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Miscellaneous

Question 1

A family brings their 16-year-old daughter to your-office for a “well-child” checkup. The child looks perfectly normal on exam-ination. As part of your well-child examination you plan to do a urinalysis. The father pulls you aside and asks you to secretly run a drug screen on his daughter with extra urine. You should:
A. Perform the screen in the manner requested.
B. Perform the screen as requested, but call the family and adolescent back into the office to review the results.
C. Explore the reasons for the request with the parents and the adolescent, performing a urine drug screen with the adoles¬cent’s permission if the history warrants.
D. Refer the adolescent to a psychiatrist for further evaluation.
E. Tell the family to bring the adolescent back to the office for a urine drug screen when she is exhibiting signs or symptoms such as euphoria or ataxia.

Answer

C. The adolescent’s permission should be obtained before drug testing. Testing “secretly” in this situation destroys the doctor ¬patient relationship.

Question 2

A previously healthy adolescent has a 3-month history of in¬creasing headaches, blurred vision, and personality changes. During a previous office visit he admitted to experimentation with marijuana over’ a 1-year prior. Physical examination demon¬strates a healthy, athletic appearing 17-year-old with decreased extra ocular range of motion and visual acuity in his left eye. The next step in his management should be:
A. Acetaminophen & ophthalmology referral
B. Neuroimaging
C. Urine drug screening
D. Trial of methysergide (Sansen) for migraine
E. Glucose measurement

Answer

B. Even though this adolescent admits 10 experimentation with drugs in the past, his Current symptoms and physical findings makes drug use a less-likely etiology. In his case, evaluation for possible brain tumor is warranted.

Question 3

An 11–year-old presents with dizziness, pupillary dilatation, nausea, fever, tachycardia, and facial flushing. she reports that she can “see” sound and “hear color”. the agent likely to be responsible for this condition is:
A. Amphetamines
B. PCP
C. Ecstasy
D. Lysergic acid diethylamide (LSD)
E. Alcohol

Answer

D. LSD is associated with symptoms that may begin 30 to 60 minutes after ingestion. Peak 2 to 4 hours later, and resolve by 10 to 12 hours, including delusional ideation, body distortion, and paranoia. “Bad trips” result in the user becoming terrified or pan¬icked; treatment is usually reassurance of the User in a controlled, safe environment

Question 4

An 8-month-old male arrives with his mother to the emer¬gency department with the complaint of decreased movement of his left arm. The child is the product of a term pregnancy, has had no significant past medical problems, and was in good health when his mother dropped him off at daycare that morning. Ra¬diograph of the upper arm shows a spiral fracture of his left humerus. You should:
A. Obtain stool for analysis for fat soluble vitamins
B. Obtain serum 1,25(OH)2 D levels
C. Admit the child and call child protective services
D. Send chromosomes for osteogenesis imperfecti analysis
E. Order serum alkaline phosphatase levels

Answer

C. A spiral fracture of the humerus is suspicious for child abuse.

Question 5

Appropriate advice for a mother who has brought her 2-week-old child to you for a routine “well-child” visit includes:
A. Sleep in the supine position is recommended.
B. Half-strength fruit juices can be initiated at 2 months of age.
C. By 1 month of age the child should be sleeping through the night.
D. Children should be able to roll over by 2 months of age and sit by 4 months of age.
E. Potty training should begin at 1 year of age.

Answer

A. Juices are avoided until approximately 6 months of age and diluting is usually not required. In¬fants do not usually sleep through the night until 2 to 3 months of age. More realistic targets for development include rolling over at 4 months of age and sitting by 6 months of age. Potty training should be initiated when the child shows interest, usually no ear¬lier than 2 years of age. Parents are advised to place healthy chil¬dren on their backs (or side) for sleep; the incidence of sudden in¬fant death syndrome (SIDS) is reduced in this sleep position.

Question 6

A 14-year-old girl, upset after a fight with her family, reports that she took a bottle of acetaminophen 6 hours previously. The most appropriate initial therapy for her includes:
A. Administration of syrup of ipecac
B. Gastric lavage
C. Administration of activated charcoal
D. Measurement of serum acetaminophen level
E. Whole-bowel irrigation

Answer

D. Administration of charcoal or ipecac and gastric or whole ¬bowel lavage might have been indicated earlier in the post-ingestion period. However, 6 hours after the ingestion of a relatively rapidly absorbed agent none of these procedures would be ex¬pected to be of great benefit. Measurement of the serum aceta¬minophen level 4 or more hours after ingestion can give an in¬dication as to the probability of liver toxicity and the need for the antidote, N-acetylcysteine (Mucocyst).

Question 7

2-year-old child is brought into the emergency center with the complaint of coughing, which developed approximately 1 hour prior to admission. The mother reports that the child was found with a bottle of “Old English Furniture Polish” a few hours ear¬lier in the day. The most likely explanation for this child’s con¬dition is:
A. Organophosphate poisoning
B. Hydrocarbon aspiration
C. Methanol ingestion
D. Ethylene glycol ingestion
E. Chlorine inhalation

Answer

B. The agent in the question is one of many hydrocarbon prod¬ucts used in the home. The onset of the pulmonary symptoms can be delayed for several hours.

Question 8

An adolescent arrives to the emergency center with tachycardia, nausea, vomiting, and abdominal pain. His family says that he was found in his room about an hour ago “talking out of his head about bugs crawling on him.” His electrocardiogram (EKG) shows tachycardia and various arrhythmias. The most likely agent causing these symptoms is:
A. Opiate
B. Benzodiazepine
C. Carbamate insecticide
D. Methanol
E. Cocaine

Answer

E. Cocaine intoxication can result in all of the symptoms refer¬enced in this question, including lethal cardiac arrhythmias, even myocardial infarction, and cerebral vascular accidents

Question 9

An 8-year-old was flown into your emergency center from a ru¬ral hospital. He had been helping his father on their family farm. The sketchy history obtained was that the child developed nau¬sea and vomiting, had profuse sweating, and began to “foam at the mouth” before he became weak, confused, and had a seizure. Approximately 15 minutes after his arrival to the emergency center a nurse and respiratory therapist who were caring for him begin to complain of nausea and vomiting, blurred vision, and increased lacrimation. The most important next step in this sit¬uation is:
A. Closure and quarantine of the emergency center
B. Administration of serum immunoglobulin (Ig) G to all staff
C. Rifampin prophylaxis for the child, his family, and all exposed healthcare workers
D. Removal of all clothing from the child and the affected staff followed by thorough cleansing of all body surfaces
E. Hyperbaric oxygen to all symptomatic persons

Answer

D. The child in the question was likely exposed to organophos¬phate poison on the farm. His clothing was contaminated, and contact with the child without appropriate barriers allowed ab¬sorption of organophosphate from the child’s clothing through the staff’s skin allowing them to develop symptoms. Appropri¬ate therapy for organophosphate exposure is to remove the clothing and cleansing of all skin surfaces.

Question 10

An 8-year-old mentally delayed child ingests the contents of a mercury thermometer. Which of the following symptoms are most likely to be seen?
A. No symptoms
B. Chest pain and dyspnea
C. Ataxia, dysarthria, and paresthesias
D. Gingivostomatitis, tremor, and neuropsychiatric disturbances
E. Pulmonary fibrosis

Answer

A. The child in the question is likely to develop no symptoms (the quantity of mercury would be small) but an acute ingestion of elemental mercury might include a variety of gastrointestinal complaints. If the elemental mercury were in vapor form the gastrointestinal complaints would be seen along with fever, chills, headaches, visual changes, cough, chest pain, and possi¬bly pneumonitis and pulmonary edema. Ingestion or exposure to inorganic mercury salts (as found in pesticides, disinfectants, explosives, and dry batteries) would result in gastroesophageal burns, nausea, vomiting, abdominal pain, hematemesis, hema¬tochezia, cardiovascular collapse, or death. Ataxia, dysarthria, and paresthesias are seen in methyl mercury intoxication such as after exposure to contaminated fish. Gingivostomatitis, tremor, and neuropsychiatric disturbances are seen with chronic inorganic mercury intoxication.

Question 11

A 4-year-old child is found with a bottle of insecticide that con¬tains arsenic. Symptoms most likely to Occur include:
A. Constipation
B. Bradycardia with third-degree heart block
C. Hemorrhagic gastroenteritis with third spacing of fluids
D. Hyperreflexia.
E. Hypothermia

Answer

C. The acute ingestion of arsenic would result. in nausea, vom¬iting, abdominal pain, and diarrhea. The third spacing and hem¬orrhage in the gut can lead to cardiovascular hypovolemic shock. The cardiac symptoms include ventricular tachycardia (QT prolongation) and congestive heart failure. These patients can develop seizures, cerebral edema, encephalopathy, and coma. Early on, patients develop loss of deep tendon reflexes, paralysis, painful dysesthesias, and respiratory failure similar to Guillain-Barre syndrome. Fever, anemia, alopecia, hepatitis, and renal failure can also be seen.

Question 12

Exposure to environmental toxins can occur in several ways. Which of the following is the most likely mechanism of exposure?
A. Transplacental exposure to benzene
B. Exposure of a child to beryllium from the child’s parents’ clothing
C. Iron intoxication from vehicular emissions
D. Asbestos exposure from hazardous arts and crafts materials
E. Lead toxicity from ingesting pieces of a pencil

Answer

B. Fat-soluble compounds can be transmitted transplacentally (but benzene would be unusual). Parents’ work clothes can transmit potentially hazardous compounds to children. It is un¬likely that asbestos would be contained in arts and crafts sup¬plies. Vehicular emissions are responsible for any number of pollutants, many of which are carcinogens, but iron intoxication would be unusual. Pencil “lead” is actually graphite (carbon) and not elemental lead.

Question 13

developmentally delayed 18-year-old female tells her mother that someone at her daycare has been “messing with her.” The mother brings her to your clinic to be evaluated for sexual abuse. Which of the following statements about this child’s pos¬sible sexual abuse is more likely to be true?
A. This developmentally delayed girl is at a lower risk for abuse than her non-delayed counterparts.
B. This girl was most likely sexually abused by a stranger.
C. If this child is a victim of chronic sexual abuse, she is unlikely to have physical evidence of abuse.
D. Most children, like this girl, immediately disclose their sexual abuse.
E. If this nonsexually active adolescent develops a culture positive for chlamydia, herpes, or gonorrhea, a nonsexually transmitted infection source must be sought out.

Answer

C. The majorities of children who have been abused over a period of time do not report the abuse and show no physical evidence of penetrating vaginal trauma. This could be due to the child’s ability to heal tissues in this area or to the perpetrator’s lack of total penetration of the female sexual organ or anus. The perpe¬trator in most cases of sexual abuse are known to the victim. Finding, in a nonsexually active patient, a sexually transmitted disease, such as Chlamydia, gonorrhea, and herpes, is diagnos¬tic of sexual abuse.

Question 14

A 9-year-old boy comes to clinic with rectal bleeding. He states that he has had bright red bleeding off and on for a few months. He has a history of constipation and intermittent encopresis. He denies any inappropriate touching in the area. Upon examina¬tion, the child’s anus has lost its stellate pattern and its tone. He has three deep fissures in the anus and a scar at 8 0′ clock. What is a likely cause of the boy’s findings?
A. Penetrating anal trauma
B. Constipation
C. Eczema
D. Hirschsprung disease
E. Hemorrhoids

Answer

A. Repeated penetrating anal trauma causes loss of stellate pat¬tern of the anus, loss of tone, and deep fissures. Constipation would be less likely to cause such dramatic findings. Sexual abuse must be suspected and further history is indicated

Question 15

An 8-year-old boy complains of severe pain with the movement of his ear. He has no fever, nausea, vomiting, or other systemic symptoms. He has been in good health, having just returned from summer camp where he swam, rode horses, and water¬skied. Examination of his ear reveals a somewhat red pinna that is extremely tender with movement, a very red and swollen ear canal, but an essentially normal tympanic membrane. The most appropriate next course of therapy is:
A. High dose oral amoxicillin
B. Intramuscular ceftriaxone
C. Tympanocentesis and culture
D. Administration of topical mixture of polymyxin and corticosteroids
E. Intravenous vancomycin

Answer

D. The patient in the question likely has an otitis externa that was caused by his swimming (also known as swimmer’s ear). Treatment is the application of a topical agent as described

Question 16

A 12-year-old boy comes to your office complaining of right knee pain that is worse after he runs. His pain started I week af¬ter he joined the track team. Upon examination he has tender¬ness of the tibial tubercle. Which of the following statements is true?
A. The most likely diagnosis is slipped capital femoral epiphysis.
B. Initial therapy consists of immobilization.
C. The most likely cause for his pain is a stress fracture.
D. Use of a properly fitted orthotic device in his left shoe will allow him to continue running while alleviating his discomfort.
E. Decreasing his activity should alleviate the pain.

Answer

E. This adolescent’s history is consistent with Osgood-Schlatter disease. Initial therapy includes ice after exertion and rest

Question 17

A 6-month-old male infant with right-sided dacryostenosis presents with mucopurulent discharge and an indurated, erythematous, tender 1 cm mass on the right side just below his nasal bridge. He has a temperature of 101F (38.3°C). The next step in therapy is to:
A. Administer intravenous antibiotic therapy.
B. Begin a course of topical antimicrobial treatment.
C. Recommend massage and warm compresses to the affected area.
D. Incise and drain the area.
E. Refer the child for an outpatient ophthalmologic evaluation.

Answer

A. This infant has dacryocystitis and needs immediate treat¬ment with systemic antibiotics. After initial therapy, surgical treatment is usually necessary. Topical antimicrobial therapy is inadequate.

Question 18

A 4-month-old male infant presents with excessive tearing on the right side. His mother states he becomes irritable in bright light and calms only in a darkened room. On physical examina¬tion he appears to have asymmetry of his eyes with the right eye appearing to be larger than the left. Which of the following statements is true?
A. Warm compresses and gentle massage are first-line therapy.
B. In most cases, treatment is nonsurgical.
C. The infant has the classic features of Down syndrome.
D. Immediate systemic antibiotic therapy will reduce complications.
E. Immediate referral to a pediatric ophthalmologist is warranted.

Answer

E. With the history of excessive tearing and photophobia and examination finding of corneal enlargement, this infant should be evaluated immediately for congenital glaucoma.

Question 19

which of the following groups of children are at an especially high risk of hearing loss?
A. A full-term, large-for-gestational-age infant male born to a mother with gestational diabetes
B. An appropriate for gestational age (AGA) infant who is the product of a 34-week pregnancy who had Apgar scores of 7 at 1 minute and 8 at 5 minutes
C. A full-term 3300-g birth weight infant born by repeat cesarean section who had a peak total bilirubin of 18 mg/dL at 72 hours of life
D. A full-term AGA infant receiving cefotaxime and ampicillin for 48 hours after having an evaluation for suspected sepsis
E. A full-term AGA infant born by cesarean section for placental abruption with Apgar scores of 3 at 1 minute and 5 at 5 minutes

Answer

E. Infants born with Apgar scores of 4 or less at 1 minute and 6 or less at 5 minutes require audiologic evaluation. Other infants who should have ABR testing include those with a family history of childhood SNHL; cytomegalovirus, rubella, syphilis, herpes, or toxoplasmosis infection; craniofacial anomalies; birth weight less than 1500 g; hyperbilirubinemia at a level requiring exchange transfusion; bacterial meningitis; mechanical ventilation for greater than 5 days; and stigmata of syndrome associated with hearing loss, especially those with renal abnormalities.

Question 20

Which of the following describes the most common form of child maltreatment?
A. Sexual abuse
B. Physical abuse
C. Neglect
D. Emotional abuse
E. Munchausen syndrome by proxy

Answer

C. The most common form of child maltreatment is neglect (the failure to provide adequate nutrition, shelter, supervision, or health care).

Question 21

A 12 month child comes to the office for a routine well-child examination. He was hospitalized 3 months prior for Kawasaki disease, and was taken off aspirin 3 weeks prior to that visit. His most recent echocardiogram was normal, special consideration should be paid for:
A. His developmental assessment
B. The abdominal examination
C. Live-vaccine administration
D. Serum hemoglobin evaluation
E. Assessment of possible lead toxicity

Answer

C. Live-virus vaccines (measles-mumps-rubella and varicella vaccines) should be delayed for 11 months following adminis¬tration of high-dose IVIG because of its potential to interfere with the immune response. The measles vaccine, typically given at the 12-month visit, may be given if the child’s risk of expo¬sure is high, but reimmunization will be required unless sero¬logic testing indicates adequate antibody titers.

Question 22

A 14-year-old is found to be ataxic on the school grounds. He is brought to the emergency department of a local hospital where he appears to be euphoric but emotionally labile and somewhat disoriented. On physical examination he has nystagmus and hyper-salivation. Many notice his abusive language. The agent most likely responsible for his condition is:
A. Alcohol
B. Cocaine
C. Barbiturates
D. Phencyclidine (PCP)
E. Amphetamines

Answer

D. PCP is associated with hyperactivity, hallucinations, abusive language, and nystagmus.

Question 23

A 15-year-old girl presents with the complaint of abdominal pain, vomiting, and lethargy for 3 days’ duration. On physical exami¬nation her chest and throat are clear, but her abdominal examina¬tion is significant for right lower quadrant pain. Rectal exami¬nation is equivocal for pain, and her pelvic examination is re¬markable for pain upon movement of her cervix. Laboratory data include an elevation of her white blood cell count, serum glu¬cose of 145 mg/dL, and serum bicarbonate of 21 meq/dL. Her urinalysis is remarkable for 1 + white blood cells, I + glucose, and 1 + ketones. The most likely diagnosis is:
A. Diabetic ketoacidosis
B. Pelvic inflammatory disease
C. Gastroenteritis
D. Appendicitis
E. Right lower lobe pneumonia

Answer

B. The patient in the question likely has pelvic inflammatory dis¬ease. The glucose in the urine is a stress-response to the infection, and does not represent glucose metabolism problems. All of the options in the question can present with abdominal pain. While diabetes mellitus is in the differential, a patient with DKA more likely presents with ketoacidosis (significantly decreased serum bicarbonate levels) and high serum glucose levels.

Question 24

Students attending school built in 1951 are at risk for which of the following?
A. Dichlorodiphenyltrichloroethane (DDT)
B. Mercury
C. Asbestos
D. Polychlorinated biphenyls (PCBs)
E. Arsenic

Answer

C. Between 1947 and 1973 asbestos was commonly sprayed on school ceilings as a fire retardant. Deterioration of this sub¬stance results in microscopic fibers being released into the air. Placement of barriers is usually sufficient pro¬tection against this carcinogen.

Question 25

Screening tests are included as part of the “well-child” examination. Which of the following statements about screening tests is true?
A. All children should undergo tuberculosis skin testing at 12 months of age.
B. Pelvic examinations should be part of the examination of a sexually active adolescent.
C. Universal cholesterol screening should begin at 11 months of age.
D. Screening hematocrits should be obtained on all infants at 2 months of age.
E. Lead testing is obtained on all 12- and 14-month-old infants.

Answer

B. Tuberculosis and lead testing are performed only on children at risk, or as required by law. Pelvic examinations are done when adolescents become sexually active, or by 18 to 21 years of age. Screening hematocrits should commence at 9 to 12 months of age, and cholesterol screening is done for children with familial risk factors.

Question 26

Three days after beginning oral amoxicillin for otitis media, a 4-year-old boy is noted to have continued fever, ear pain, and swelling with redness behind his ear. His ear lobe is pushed su¬periorly and laterally. He seems to be doing well otherwise. The most appropriate course of action includes:
A. Myringotomy and parenteral antibiotics
B. Tympanocentesis
C. Change to oral amoxicillin-c1avulanate
D. Topical steroids
E. Nuclear scan of the head

Answer

A. The child has mastoiditis. The diagnosis can be made clinically, but CT scan is sometimes needed if the case is not so obvious. Appropriate treatment includes myringotomy and culture of the fluid with initiation of parenteral antibiotics. If rapid im-provement does not occur in the next 24 to 48 hours, surgical drainage of the mastoid air cells may become necessary.

Question 27

17 -year-old boy presents to the emergency center with left shoulder and left upper quadrant tenderness and vomiting. He had infectious mononucleosis last month. He was playing flag football with his friends when the pain started an hour ago, but he does not remember being hit in his back or abdomen. His exam reveals a heart rate of 150 beats per minute and a blood pressure of 80/50 mmHg. He is pale, weak, and seems disoriented.
A. Laparoscopic appendectomy
B. Fluid resuscitation and blood transfusion
C. Intravenous antibiotics
D. Hospital admission for observation
E. DC shock of SVT.

Answer

B. The patient described is in shock, and likely has splenic rup¬ture with intraperitoneal bleeding. He will die shortly if not ag¬gressively resuscitated with fluids and blood. Evaluation by sur¬gery for potential removal of the ruptured spleen should follow quickly.

Question 28

An 8-year-old girl arriving at your school-based clinic with the chief complaint of a rash on her chest, abdomen, and arms. It started with one small scaly red area on her chest and then spread. It itches “a little.” She had a sore throat and headache last week, but now feels better. She is taking no medications and knows nothing of her family history. Physical examination re¬veals salmon-colored, flat, finely scaly oval eruptions on her chest, abdomen, back, and upper arms, stopping at her umbili¬cus and elbows. Which of the following is the most likely ex¬planation for this child’s findings?
A. Tinea versicolor
B. Pityriasis rosea
C. Syphilis
D. Atopic dermatitis
E. Contact dermatitis

Answer

B. Pityriasis rosea may mimic tinea versicolor, yet is preceded by a “herald patch,” an annular, scaly erythematous lesion. The lesions are salmon-colored and in a Christmas-tree formation, following the lines of the skin. The cause is unknown. Treatment may include antihistamines, topical antipruritic lotions and creams, topical corticosteroids, and phototherapy, none of which is very effective. The rash usually lasts up to 6 weeks and then resolves. It can be confused with a form of eczema (called nummular eczema) and in the sexually active adolescent syphilis should also be considered.

Question 29

A 13-year old boy comes to your office with I week of limping and right (knee pain). Upon examination, the patient is found to be overweight with diminished ability to flex and internally ro¬tate his right femur. The next step is to:
A. Instruct the patient to rest and apply ice to the affected area.
B. Prescribe daily oral nonsteroidal antiinflammatory agents until the pain is resolved.
C. Order a magnetic resonance imaging to evaluate the adolescent’s knee and hip.
D. Arrange for an orthopedic surgery consultation.
E. Prescribe a short course of oral steroids to decrease inflam¬mation and recommend weight loss to avoid recurrence

Answer

D. The most likely diagnosis is slipped capital femoral epiph¬ysis. The patient is put on bed rest and orthopedic surgery con¬sultation is required.

Question 30

A mother brings her 26-month-old son to the clinic because she is concerned about his hearing. She notes that over the past few weeks, she has had to speak more loudly for him to respond. He has greater than a 50-word vocabulary and can put 2 to 3 words together to form short sentences. Three weeks prior to this ex-amination, the child had an upper respiratory infection. Which of the following is the best next step in treatment?
A. Order ABR testing for the child.
B. Perform otoscopy with insufflation
C. Send the child for a complete audiologic evaluation.
D. Perform hearing screening in the office.
E. Explain to the child’s mother that 2-year-old children often do not respond to their parents.

Answer

B. This child has normal speech development and was recently noted to have a possible hearing deficit. With the history of re¬cent upper respiratory tract infection, this child is at risk for oti¬tis media with effusion, and as such, for conductive hearing loss. Otoscopy with insufflation (gently blowing air into the ear canal to determine movement of the tympanic membrane) is helpful for qualitative evaluation of middle ear effusions. Tym¬panometry is a reliable, quantitative tool for assessing middle ear effusions. If the child does not have conductive hearing loss, further evaluation is indicated

Question 31

Which of the following is false regarding sensory neural hearing loss?

a) The incidence is twice as high in babies admitted to neonatal intensive care units
compared with the normal population.
b) The risk is increased in children who have had rubella.
c) Approximately 1 per 1000 children will be affected
d) The risk is increased in TB meningitis
e) The risk is increased in Down’s Syndrome.

Answer

The correct answer is e
Sensory neural hearing loss is caused by lesions in the cochlea or the auditory nerve or central
connections. It may be unilateral or bilateral. Language acquisition and secondary educational difficulties
follow, with social isolation, and an increased risk of mental health problems. The approximate incidence
is 1 per 1000 children. Risk factors include:
• NICU admission: low birth weight, less than 32 weeks gestation, prolonged ventilation,
prolonged jaundice, ototoxic drugs, hypoxic ischemic encephalopathy, neonatal meningitis.
• Congenital infection (rubella, CMV).
• Dysmorphic syndromes (affecting head and neck).
• Family history of a close relative needing a hearing aid below the age of 5 years.
• Infections: acute bacterial or TB meningitis, mumps (latter usually unilateral).
Conductive hearing loss is related to middle ear pathology. This is commoner in Down’s Syndrome, cleft palate, Turner’s Syndrome, and facial malformation syndromes.

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