduced
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Printed in the USA
Library of Congress Cataloging-in-Publication Data
Fine, Katie S. (Katie Snead)
Pediatric board recertification / Katie S. Fine.
p. ; cm.
Includes index.
ISBN-13: 978-1-4051-0507-1 (alk. paper)
ISBN-10: 1-4051-0507-0 (alk. paper)
1. Pediatrics–Examinations, questions, etc. 2. Pediatricians—Certification—United
States—Examinations, questions, etc. I. Title.
[DNLM: 1. Pediatrics—Examination Questions. 2. Specialty Boards—Examination
Questions. WS 18.2 F495p 2008]
RJ48.2.F53 2008
618.9200076—dc22
2007049606
Care has been taken to confirm the accuracy of the information presented and to describe
generally accepted practices. However, the authors, editors, and publisher are not responsible
for errors or omissions or for any consequences from application of the information in this
book and make no warranty, expressed or implied, with respect to the currency, completeness,
or accuracy of the contents of the publication. Application of the information in a particular
situation remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection
and dosage set forth in this text are in accordance with current recommendations and practice
at the time of publication. However, in view of ongoing research, changes in government
regulations, and the constant flow of information relating to drug therapy and drug reactions,
the reader is urged to check the package insert for each drug for any change in indications
and dosage and for added warnings and precautions. This is particularly important when the
recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug
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responsibility of the health care provider to ascertain the FDA status of each drug or device
planned for use in their clinical practice.
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10 9 8 7 6 5 4 3 2 1
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Contents
Preface iv 17 Disorders of the Genital System . . . . . .313
CME Overview v 18 Neurologic Disorders . . . . . . . . . . . . . .321
19 Musculoskeletal Disorders . . . . . . . . . .351
1 Normal Growth and Development . . . . .1
20 Dermatologic Disorders . . . . . . . . . . . .365
2 Nutrition and Nutritional Disorders . . . . . .7
21 Collagen, Vascular, and Other
3 Preventive Pediatrics . . . . . . . . . . . . . . . .21
Multisystem Diseases . . . . . . . . . . . . . . .381
4 Poisonous Ingestions and Environmental
22 Disorders of the Eye . . . . . . . . . . . . . . . .391
Exposures . . . . . . . . . . . . . . . . . . . . . . . . .37
23 Disorders of the Ear, Nose,
5 Infant Medicine . . . . . . . . . . . . . . . . . . . .47
and Throat . . . . . . . . . . . . . . . . . . . . . . .401
6 Genetic Disorders and Congenital
24 Adolescent Medicine . . . . . . . . . . . . . . .427
Anomalies . . . . . . . . . . . . . . . . . . . . . . . .75
25 Sports Medicine in the
7 Fluid and Electrolyte Disorders . . . . . . .85
Pediatric Patient . . . . . . . . . . . . . . . . . . .449
8 Metabolic Disease . . . . . . . . . . . . . . . . . .99
26 Substance Use and Abuse . . . . . . . . . . .459
9 Diseases of Allergy
27 Developmental Pediatrics . . . . . . . . . . .471
and Immunology . . . . . . . . . . . . . . . . . .111
28 Psychosocial Issues . . . . . . . . . . . . . . . .485
10 Infectious Disease . . . . . . . . . . . . . . . . .129
29 Principles of Critical Care and
11 Endocrine Disorders . . . . . . . . . . . . . . .175
Emergency Medicine . . . . . . . . . . . . . . .505
12 Gastrointestinal Disorders . . . . . . . . . .193
30 Pharmacologic Principles
13 Respiratory Disorders . . . . . . . . . . . . . .219 in Pediatrics . . . . . . . . . . . . . . . . . . . . . .515
14 Cardiovascular Disease . . . . . . . . . . . . .247
Index 521
15 Disorders of the Blood and
CME Evaluation/Answer Form
Neoplastic Disorders . . . . . . . . . . . . . . .269
16 Renal Disorders . . . . . . . . . . . . . . . . . . .289
iii
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Preface
You need this book. cian’s assistant, or nurse practitioner who evaluates and
You’re busy. You have patients to see. A business to run. treats infants and children. Or a pediatrician re-entering
A family to care for. And a life! You don’t have time to pe- active practice after a break to raise children or sail around
ruse five years of Pediatrics in Review, take a weekend to at- the world a few times. Or a rural physician with few op-
tend an expensive board seminar, or read through a heavy portunities for CME beyond internet-based assessment
tome geared to first-time testers. The recertification date is tools. This book is for you.
coming up, and the examination isn’t cheap. You need one Pediatric Board Recertification is designed for medical
source that gives you everything you need and nothing you professionals who have a basic foundation of pediatric
don’t. You need complete, clear, and concise. This book is knowledge, but want to review for the American Board of
for you. Pediatrics recertification examination or simply remain
Or maybe you are in academic medicine, research, or a current in the field while earning Continuing Medical Ed-
specialty field. You know everything there is to know about ucation credit. Each chapter in the book encompasses a
sarcoidosis, lung transplantation, or violent injury preven- single subject. Every subject listed in the ABP examination
tion, but your only recent exposure to general pediatrics is content outline is covered in these pages. The number of
the local weekly Grand Rounds conference, which you at- pages and questions dedicated to each topic parallels that
tend mainly for the free coffee and blueberry muffins. topic’s percentage on the actual test. Tables and figures are
You’d like to keep your general pediatrics certification cur- complementary to the text, clarifying information rather
rent, but it feels like such a hassle to stay abreast of topics than bundling ideas together to save space.
you don’t really touch on in your day-to-day practice. This It is my sincere hope that, whatever your reason for pur-
book is for you. chase, you find Pediatric Board Recertification to indeed
Or maybe you are looking for a reliable source for up- be exactly what you need.
to-date information on general pediatrics that also provides
required CME credit. Or you are a family practitioner, physi- Katie S. Fine, MD
iv
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Continuing Medical Education
(CME) Overview
Release Date: March 1, 2008
Accreditation:Lippincott CME Institute, Inc. is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
Commercial Support: No commercial support has been received for this activity.
Credit Designation: Lippincott CME Institute, Inc. designates this educational activity for a maximum of 30
AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their
participation in the activity.
Target Audience:This CME activity is intended for pediatricians (both domestic and foreign medical graduates)
with an interest in studying for the American Board of Pediatrics recertification examination. It is also appropriate
for resident physicians who are studying for their initial certification, as well as for additional practitioners
(family practice physicians, nurse practitioners, and physician assistants) interested in the diagnosis, management,
and prevention of pediatric disease.
Statement of Need: Each year, approximately 3,000 physicians take the American Board of Pediatrics (ABP)
Recertification Examination; another 3,000 take the initial Certification Examination. Recertification is required
every 7 years. Board certification is required for participation in most insurance plans and admitting privileges
at the majority of US hospitals. In addition, pediatricians must be board-certified in order to obtain the rank of
American Academy of Pediatrics Fellow (FAAP).
Although the test is not exceedingly difficult, there is a core body of knowledge that must be mastered and main-
tained in order to pass the exam. According to the American Board of pediatrics web site (www.abp.org), “pass
rates...range from 88% to 100%.” Failure to pass the examination can result in loss of certification by the board,
which negatively affects the individual’s employment opportunities.
The overall goal of this CME activity is to improve the clinical knowledge of participants, which will allow
them to be well prepared for the board certification examination or recertification examinations and achieve
board recertification as well as help them improve their care of patients. This activity provides the participant
with a feel for the formal examination through the use of questions written in the format of those presented on
the actual board examination. The topics that are covered by the activity content are those detailed by the
American Board of Pediatrics; minimum competency requirements are provided in each general and specialty
area. Thus, this content also provides concise, targeted, yet thorough review of all diagnostic, management, pri-
mary care, and prevention information deemed essential for the practice of pediatrics by the American Board of
Pediatrics.
v
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vi CMEOverview
Participants will be required to complete a CME quiz that helps assess their learning of the activity’s content.
Participants will also be asked to complete an evaluation assessment questionnaire that gauges: 1) participants’
ability to meet of the learning objectives; 2) participants’rating of the activity’s overall quality; 3) participants’
rating of the activity for its effectiveness in preparing them for the certification or recertification exam; 4) partic-
ipants’intention to change his/her practice behavior in a manner that would improve patient care and health; 5)
participants’perception of commercial bias; and 6) length of time spent in the activity.
In addition, the continuing medical education (CME) credit earned from completion of this review will allow
the participant to report 30 hours of dedicated medical review time while preparing for the examination.
Individual states generally require an average of 25 hours of CME credit per year to maintain licensure to
practice.
Additional Sources: American Academy of Pediatrics, Committee on Pediatric Workforce. Pediatrician work-
force statement. Pediatrics. 2005;116:263–269.
American Board of Pediatrics PMCP Content Outline 2007 (www.abp.org/ABPWebSite/pmcp/outlines/
pmcpoutline.pdf)
American Board of Pediatrics website (www.abp.org)
Freed GL, Uren RL, Hudson EJ, et al. Policies and practices related to the role of board certification and recerti-
fication of pediatricians in hospital privileging. JAMA. 2006;295:905–912.
PREP®The Curriculum. 2007 Content Specifications and PREP®Study Guide
Faculty Credentials and Disclosure Information: Katie Fine, MD, is in private pediatric practice in Charlotte, N.C.
Dr. Fine has disclosed that she has no financial interests in or relationships with any commercial companies per-
taining to this educational activity.
Estimated Time to Complete the Educational Activity:It is estimated that this CME activity should take the aver-
age target audience member approximately 30 hours to read the activity’s material and answer the CME quiz
questions.
Identification and Resolution of Conflict of Interests: Lippincott CME Institute, Inc. has identified and resolved
any faculty conflicts of interest regarding this educational activity.
General Learning Objectives: After participating in this CME activity, the physician will be able to:
1. Identify normal and abnormal growth patterns in children and adolescents, and describe the diagnosis and
management of conditions associated with disordered growth.
2. Differentiate normal from abnormal development in children and adolescents, and discuss the diagnosis and
management of developmental delay and developmental deviancy.
3. Discuss with parents the specialized nutritional requirements of infants, children, and adolescents.
4. Describe the diagnosis and management of caloric and vitamin deficiency and excess.
5. Explain how chronic disease impacts the growth, nutrition, and development of the pediatric patient.
6. Recall the current ACIP recommendations regarding immunization schedules for primary vaccinations,
boosters, inoculation against influenza and pneumococcal disease, and catch-up immunizations, including
new recommendations regarding vaccinations against human papillomavirus and rotavirus.
7. Outline the age-appropriate anticipatory guidance, preventive care, and appropriate screening at each routine
health maintenance visit.
8. Identify the signs and symptoms of accidental and intentional ingestions and environmental exposures.
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CMEOverview vii
9. Outline the routine care of the newborn, as well as the disease processes and emergencies in this age group.
10. Recall how prenatal exposures and congenital infections present, and outline their management accordingly,
including limitation of long-term sequelae.
11. State the fluid, electrolyte, and acid-base requirements of the healthy pediatric patient; identify systemic
disorders which result in imbalance and their management.
12. Define the clinical manifestations of genetic and metabolic disease, including presentations and dysmorphisms,
as well as modes of inheritance and methods of pre- and postnatal diagnosis.
13. Recall the pathophysiology of pediatric allergic and immunologic disorders, their typical presentations, and
management.
14. Describe the organisms associated with pediatric infectious disease, including bacteria, viruses, fungi,
parasites, and atypical organisms; identify their various disease presentations; discuss their appropriate
management; and predict complications and long-term sequelae.
15. Point out the presentation of pediatric disorders of the endocrine system and describe appropriate diagnostic
studies and management.
16. Identify the presentation of pediatric disorders of the upper and lower respiratory system and describe their
diagnostic evaluation and appropriate management.
17. Describe the presentation of pediatric disorders of the gastrointestinal system; summarize the diagnostic
evaluation and appropriate management of gastrointestinal symptoms (emesis, abdominal pain, etc).
18. Discuss the presentation of pediatric disorders of the cardiovascular system, including but not limited to
congenital heart disease; plan the appropriate diagnostic evaluation.
19. Cite the pathophysiology of pediatric disorders of the blood, including hemoglobinopathies, coagulopathies,
membrane defects, anemias, leukocytic disorders, platelet disorders, and neoplasms; describe their diagnostic
evaluation and appropriate management.
20. Recall the presentation of pediatric disorders of the kidneys and upper and lower genitourinary system;
discuss the diagnostic evaluation and appropriate management of typical symptoms.
21. Define the significance of neurologic signs and symptoms in the pediatric patient and evaluate accordingly;
recall the presentation and management of infection, congenital malformations, seizures, strokes, spinal cord
disease, peripheral neuropathies, muscular dystrophies, and central nervous system trauma.
22. Recognize the presentation of pediatric musculoskeletal and collagen-vascular disorders; describe the
diagnostic evaluation; manage appropriately; and predict complications and long-term sequelae.
23. Describe common pediatric skin lesions, associated findings, and treatment.
24. Discuss the developmentally-appropriate screening, diagnosis and management of congenital and pediatric
eye disorders; point out indications for referral.
25. Summarize the presentation of pediatric disorders of the ear, nose, and throat, as well as recommended
diagnostic evaluations, therapies, and complications.
26. Describe normal and abnormal physical, psychosocial, and cognitive development in the adolescent.
27. Identify the presentations and managements of gynecologic disorders, substance use and abuse, and
psychiatric conditions in adolescent patients.
28. Discuss disorders of cognition, language, learning, attention, and behavior in children and adolescents.
29. Identify the psychological issues and problems that present during specific developmental stages in the child
and adolescent, and describe their appropriate management.
30. Plan for emergency and critical care interventions in the pediatric patient, including abuse, burns, wounds,
trauma, life support, and cardiopulmonary resuscitation.
31. State the principles of pharmacology relating to pediatric medication, including risks, benefits, adverse
effects, conscious sedation, and pain management.
Method of Physician Participation: To earn CME credit, participants must first read the text and complete the
CME examination and evaluation assessment questionnaire. Participants can mail a photocopy of the Exam
Answer Sheet and Evaluation Assessment Form, along with a check or money order for the $20 processing fee,
to Lippincott CME Institute, Inc., 770 Township Line Road, Suite 300, Yardley, PA 19067. Entries must be
received by LCMEI by the expiration date of February 28, 2011. Acknowledgment will be sent to participants
within 6 to 8 weeks of participation. For more information, call [phone].
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1
Normal Growth and Development
GROWTH ASSESSMENT ■ Breast-fed infants on average lose a greater percentage
oftheir birthweight than formula-fed infants and thus,
Growth Parameters generally take longer to regain their birthweight.
■ Healthy infants double their birthweight at age 4 to
In pediatric medicine, growth is an important indicator of
5months and triple their birthweight by age 12 to
a patient’s nutritional status and general health. Routine
14months.
assessment of growth parameters includes:
■ The average newborn length in the United States is 50 cm
(almost 20 in).
■ weight in all patients
■ Between the ages of 3 and 4 years, a healthy child’s
■ length in infants at birth to age 3 years
stature should reach double that child’s birth length.
■ head circumference in infants at birth to age 3 years
■ height in children (cid:1)2 years ■ The average newborn head circumference in the United
■ body mass index (BMI) in children (cid:1)2 years States is 36 cm (about 14 in).
■ Head circumference is expected to increase by almost 30%
BMI is calculated by: during the first year of life (average 47 cm, about 18.5 in).
■ dividing the patient’s weight in kilograms by the patient’s
Abnormalities in Head Circumference
height in meters squared: (kg/m2), OR
■ dividing the patient’s weight in pounds by the patient’s
At birth, normal head circumference ranges from about 32.5
height in inches squared, then multiplying the result by
to 38 cm (12.8 to 15 in). Head circumference provides an
703: (lb/in2) (cid:2) 703
indirect assessment of brain growth.
Microcephaly is defined as a head circumference greater
Children at risk for abnormal growth patterns include
those (cid:3)5th percentile or (cid:4)95th percentile, respectively, than two standard deviations below the mean. Most cases
are due to small brain size. Microcephaly is associated with
forweight and/or height. Patients who have BMIs between
an increased incidence of mental retardation. Microcephaly
the85th and 95th percentiles are considered at risk of
overweight, and those (cid:1)95th percentile are considered may be primary (genetic) or secondary (acquired).
overweight. These cutoffs may be modified as BMI gains in ■ Primary microcephaly is present at birth and is typically
standard usage. The real value of growth assessment be- familial or associated with specific genetic abnormalities
comes evident over time; the different parameters form such as Down syndrome.
“growth curves” that can reveal sudden and/or unexpected ■ Secondary microcephalyresults from an insult to the brain
changes in growth velocity, although the patient’s actual in utero or during the first 2 years of life. Examples include
measurements may still be inthe normal range. Children congenital infections, in utero drug or alcohol exposure,
who “fall off” their expected growth curves, especially maternal hypertension during pregnancy, meningitis, fail-
when measurements cross two percentile lines, warrant ure to thrive, and hypoxic encephalopathy. When the
further investigation into the cause of their decelerated cause is a prenatal event, the earlier in development the
growth. event occurs, the smaller the head will be. The infant with
Several important rules of thumb regarding growth in a normal head circumference at birth and subsequent de-
children are listed below. velopment of microcephaly has acquired microcephaly by
definition. Examination of the head circumference growth
■ The average newborn weight in the United States is 3.5 kg
chart and a careful history and physical examination usu-
(7 lb, 11 oz).
ally suggest the diagnosis.
■ Newborns lose weight in the first several days after birth;
weight loss that exceeds 10% of birthweight is considered Macrocephalyis defined as a head circumference greater than
abnormal and requires immediate intervention. two standard deviations above the mean (alternatively,
■ Newborns should regain their birthweight by days of life (cid:4)97th percentile). Familial (inherited) macrocephaly is typi-
10 to 14. cally associated with normal intelligence. These infants are
1
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2 Pediatric Board Recertification
born with large heads, and their head circumference disorders, metabolic storage disease, bleeding, or hydro-
growthcurves tract along a consistent percentile. There is cephalus. Hydrocephalus is an abnormal accumulation
no associated cerebral pathology. The development of ofcerebrospinal fluid within the ventricles through im-
macrocephaly after birth may result from neurocutaneous paired absorption or increased production. In the infant,
TABLE 1-1
NORMAL DEVELOPMENTAL MILESTONES
Age Gross Motor Fine (Visual) Motor Language Social/Adaptive
Birth to 1 mo Raises head slightly in prone Follows with eyes to Alerts/startles to sound Fixes on face (at birth)
position midline only; hands
tightly fisted
2 mo Raises chest and head off bed Regards object and Coos and vocalizes Social smile;
in prone position follows through 180º arc; reciprocally recognizes parent
briefly retains rattle
4 mo Lifts onto extended elbows in Reaches for objects with Orients to voice; laughs Initiates social
prone position; steady head both hands together; bats and squeals interaction
control with no head lag; rolls at objects; grabs and
over front to back retains objects
6 mo Sits but may need support; Reaches with one hand; Babbles Recognizes object or
rolls in both directions transfers objects person as unfamiliar
hand-to-hand
9 mo Sits without support; crawls; Uses pincer grasp; Imitates speech sounds Plays gesture games
pulls to stand finger-feeds (nonspecific “mama,” (“pat-a-cake”);
“dada”); understands “no” understands own
name; object
permanence; stranger
anxiety
12 mo Cruises; stands alone; takes a Can voluntarily release Discriminative use of Imitates; comes when
few independent steps items “mama,” “dada,” plus called; cooperates
one to four other words; with dressing
follows command with
gesture
15 mo Walks well independently Builds a two-block tower; Four to six words in Begins to use cup;
throws ball underhand addition to above; uses indicates wants or
jargon; responds to needs
one-step verbal command
18 mo Runs; walks up stairs with Builds a three-block tower; Uses ten to 25 words; Uses words to
hand held; stoops and uses spoon; spontaneous points to body parts communicate wants
recovers scribbling when asked; uses words or needs; plays near
to communicate needs (but not with) other
or wants children
24 mo Walks unassisted up and Builds four- to six-block Uses 50+ words, two- and Removes simple
down stairs; kicks ball; tower; uses fork and spoon; three-word phrases; uses “I” clothing; parallel play
throws ball overhand; jumps copies a straight line and “me;” 50% of speech
with two feet off the floor intelligible to stranger
36 mo Pedals tricycle; broad jumps Copies a circle Uses five- to eight-word Knows age and
sentences; 75% of speech gender; engages in
intelligible to stranger group play; shares
4 y Balances on one foot Copies a cross; catches ball Tells a story; 100% of Dresses self; puts on
speech intelligible to shoes; washes and
stranger dries hands;
imaginative play
5 y Skips with alternating feet Draws a person with six Asks what words mean Names four colors;
body parts plays cooperative
games; understands
“rules” and abides by
them
6 y Rides a bicycle Writes name Identifies written letters Knows right from left;
and numbers knows all color names