Earn Three Category 1 CME Credits by Following These Instructions
Pediatricians now have the opportunity to earn Category 1 continuing-medical-education credits by reading the foregoing articles in this issue of Pediatric Annals and satisfactorily answering the following quiz. Follow these six simple instructions:
1. Read every question carefully. Questions are based on articles in this issue, and answers can be found by reading the articles. Select the one best answer and mark it on the answer form found at the end of the quiz.
2. Type or print your full name and address (including zip code) and your social-security number in the spaces provided.
3. Enclose check or money order ($10) made out to Pediatric Annals CME Quiz. Mail with your answer form to:
501 Madison Avenue
New York, N.Y. 10022
4. As an organization accredited for continuing medical education, the Lenox Hill Hospital of New York certifies that this continuing-medical-education activity meets the criteria for three credit hours in Category 1 of the Physician's Recognition Award of the American Medical Association, provided it is used and completed as designed.
5. You will be advised of your score after your answers are graded following the cut-off date for this quiz (see answer form). Correct answers to any questions you have missed will be indicated. Unanswered questions will be considered incorrect and so scored. A minimum score of 70 per cent must be obtained in order for credits to be awarded.
6. All replies and results are confidential. Answer sheets, once graded, will be returned, and no record of scores will be maintained. The Department of Pediatrics at Lenox Hill Hospital will keep only a record of participation, indicating the completion and awarding of three hours of Category 1 credit to individual physicians.
CME Quiz: The Diagnosis of Epilepsy
1. A 13-month-old infant, well-developed and previously normal, develops a temperature of 101°. Suddenly his arms and legs shake, and his eyes roll back. This condition lasts for about three minutes. A pediatrician diagnoses the attack as a simple febrile convulsion secondary to otitis media. If this diagnosis is correct, which of the following aided in making the diagnosis? (Mark the one best answer.)
A. Age of the patient.
B. Intercurrent otitis media.
C. Seizure after onset of fever.
D. All of the above.
2. If the diagnosis of "simple febrile convulsion" is correct, one would expect the electroencephalogram to be normal
A. One day after the seizure, if the child is afebrile.
B. Three days after the seizure, if afebrile for two days.
C. Seven days after the seizure, if afebrile for six days.
D. Fourteen days after the seizure, if afebrile for 13 days.
3. If the diagnosis of "simple febrile convulsion" is correct, we would expect
A. No increase in the odds that the boy will develop afebrile convulsions (epilepsy) later in life.
B. A 5 per cent chance that this boy will develop epilepsy later in life (i.e., one out of 20 infants receiving such a diagnosis will develop epilepsy).
C. A 10 per cent chance that he will develop epilepsy in later life.
D. None of the above answers is correct.
4. A diagnosis of "epileptic seizures precipitated by fever" has been made for an infant with signs similar to those described in question 1 . Anticonvulsant drugs have been advocated to prevent future seizures. Such medications should be used
A. At the first sign of fever until the boy is 10 years old.
B. Intermittently, when an infection is suspected.
C. Continuously for a prolonged period, so as to keep the blood-level concentration up to at least 16 µg./ml.
D. Only in infants and children below the age of five.
5. The child in question 1 develops two more simple febrile convulsions at ages 18 and 21 months. When he has reached the age of seven years one can expect that
A. His scholastic abilities will be below those of his age peers.
B. He will not have any mental deterioration resulting from these brief convulsive episodes.
C. There will be an increased likelihood that he will develop psychomotor epilepsy even though his seizures were of short duration.
D. There will be a good possibility that he will eventually develop "febrile status epilepticus."
6. There is not universal agreement that a lumbar puncture should be done when a child has had a single febrile convulsion. Most authorities, however, do agree that a lumbar puncture is indicated if
A. A generalized seizure occurs in a four-month-old infant.
B. An eight-year-old boy who has headaches and a temperature of 39° C. has his first convulsion.
C. A child who is two years old has a temperature of 41° C. and experiences his first seizure. He is supposed to leave the city with his parents in two days.
D. A child falls into any of the above categories.
7. A four-year-old boy with a history of convulsions is brought to you for prevention of future attacks. His history reveals no seizures before the age of three, when he developed shaking of the hands and feet, without fever. The shaking lasts about five minutes and then stops spontaneously. You ask the mother if she has noticed anything unusual before the attacks. She is not sure, and you explain that prodromes can take different forms. Among the forms prodromes might have taken in this case are
A. Psychic (i.e., bizarre behavior before the seizure).
B. Sensory (i.e., hearing strange noises).
C. Motor (i.e., twitching of the mouth).
D. Any of the above.
8. The boy described in question 7 faits into a deep steep following his shaking episodes. The sleep lasts about two hours, and then he wakes up, unusually irritable. The irritability lasts about an hour. From the information presented, the most likely diagnosis is
A. Major motor epilepsy.
B. Petit mal.
C. Temporal-lobe seizure.
D. Myoclonic seizure.
9. As part of the work-up of the patient described in question 7, skull x-rays are ordered. They reveal no abnormality. In reviewing this situation, you realize that
A. You were correct in ordering them, because routine skull x-rays sometimes reveal the etiology of a seizure disorder.
B. You probably should not have ordered them, since x-rays should not be taken routinely in the workup of epileptic patients because of the irradiation required.
C. You should not have ordered them routinely, because x-rays rarely reveal any abnormality indicative of epilepsy.
D. From the absence of abnormality, you can make a firm diagnosis of febrile convulsions.
10. As part of the work-up of the patient described in question 7, an EEG is performed in the interictal period. The findings are normal. This may be because
A. The EEG was taken in the interictal period.
B. The interictal EEG of a child with grand-mal epilepsy may be normal.
C. You did not take a repeat EEG in both awake and sleep state.
D. All of the above answers are correct.
11. As part of the work-up of the patient in question 7, a computerized axial tomography (CAT) scan is ordered. This procedure
A. Should rarely be performed, because other examinations giving the same data are available.
B. Should rarely be performed since it is too expensive.
C. Should not be done if skull x-rays and EEG are normal.
D. Should be performed when there are well-defined indications of brain abnormality, as it is a safe, noninvasive technique that can detect subtle differences in tissue density.
12. A 13-year-old boy has had recurrent seizure attacks. The EEG is only suggestive of a seizure episode. However, the boy is placed on anticonvulsant medication and remains seizure-free for several months. This can be attributed to
A. The anti-convulsant properties of the medication.
B. The "placebo effect" of the medication.
C. An incorrect diagnosis of epilepsy.
D. Any of the above (A, B, C).
13. A seven-year-old girl is brought to you for evaluation. She complains of a dull ache in the area of the navel, which occurs at least five times during the day and lasts each time for about 30 minutes. This pain appears both at home and at school. No precipitating factor can be found. Previous work-up included a normal IVP, barium enema, and gastrointestinal and small-bowel series. An EEG is abnormal, and a diagnosis of epilepsy is made.
A. The diagnosis is indubitably correct.
B. The diagnosis is probably correct if the EEG abnormalities occurred concomitantly with clinical symptoms.
C. The diagnosis of abdominal epilepsy should not have been made, since the EEG shows the same abnormality both during and between attacks.
D. Psychosomatic symptoms can sometimes cause an abnormal EEG; the child should be referred for psychiatric treatment.
14. A 12-year-old boy is brought to your office for diagnosis of headaches. The headaches are located in the right temporal region and last about an hour. They can occur at any time and appear about four out of every seven days. The complete examination - including neurologic examination and a detailed eye examination - produce no abnormal findings. The EEG shows nonspecific electrical irregularities.
A. A diagnosis of epilepsy can be made.
B. A diagnosis of brain tumor can be considered.
C. A diagnosis of migraine should be entertained.
D. A diagnosis of tension headaches should be made.
15. An 11 -year-old girl has staring spells that last about 15 seconds. These spells recur two to three times daily. She has been given phenobarbital 30 mg. three times daily but this has not influenced the staring spells. The most likely diagnosis is
A. Grand-mal epilepsy.
B. Petit-mal epilepsy.
C. Myoclonic epilepsy.
D. Autonomic epilepsy.
16. The electroencephalogram in the patient described in question 15 shows a diffuse, bilaterally synchronous spike-and-wave form recurring at frequencies of three per second. This disorder usually makes its initial appearance
A. During childhood.
B. At age of 15 years.
C. After the age of 21 years.
D. Before three years of age.
17. If the EEG of the patient in question 15 had shown spikes localized in the right anterior temporal area and these spikes occurred during sleep but also were occasionally seen while the child was awake, you know that
A. This type of epilepsy probably made its initial appearance in early childhood, before the age of three.
B. This type of epilepsy probably made its initial appearance after the time the child started school, (above the age of six).
C. This type of epilepsy is common in children.
D. This type of epilepsy is never followed by mumbling or other repetitive activities.
18. An 11-month-old infant is brought to your office because the mother has noticed that since sitting he has had, at least 15 times a day, a sudden jerking of the head, usually associated with an outward thrust of the arms. An EEG shows short bursts of high-voltage, diffuse fast spikes, and highamplitude slow waves associated with high-voltage fast spikes. These electrical aberrations recurred at least once every 10 seconds throughout the tracing. The clinical picture and electroencephalogram are best described as
A. A variation of normal.
B. A form of grand-mal epilepsy.
C. Petit-mal epilepsy.
D. Myoclonic epilepsy.
19. The mental status of the patient described in question 18 is usually
D. Unknown; patient Is too young to have mental status evaluated.
20. A 15-year-old girl has fainted three times during the past year. The syncope does not last for more than a minute. A diagnosis of epilepsy was made by the previous physician when the electroencephalogram showed "nonspecific electrical irregularities."
A. This diagnosis is usually correct.
B Extensive investigation and protracted follow-up study usually show that such a case is not epileptic in etiology.
C. A postconcussion syndrome could be suspected.
D. None of the above.