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An 8-year-old girl presents with bilateral ankle pain, a purpuric/petechial rash on her legs, and swelling of her feet. She has no fever. She reports having had rhinorrhea a week ago. Laboratory tests show a normal CBC, and Lyme and ASO titers are negative. She has mild hematuria and no proteinuria.
What is the diagnosis?
Options:
A: Post-streptococcal arthritis.
B: Lyme disease.
C: Systemic lupus erythematosus.
D: Henoch-Schönlein purpura.
E: Immune thrombocytopenia.
| D | |
A father has just moved to the area and brings his 1-month-old son, 3-year-old daughter, and 7-year-old son for their well-child checks. It is May and all are healthy and doing well. He has heard from neighbors that there are ticks and mosquitos in the area that harbor infectious diseases. He asks you for advice on how to prevent both tick- and mosquito-borne infections.
You suggest that he should:
Options:
A: Avoid letting the children play outside in the evening time.
B: Apply DEET to exposed skin of all the children before they go outside.
C: Apply permethrin to exposed skin of all the children before they go outside.
D: All of the above.
E: None of the above.
| E | |
A 5-day-old infant boy presents to the emergency department 30 minutes after what his mother describes as a seizure. She states that he abruptly stiffened for a few seconds, then “his eyes rolled back.” This was followed by a period of sleepiness from which he seems to be recovering. He was born at term, there were no pregnancy or delivery complications, and he has done well since birth. On physical examination, he weighs 4.1 kg and appears to be a healthy infant. He is irritable but consolable. Shortly after an IV catheter is placed and his blood is sent for laboratory studies, he begins to seize. He is given a 0.4 mg IV dose of lorazepam, to no avail. The laboratory technician calls with a critical value: his calcium level is 5.2 mg/dL. There are no other critical values. He continues to seize.
What is the next most appropriate step in this child’s management?
Options:
A: Give another 0.4 mg IV lorazepam.
B: Give a 20 mg/kg IV loading dose of fosphenytoin.
C: Give a dose of IV calcium gluconate.
D: Repeat a blood draw for an ionized calcium measurement.
E: Give a dose of IV calcium chloride.
| C | |
A 3-year-old girl is brought to your clinic by her mother, who is concerned about her daughter’s worsening eye redness, tearing, and lid swelling of 1 month’s duration. Per parental history, the girl is a constant eye rubber. On exam, in addition to the ocular findings described by the mother, you notice some mild scaly skin inside the elbows and on the upper eyelids. The patient’s past medical history is also significant for a nut allergy.
What is the most likely diagnosis?
Options:
A: Ocular rosacea.
B: Viral conjunctivitis.
C: Bacterial conjunctivitis.
D: Molluscum contagiosum.
E: Atopic conjunctivitis.
| E | |
An 8-year-old boy is new to your practice. You note as he enters the room with his mother that he seems somewhat “off balance” to which his mom replies that she had noted changes in his gait for the last 3 to 4 years, but thought he was just “clumsy.” You are reviewing his medical history and find that he has been treated for recurrent otitis media and sinusitis despite having three sets of tympanostomy tubes since age 2. On examination, you note several superficial blood vessels apparent in the eyes and on the pinna of the ear. Concerned with the history and examination findings, you order a CBC that demonstrates profound lymphopenia as well as quantitative immunoglobulin levels and vaccine titers to pneumococcus and tetanus, all of which are low.
What diagnosis are you most concerned with based on the constellation of symptoms?
Options:
A: Neuroblastoma.
B: Chédiak-Higashi syndrome.
C: WHIM syndrome.
D: Ataxia-telangiectasia.
E: Hyper-IgM syndrome.
| D | |
A 12-year-old African-American male has an 8-year history of severe persistent asthma. He uses 2 puffs of an albuterol metered-dose inhaler (MDI) for treatment of acute respiratory symptoms and 2 puffs twice daily of fluticasone, 44 mcg/puff MDI, for maintenance control. Over the past 2 months, he has needed four refills of albuterol while obtaining a monthly refill of his fluticasone. He states he is using his albuterol inhaler five or six times a day with minimal relief of symptoms. He wakes up at night a couple of times a week with coughing. His asthma is poorly controlled and needs additional therapy; therefore, you decide to increase his fluticasone to 220 mcg/puff, in 2 puffs twice a day.
Which of the following adverse effects is/are associated with long-term inhaled corticosteroid use?
Options:
A: Increased heart rate.
B: Longitudinal growth suppression.
C: Skin thinning.
D: Serum electrolyte abnormalities.
| B | |
A male infant is born at 24 weeks’ gestational age after his mother experiences preterm labor. Following a 4-month hospitalization in the NICU, he is discharged at 39-5/7 weeks’ corrected gestational age. The infant is feeding well by mouth on fortified maternal breastmilk. He is discharged home on supplemental oxygen at a rate of 1/8 L/min.
Which statement is true regarding this infant’s lung disease?
Options:
A: This infant has chronic lung disease of prematurity (bronchopulmonary dysplasia) confirmed by the need for supplemental oxygen beyond 36 weeks’ gestational age.
B: This infant’s lungs were likely in the canalicular stage of development at the time of birth.
C: This infant’s lungs are likely between saccular and alveolar stages of development at the time of discharge.
D: Vitamin A and caffeine are two medications that have been shown to decrease the severity of lung disease of this type.
E: All of the above.
| E | |
You are seeing a 15-year-old adolescent girl with a chief complaint of “neck swelling.” She reports noticing a small bump in the midline of her neck for the past several weeks that seems to have gotten significantly larger in the past several days. Physical exam is notable for bilateral anterior cervical lymphadenopathy and a nontender, 2 cm right-sided thyroid nodule. You notice that her voice sounds rather hoarse. Given the history and physical exam, you are concerned that she may have thyroid cancer.
All of the following are clinical features that may be associated with thyroid carcinoma EXCEPT:
Options:
A: History of external radiation to the head or neck, or both.
B: History of exposure to nuclear fallout.
C: Bradycardia.
D: Dysphagia.
E: Vocal cord paralysis.
| C | |
A 6-month-old boy comes for evaluation of short stature. The history shows that the child was born after an uncomplicated pregnancy and delivery. He has been well with no medical complications or hospitalizations. The parents do not remember that anyone was concerned about his size at birth, but they noted shortly thereafter that he was not growing as they expected and they felt that he has short extremities. They also report that recently he has been snoring more at night and has loud breathing during the daytime. On physical examination, growth parameters show height 60 cm (<5th percentile), head circumference 46 cm (>95th percentile). You note macrocephaly, frontal bossing, flat nasal bridge, hypoplasia of the maxilla, rhizomelic shortening of the extremities, lumbar lordosis, and short hands and feet.
Based on the clinical features the most likely diagnosis is:
Options:
A: achondroplasia
B: growth hormone deficiency
C: hypochondroplasia
D: osteogenesis imperfecta (OI)
E: Turner syndrome
| A | |
A newborn girl named Anita presents with a lumbar meningomyelocele, noted in the delivery room of a community hospital. Mom is a 29-year-old woman with two normal children. The pregnancy was uneventful. Because of failure of labor to progress after 24 hours, a cesarean delivery was performed using general anesthesia. You are summoned by your emergency beeper and arrive 15 minutes later to the hospital obstetric operative delivery room. The father is in the delivery room looking pale and tearful. On physical examination, Anita is 6 pounds, robust and has a vigorous cry, a good urine stream, spontaneous knee flexion and extension, and club feet. The delivery room nurses have applied a sterile dressing to Anita's back. Known etiologies or associations of neural tube disorders include all of the following except
Options:
A: taking prenatal vitamins before conception
B: chromosomal disorders
C: maternal anticonvulsants
D: first-trimester hyperthermia
E: multiple malformation syndromes
| A | |
A 2-month-old full-term infant is noted to have a decreased red reflex bilaterally. The pupils are normal, the conjunctiva is not inflamed, and something white can be seen in the center of both pupils. There is a family history of cataracts in the mom and the maternal aunt at a young age.
The most likely diagnosis is:
Options:
A: Retinoblastoma
B: Retinal detachment
C: Coats disease
D: Bilateral congenital cataracts
E: Corneal scarring
| D | |
You are seeing a 1-year-old boy for a well-child visit. In reviewing his history, you note that he has had 4 episodes of otitis media and 1 hospitalization for pneumonia, and has had eczema since 4 months of age. You obtain a screening CBC and note that he has Hgb of 11 g/dL, WBC of 6 × 10 9 /L, and a platelet count of 47 × 10 9 /L. The pathologist notes that the platelets appear small.
You suspect that this patient has:
Options:
A: Thrombocytopenia absent radius
B: Wiskott-Aldrich syndrome (WAS)
C: Fanconi anemia
D: Congenital amegakaryocytic thrombocytopenia
E: Hyper-IgE syndrome
| B | |
A 14-month-old infant is brought to your office because the mother has noted crossing of the eyes. On examination, the light reflex is centered in the pupils, there is no movement on the alternate cover test, and the patient has full eye movements.
The most likely diagnosis is:
Options:
A: Fourth nerve palsy
B: Acute sixth nerve palsy
C: Intermittent exotropia
D: Accommodative esotropia
E: Pseudostrabismus
| E | |
A 13-year-old boy is seen in the pediatrician's office for a 3-day history of pain in the right knee and a limp. He reports the pain began as dull and deep in the right thigh, and that over the previous 2 days he began to have pain in the right knee and a limp on that side. He reports that he has been unable to participate in sports due to pain. Over-the-counter ibuprofen and acetaminophen have been minimally helpful. He has had no fever, nausea, vomiting, or trauma. He denies alcohol, drugs, or sexual activity. His past medical history is positive for mild hypertension noted on the previous year's well-child examination. On physical examination his height is 170 cm (5′7″), weight 100 kg (220 lb), and BMI 34.5 kg/m2. The right leg shows reduced internal rotation, reduced abduction, and reduced flexion. Upon flexion of the right hip the right thigh and leg rotate externally.
Which of the following is the most likely diagnosis?
Options:
A: Legg-Calvé-Perthes disease
B: Slipped capital femoral epiphysis
C: Osteomyelitis
D: Septic arthritis of the hip
E: Transient synovitis
| B | |
An otherwise healthy 4-week-old infant male is noted to have vesicles and pustules on his palms and soles The patient's mother thinks the eruption may be pruritic because the infant is not sleeping well and is constantly rubbing his hands and feet. The mother describes the lesions as "coming in waves." Other members of the family are not itching.
What is the most likely diagnosis?
Options:
A: Acropustulosis of infancy
B: Congenital syphilis
C: Scabies
D: Sucking blisters
E: Contact dermatitis
| A | |
A 7-year-old child has spent the majority of the summer afternoons swimming in the community pool. He develops a bright red eye with scant discharge; the eye is irritated and has a sandpaper feeling to it. Two days later, the other eye becomes involved. The conjunctival injection lasts for 3 weeks.
The most likely diagnosis is:
Options:
A: Viral conjunctivitis, likely adenoviral
B: Bacterial conjunctivitis, likely streptococcal
C: Corneal abrasion
D: Foreign body in the eye
E: Chemical reaction to chlorine
| A | |
A 9-year-old boy is seen in the pediatrician's office with a several days' history of weakness of his mouth. He reports that he had a viral upper respiratory tract infection (URI) about 2 weeks prior. He denies headache, fever, vomiting, constipation, or weakness. He has been a healthy child without serious previous illnesses. On physical examination the vital signs are normal. The left side of his mouth droops, he is unable to completely close his left eye, and his smile is asymmetric (Photograph). The mucous membranes are pink, moist, and without lesions. Extraocular eye movement and fundoscopic examinations are normal. The chest is clear. Heart has a normal S1 and S2 without murmur. The abdomen is soft and nontender. No hepatosplenomegaly or adenopathy is noted. Gait, sensation, and deep tendon reflexes are normal.
Which of the following is the most likely diagnosis?
Options:
A: Guillain-Barré syndrome
B: Botulism
C: Cerebral vascular accident
D: Brainstem tumor
E: Bell palsy
| E | |
A 48-hour-old neonate in the normal newborn nursery is seen by the neonatologist after developing deep cyanosis with crying.
He was born vaginally at term to a 19-year-old mother with scant prenatal care. She reports no problems during the pregnancy other than third trimester hypertension. On physical examination vital signs and growth parameters are normal. Head is normocephalic. Fontanelles are flat. Chest has good air movement without distress. Heart has increased apical impulse that is displaced to the left. Left ventricular impulse is prominent. The first heart sound is increased in intensity; the second heart sound is single. A 4 out of 6 holosystolic murmur along the left sternal border is found. Distal pulses are normal. Capillary refill is less than 3 seconds. Abdomen is soft, nontender, and the liver is felt 3 cm below the costal margin.
Which of the following is the most likely diagnosis?
Options:
A: Transposition of the great arteries
B: Truncus arteriosus
C: Tricuspid atresia
D: Tetralogy of Fallot
E: Hypoplastic left heart syndrome
| C | |
A 2-year-old male is brought in by his mother for his well-child visit.
He was the full-term product of a normal pregnancy, and has had a normal postnatal course with no hospitalizations. He drinks tap water supplied by your city. He eats a balanced diet including daily fruits, vegetables, and meat and without abnormal eating patterns. He does not take any supplements except a multivitamin. He is growing well and has a normal physical examination, only notable for black staining on the teeth.
The most likely cause of this is:
Options:
A: Tetracycline use during his gestation
B: Iron staining
C: Excessive fluoride
D: Hyperbilirubinemia
E: Inadequate teeth brushing
| B | |
This patient requires surgery.
The patient's abdominal radiograph improves during the next few days. The platelet count is stable.
Which is the most likely complication of necrotizing enterocolitis (NEC)?
Options:
A: intestinal stricture
B: chronic constipation
C: neurodevelopmental problems
D: increased risk of food allergies
E: increased risk of irritable bowel syndrome
| A | |
A 14-year-old boy is seen in the pediatric office with a 14-day history of rash.
He reports that the first lesion (Photograph A) began on his lower back and then additional lesions developed a few days later (Photograph B). He reports the rash is slightly pruritic, but denies fever, nausea, vomiting, headache, or musculoskeletal symptoms. His past history is positive only for mild seasonal allergic rhinitis for which he occasionally takes over-the-counter antihistamines. His vaccines are current. He is doing well in school, plays football, and denies sex, alcohol, and drug use. On physical examination he has a temperature of 37°C (98.5°F), a heart rate of 92 beats per minute, a respiratory rate of 16 breaths per minute, and a blood pressure of 110/69 mm Hg. The mucous membranes are moist and without lesions. The chest is clear. Heart has a normal S1 and S2 without murmur. The genitourinary examination is normal Tanner 4. The rash on the abdomen and back are slightly raised at the edges with a somewhat scaly appearance in the center.
Which of the following is the most likely diagnosis?
Options:
A: Contact dermatitis
B: Pityriasis rosea
C: Seborrheic dermatitis
D: Lichen planus
E: Psoriasis
| B | |
A 3.4-kg newborn girl presents with an oral lesion seen below.
There is a pedunculated, soft tissue mass attached to the alveolar ridge by a broad base.
What is the diagnosis?
Options:
A: Eruption hematoma
B: Ankyloglossia
C: Congenital epulis
D: Neonatal cyst
E: Fibroma
| C | |
At a newborn's 1-month follow-up appointment the parents note a lesion on the child's back that has occasionally appeared raised and fluid filled (left).
One month later, the child presents with multiple tan brown plaques, some with a thickened surface, over the trunk and extremities (right).
You inform the parents:
Options:
A: the child needs a bone marrow biopsy
B: the child needs a bone marrow transplant
C: these lesions will fade and resolve by 10-12 years of age
D: the child has neurofibromatosis
E: the child needs a rapid plasma reagin (RPR)
| C | |
You see a patient in an urgent care center and notice the presence of microbrachycephaly and micrognathia.
The patient has a low hairline, synophrys, arched eyebrows, long eyelashes, a thin upper lip and low-set ears. In examining the patient's extremities, you note spade like hands, 2–3 syndactyly of toes.
What is the most likely syndrome?
Options:
A: Moebius sequence
B: Sturge–Weber syndrome
C: Cornilia de Lange syndrome
D: Beckwith–Wiedemann syndrome
E: Cleidocranial dysplasia
| C | |
A 15-year-old girl is evaluated in the emergency department (ED) for abdominal pain and fevers.
The fevers started about 3 weeks ago and have not resolved despite intermittent treatment with acetaminophen and ibuprofen. The girl has had some right upper quadrant pain for the last several days and had a small bump on her right arm a few weeks ago that has since resolved. She cannot remember any other symptoms. Because of no improvement in symptoms her family brought her in to be evaluated. On exam you note her to be febrile to 38.5°C (101.3°F) with a heart rate of 110 beats per minute, but she is non–toxic appearing. She has a somewhat tender right axillary lymph node that feels like it is approximately 3 cm in diameter. She has some tenderness in the right upper quadrant and the liver edge is palpable about 2 cm below the right costal margin. Her lab results are remarkable for a mildly elevated white blood cell count of 13,000 with neutrophil predominance and normal liver function tests. A computed tomography (CT) scan with contrast is ordered and shows a normal appendix and gallbladder but some mild hepatomegaly with multiple scattered small abscesses.
You explore the history further and are most likely to find that:
Options:
A: She recently went to rural Mexico.
B: She has a kitten at home.
C: She had Staphylococcus aureus bacteremia a few months ago that was treated with IV antibiotics.
D: She drinks unpasteurized milk.
E: None of the above.
| B | |
A newborn female weighs 4.6 kg. She has a large tongue and an umbilical hernia.
She is noted to have facial hemangiomata, pits on the backs of her ear helices, and double creases in her earlobes. Abdominal ultrasound reveals enlarged, lobulated kidneys.
Her likelihood of having cognitive impairments is most related to the presence of:
Options:
A: Hemihyperplasia
B: Hypoglycemia
C: Jaundice
D: Obstructive apnea
E: Wilms tumor
| B | |
A neonate of uncertain gestational age is born precipitously to a 36-year-old, G1P0→1 mother.
Forceps were required to deliver the infant. The right lower extremity is noted immediately to have a large defect similar to an erosion ( Fig. 13-8 ). The right and left legs are of equal length and demonstrate good mobility. Per delivery records there were no other erosions, cutaneous defects, or anomalies noted with the initial assessment after birth. Both the maternal and paternal medical histories were unknown. The mother did not have any prenatal care.
What is the diagnosis?
Options:
A: Birth trauma
B: Aplasia cutis congenita (ACC)
C: Goltz syndrome
D: Adams–Oliver syndrome
E: Amniotic band syndrome
| B | |
A 3-month-old infant girl was urgently added to your scheduled clinic appointments.
Her mother became concerned when looking at family photos from a few weeks ago. She noticed that the light reflex appeared significantly duller in her daughter’s eyes than in the rest of the family. On further inspection, you confirm that the red reflex is diminished bilaterally. In addition, when viewing the patient’s eyes with direct ophthalmoscopy you note some cloudiness to her pupils. The mother states that her daughter is otherwise healthy and has received all appropriate vaccinations. The remainder of her examination is normal.
All the following are associated with the patient’s condition EXCEPT:
Options:
A: Positive family history.
B: Down syndrome.
C: Galactosemia.
D: Trauma.
E: Intrauterine infection.
| D | |
An 8-year-old boy presents with recurrent erythema, scale, and pruritus of the antecubital and popliteal fossae.
His mother notes that his skin problems tend to flare in the winter months. Social history is notable for a pet cat. You suspect atopic dermatitis.
What additional cutaneous finding supports your diagnosis?
Options:
A: Alopecia.
B: Erythema and scale of alar creases.
C: Keratosis pilaris.
D: Nail pits.
E: Scaling of elbows and knees.
| C | |
A 10-day-old male infant is admitted to the pediatric intensive care unit (PICU) for fever, seizures, and somnolence.
His anterior fontanelle is full. A CT scan of the head did not show acute abnormalities. CSF showed elevated white blood cells with mostly neutrophils, elevated protein, and low glucose. You suspect meningitis and start antibiotics.
What are the most likely organisms in a patient of this age?
Options:
A: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b.
B: N. meningitidis, S. pneumoniae.
C: Group B Streptococcus, Escherichia coli, Listeria monocytogenes.
D: S. pneumoniae, N. meningitidis, L. monocytogenes.
| C | |
You are attending in the newborn nursery and the lactation consultant has concerns that a full-term, 2-day old male infant is not feeding well due to a short lingual frenulum.
On exam, you notice that the infant is unable to protrude the tongue past the alveolar ridge and his weight is down 8% from birthweight. The mother has experience breastfeeding her other two children and feels that the infant does not latch on well during feeding.
Which of the following is the most appropriate next step in the management of this infant?
Options:
A: Order a CBC with white blood cell count differential, C-reactive protein, and blood culture.
B: Start empiric IV ampicillin and gentamicin for presumed early-onset sepsis.
C: Start intravenous fluids for dehydration.
D: Arrange for a frenulectomy.
E: Instruct the mother to increase the frequency of feeding attempts to every 2 hours.
| D | |
You are attending on the general pediatric service and have a 4-year-old male patient who was admitted with fever and unilateral neck swelling.
Exam reveals a 3 × 4 cm area of right-sided cervical swelling that has central fluctuance. It is tender to palpation and the overlying skin is erythematous. The patient was previously healthy and has no known animal exposures. He does not appear to have poor dentition.
Acute unilateral cervical lymphadenitis is commonly caused by all of the following EXCEPT:
Options:
A: Streptococcus pyogenes (GAS).
B: Staphylococcus aureus.
C: Atypical mycobacteria.
D: Bartonella henselae.
E: Human immunodeficiency virus.
| E | |
A 5-year-old previously healthy boy is hospitalized with a 3-day history of malaise, fever, and generalized erythema.
He complains of skin pain. He was given acetaminophen (Tylenol) for the past 3 days without relief. Examination is notable for flaccid bullae and desquamation of the chest and axillae. Oral, ocular, and genital mucosae are clear. Touching the skin causes it to slough.
What is the most likely diagnosis?
Options:
A: Bullous impetigo.
B: Morbilliform drug eruption.
C: Pemphigus vulgaris.
D: Staphylococcal scalded skin syndrome.
E: Toxic epidermal necrolysis.
| D | |
A 6-year-old boy presents to your office for his yearly routine examination.
He is a very active and bright child. As part of the screening exam, you check his visual acuity, which measures 20/20 and 20/60 in his right and left eye, respectively. His pupils are equal and reactive with no evidence of a RAPD. You perform the cover-uncover and alternate cover tests and do not detect any deviation. His extraocular movements are full and his red reflex appears normal. The remainder of the exam is normal, and he is otherwise healthy with no significant past medical history. His mother recalls her brother being treated for a “lazy eye” at a young age.
What is the most likely cause of poor vision in this child?
Options:
A: Strabismus.
B: Amblyopia.
C: Cataract.
D: Cranial nerve VI palsy.
E: Retinoblastoma.
| B | |
A 13-year-old African American girl presents with acute right upper quadrant pain radiating to the shoulder.
She had one episode of nonbloody, nonbilious emesis and is nauseated. She has no fever or diarrhea. On exam, she is afebrile, obese, and uncomfortable. She has tenderness in the right upper quadrant. Her direct bilirubin, GGT, and transaminase levels are elevated.
Of the list below, the most likely diagnosis is:
Options:
A: Gastroenteritis.
B: Choledocholithiasis.
C: Splenic rupture.
D: Pancreatitis.
| B | |
A mother brings her 10-year-old daughter in for evaluation of a “neck mass.”
She reports that the child has a history of recurrent midline neck swelling for the past several years. The patient was healthy until last week when she developed a low-grade fever, rhinorrhea, and coughing. Mom then noticed a prominent midline neck swelling that appears erythematous and tender to palpation. You observe that the swelling moves upward when the patient sticks out her tongue during your exam.
Which of the following is the most likely diagnosis?
Options:
A: Lymphoma.
B: Infected brachial cleft cyst.
C: Cystic hygroma.
D: Reactive viral lymphadenopathy.
E: Infected thyroglossal duct cyst.
| E | |
A 15-year-old obese adolescent girl presents to the clinic with a 1-month history of near-daily, throbbing, early morning headaches and nausea.
She is being bullied at school because of her weight and acne. Her medications include a combined oral contraceptive pill (OCP) and retinoic acid cream. Her mother thinks she is faking symptoms to stay home from school. Her vital signs and general, and neurologic exams are normal except for blurred optic disc margins.
What is the most likely diagnosis?
Options:
A: Tension headache due to social stressors.
B: Chronic migraine.
C: Idiopathic intracranial hypertension.
D: Acute hydrocephalus.
E: None of the above.
| C | |
A 14-year-old adolescent girl was seen in her local acute care clinic for an ear infection and was noted to have thyromegaly.
She was referred to your clinic for further evaluation. She reports some fatigue and cold intolerance, but admits that it is winter and she has been staying up late texting with her boyfriend. On exam, she has a thyroid that is twice normal size with no discrete nodules. Thyroid function tests show elevated TSH of 25 μIU/mL and mildly low free T4 of 0.7 ng/dL.
The most likely cause of her hypothyroidism is:
Options:
A: Iodine deficiency.
B: Thyroid cancer.
C: Autoimmune (Hashimoto) thyroiditis.
D: Radiation exposure.
E: Congenital hypothyroidism.
| C | |
The next patient is also here to establish care.
The family is a young couple who bring their 4-month-old infant boy to see you. While very happy about the birth of their first child, they are a bit worried. They tell you that their son looks smaller than his same-age cousin, who outweighs him by 4 pounds. He throws up a lot, and they are not sure if this is normal. Even though he throws up, he still makes plenty of wet diapers each day. You confirm that he is below the fifth percentile for both length and weight. You wonder if something in the water is causing kidney problems in every infant in your clinic today, but decide that you should obtain some basic lab studies first. The serum chemistry looks something like this: Na 142 mEq/L, K 3.2 mEq/L, Cl 115 mEq/L, and CO2 10 mEq/L.
To make a diagnosis of renal tubular acidosis, you should see all of the following EXCEPT:
Options:
A: Low serum bicarbonate (CO2).
B: High serum chloride.
C: Normal serum anion gap.
D: High urine pH.
E: Normal to low serum chloride.
| E | |
A 12-year-old girl is referred to the gastroenterology clinic for evaluation of chronic abdominal pain.
She cannot describe the pain and vaguely rubs the center of her abdomen when asked where it hurts. You ask her to point with one finger and she says she can’t. She reports the pain as continuous and 10 out of 10. She has missed school. She denies vomiting, fever, diarrhea, or weight loss. The pain is not associated with eating and does not wake her from sleep. On exam, she appears well but claims to be in pain. She is not tachycardic. She winces in pain when you lightly palpate her abdomen but the pain is distractible. She has no oral ulcers or arthritis, and the rectal exam is normal, with no perianal skin tags or fissures. You suspect functional abdominal pain.
Functional abdominal pain is typically associated with which of the following findings?
Options:
A: Involuntary weight loss.
B: Significant vomiting.
C: Nocturnal symptoms.
D: Periumbilical location.
E: Fever.
| D | |
A neonatal resuscitation team is called to an impending delivery of a 41-week gestational age male infant.
The team is notified of thick meconium-stained fluid and persistent variable heart rate decelerations with slow recovery to baseline for the past 30 minutes. The mother had spontaneous rupture of membranes approximately 20 hours ago. Vacuum-assisted vaginal delivery is being attempted as the team enters the room. The infant is delivered after two pulls on the vacuum device. There was one pop-off of the vacuum device between attempts. The infant is handed to the waiting neonatal intensive care unit (NICU) team for assessment and treatment. He is not crying, has no spontaneous respirations, appears limp and cyanotic, and has a heart rate of 75 bpm.
What is the first step in the management of this infant?
Options:
A: Immediately begin tactile stimulation, including drying and gently rubbing the back to encourage respirations.
B: Apply free-flowing oxygen to the infant’s face as he is cyanotic.
C: Suction the mouth followed by the nose with a bulb syringe.
D: Intubate the trachea and suction for meconium.
E: Start positive-pressure ventilation (PPV) as the infant has no spontaneous respirations.
| D | |
A 4-month-old boy with torticollis returns to clinic for a well-child check.
His head is preferentially held in a tilt to the left and rotation to the right. He also has flattening of the right occiput. Shaking keys to the right and left side reveals that he can rotate 90 degrees to the right and 60 degrees to the left. He has a palpable mass within the left sternocleidomastoid muscle. His parents have tried adjustments to his home environment, consisting of laying him in his crib with his right side toward the wall and a music box to his left, to stimulate him to turn more to his left side.
What is the most appropriate next step in management?
Options:
A: Continued home management.
B: Referral for physical therapy.
C: MRI evaluation of the mass.
D: Referral to pediatric orthopedics.
E: Referral to orthotics.
| B | |
A mother brings her 4-year-old son to your office due to the acute onset of right eyelid swelling and redness.
The swelling started about 2 days ago and is worsening. The patient was wrestling with his brother 3 days prior and scratched the outside corner of his right eye. He is afebrile and denies any pain. On exam, the right upper and lower eyelids are swollen and erythematous. There is a healing scar at the lateral border of his right upper eyelid. Both eyes have intact extraocular movements. His pupils are round and reactive with no relative afferent pupillary defect. The conjunctiva is white and quiet. On vision testing, the patient sees 20/25 out of each eye. Mom reports putting some petroleum jelly (Vaseline) on the scar to try to help it feel better.
What is the most likely diagnosis?
Options:
A: Idiopathic orbital inflammation.
B: Orbital cellulitis.
C: Stevens-Johnson syndrome.
D: Preseptal cellulitis.
E: Atopic conjunctivitis.
| D | |
A 2-month-old previously healthy boy presents to your clinic for a well-child visit.
His parents have no major concerns. He is afebrile, his heart rate is 168 bpm, and his respiratory rate is 68 breaths per minute. He has gained 7 g/day since you saw him last at 1 month. On exam, he has a grade II/VI systolic ejection murmur and his liver is palpated 3 cm below the costal margin. You obtain a chest X-ray. The heart looks like a snowman. He does not appear cyanotic, but you ask the nurse to check his oxygen saturation (Spo2).
What is the most likely Spo2 you will obtain?
Options:
A: 100%.
B: 89%.
C: 72%.
D: 65%.
E: 40%.
| B | |
A 9-year-old girl presents with fever, rash, and bilateral joint swelling of the wrists and knees.
Once per day, she has a fever associated with a rash. Her temperature is 39°C (102.2°F). On exam, she appears ill and uncomfortable. She has tachycardia, tachypnea, hepatosplenomegaly, and warm, painful swelling of multiple joints. A rub is present on cardiac exam. Salmon-colored macules are present on her back and abdomen.
What is the diagnosis?
Options:
A: Parvovirus B19 infection.
B: Lyme disease.
C: Systemic-onset juvenile idiopathic arthritis.
D: Leukemia.
E: None of the above.
| C | |
A 3-week-old boy is brought to the emergency department seizing.
His seizures abate after administration of phenobarbital. He is noted to be febrile and sleepy after his seizure. Upon further questioning you find out he was born at term by vaginal delivery to a mother who received normal prenatal care and had no complications and no prior history of sexually transmitted or other diseases. The neonate is somnolent, has a bulging fontanelle, and is somewhat hypertonic. You decide to get blood, urine, and cerebrospinal fluid (CSF) analyses including cultures and start antibiotics. The medical student asks if you should start acyclovir to empirically treat neonatal HSV disease.
You correctly tell him:
A. This boy does not have neonatal HSV disease because he has no rash.
B. Neonatal HSV disease commonly occurs in the setting of negative maternal HSV history.
C. This boy has a high risk of neonatal HSV disease only if his mother has a history of genital HSV.
D. Central nervous system (CNS) involvement can be ruled out with a negative CSF HSV PCR.
E. Infants do not die from neonatal HSV infection.
Options:
A: This boy does not have neonatal HSV disease because he has no rash.
B: Neonatal HSV disease commonly occurs in the setting of negative maternal HSV history.
C: This boy has a high risk of neonatal HSV disease only if his mother has a history of genital HSV.
D: Central nervous system (CNS) involvement can be ruled out with a negative CSF HSV PCR.
E: Infants do not die from neonatal HSV infection.
| B | |
A 5-year-old previously healthy boy is seen in the emergency department with complaints of decreased activity tolerance and breathlessness for the past 2 days.
He has not been febrile today; however, he recently recovered from what his mother thought was the flu. His vital signs are HR 140 bpm, RR 40, BP 70/50 mm Hg, and T 37.5°C (99.5°F). The emergency department physician obtains IV access, sends off laboratory studies and a blood culture, administers a total of 40 mL/kg of isotonic fluid, and administers broad-spectrum IV antibiotics. The patient is now noted to be more tachycardic, with increased work of breathing, and pulses that are difficult to palpate.
What is the most likely cause of this child’s decompensation?
Options:
A: Septic shock.
B: Viral bronchiolitis.
C: Bacterial pneumonia.
D: Systemic inflammatory response syndrome (SIRS).
E: Congestive heart failure.
| E | |
A mother is admitted into labor and delivery with a 1-day history of dysuria, fevers to 38.9°C (102°F), and now active contractions every 2 to 3 minutes for about 1 hour.
Her fetus has an estimated gestational age of 24-3/7 weeks based on last menstrual period (LMP) and a concordant 8-week ultrasound. The mother had regular prenatal care and an uncomplicated pregnancy until now. On exam, the physician notes that the mother’s cervix is dilated to 8 cm with a bulging bag of water. She then has spontaneous rupture of membranes with green-colored, foul-smelling fluid. She rapidly delivers a 575-g male infant prior to maternal administration of betamethasone. The NICU team is present at the delivery.
Which of these statements is accurate about this infant?
Options:
A: The Apgar score can be used to reliably predict asphyxia in a very preterm infant.
B: The Apgar score is composed of five components: heart rate, respiratory effort, blood pressure, color, and oxygen saturation.
C: The Apgar score can be affected by maternal sedation or analgesia as well as neurologic conditions such as muscle disease or cerebral malformations.
D: The Apgar score is composed of five components: heart rate, respiratory effort, oxygen saturation, respiratory distress, and color.
E: None of the above.
| C | |
A 35-week gestational age infant is born by cesarean delivery to a mother with placenta previa.
The infant girl is vigorous after delivery, with Apgar scores of 8 and 8. She is brought to her mother’s chest. Fifteen minutes later the NICU team is called because the infant is experiencing worsening respiratory distress with tachypnea, retractions, and mild grunting respirations. She is placed on nasal continuous positive airway pressure (CPAP) and admitted to the NICU. The infant shows clinical improvement on CPAP, requiring approximately 25% FiO2. Her chest radiograph shows 10-rib expansion with fluid in the fissure and no other focal infiltrates. You are asked to update her family.
You tell them:
Options:
A: This is most consistent with neonatal pneumonia and sepsis. You will start antibiotics immediately and she will recover in several days to a week.
B: This is most consistent with respiratory distress syndrome resulting from surfactant deficiency related to prematurity. She may need to be intubated for surfactant administration.
C: This is most consistent with transient tachypnea of the newborn and fluid retention exacerbated by the cesarean delivery without labor. She will improve in the next 24 hours.
D: This is most consistent with meconium aspiration. She will improve within days to weeks.
E: None of the above.
| C | |
You are asked to see a formerly premature male infant in the neonatal intensive care unit (NICU) for hypoglycemia.
The infant was born at 34 weeks’ gestational age, and did not require ventilation, although he was on oxygen for a short period of time. The infant, now 38 weeks’ corrected gestational age, has continued to struggle somewhat with feeding. He is rather large for his gestational age and continues to require a rather high rate of glucose infusion. You note that he does not have hepatomegaly. His most recent serum glucose level was 76 mg/dL, and he continues to receive a 12.5% dextrose concentration infusion. If the glucose infusion is stopped, serum glucose levels drift down rather quickly. The NICU providers have started an evaluation for hypoglycemia, and neither ketosis nor lactic acidosis has been seen.
What class of disorder is most likely the cause of this patient’s hypoglycemia?
Options:
A: Congenital hyperinsulinism.
B: Glycogen storage disease.
C: Ketotic hypoglycemia.
D: Organic aciduria.
E: Congenital disorder of glycosylation type 1a (CDG1a).
| A | |
A 4-year-old girl presents to the emergency department with a chief complaint of “fever.”
Her mother reports that she was previously healthy but seemed to have a common cold last week. She has now had 3 days of fever, difficulty and pain with swallowing, as well as apparent neck pain. Physical exam is notable for cervical lymphadenopathy, neck tenderness, and a refusal to perform cervical neck extension or lateral rotation. Her posterior pharyngeal wall is erythematous and appears to be bulging.
Based on this history and physical exam, the most likely diagnosis is:
Options:
A: Viral upper respiratory infection.
B: Diphtheria.
C: Retropharyngeal abscess.
D: Neonatal impetigo.
E: Transient neonatal pustular melanosis.
| C | |
A 2-day-old healthy full-term Caucasian boy presents with papules and pustules and surrounding erythema on the face, trunk, and extremities.
The parents report that the bumps were not present at birth.
What is the most likely diagnosis?
Options:
A: Erythema toxicum neonatorum.
B: Neonatal acne.
C: Neonatal herpes.
D: Neonatal impetigo.
E: Transient neonatal pustular melanosis.
| A | |
A 15-year-old boy develops a single asymptomatic patch of alopecia.
He was not concerned until multiple additional patches were noted. His mother has not witnessed him pulling his hair.
What is the most likely diagnosis?
Options:
A: Alopecia areata.
B: Syphilis.
C: Telogen effluvium.
D: Tinea capitis.
E: Trichotillomania.
| A | |
A 6-month-old girl presents as a new patient for a well-child check.
Her length is below the third percentile and her weight is at the 10th percentile. Head circumference is greater than the 90th percentile. Her mother is 5 feet, 4 inches tall (50th percentile), and her father is 5 feet, 8 inches (25th percentile). She has normal eyes, a prominent forehead, and a prominent curve to her spine. She also demonstrates mild hypotonia.
The most likely diagnosis is:
Options:
A: Achondroplasia.
B: Osteogenesis imperfecta.
C: Klippel-Feil syndrome.
D: Trisomy 21.
E: Familial short stature.
| A | |
A mother brings her 4-month-old infant for a well-child visit.
She has no concerns other than the fact that the infant’s left eye does not seem to be as big as the right eye. On exam, you notice a very faint lid crease, eyelid lag on downgaze, barely visible corneal reflex, and poor elevation of the upper lid on the left side. The rest of the exam, including pupils and extraocular movements, is normal.
The child most likely has:
Options:
A: Congenital cranial nerve (CN) III palsy.
B: Congenital ptosis.
C: Congenital Horner syndrome.
D: Acquired aponeurotic ptosis.
E: Marcus Gunn jaw-winking syndrome.
| B | |
A 2-year-old boy is brought to your clinic for evaluation after an episode of painless gross hematuria.
His mother reports that he had a red-tinged void in his diaper last night, although his void this morning was normal colored. The patient is otherwise healthy, on no medications, and appears to be in no pain. His physical examination reveals a painless, left-sided abdominal mass palpated toward the flank, which does not move with respiration. Urinalysis in clinic today reveals trace heme and no red blood cells. You decide to order an abdominal ultrasound to evaluate the mass further.
Which is the most likely diagnosis?
Options:
A: Wilms tumor.
B: Neuroblastoma.
C: Splenomegaly.
D: Pyelonephritis.
E: Rhabdomyosarcoma.
| A | |
An 8-month-old boy is brought to the emergency department for evaluation of a skin rash.
He has been healthy and this is his first illness. He has no known drug allergies. His mother reports that he developed a red raised rash on his cheeks and around his mouth earlier today. The rash does not appear to bother the infant. He is afebrile and otherwise acting normally while eating a popsicle in the room.
Given this presentation, your clinical suspicion is for:
Options:
A: Facial cellulitis.
B: Hives.
C: Cold panniculitis.
D: Eczema.
E: Pressure erythema.
| C | |
A mother brings to the clinic a 6-week-old girl who has a high-pitched inspiratory noise that worsens with excitement.
The girl has no respiratory distress or hoarseness. She has never turned blue or stopped breathing. She breastfeeds well and is growing normally.
What is the most likely cause of the inspiratory noise?
Options:
A: Foreign body.
B: Vocal cord paresis.
C: Laryngomalacia.
D: Tracheomalacia.
E: Aberrant right subclavian artery.
| C | |
A newborn male is found to have hyperextended knees and bilateral clubfeet.
Both hips are flexed and have limited abduction; the spine appears straight and without any cutaneous lesions. The pregnancy was unremarkable, other than decreased fetal movement on prenatal ultrasounds.
All of the following would be consistent with a diagnosis of amyoplasia EXCEPT:
Options:
A: Cognitive delay.
B: Lack of flexion creases at joints.
C: Bilateral hip dislocations.
D: Difficulty swallowing.
| A | |
A newborn infant is admitted to your service at 1 hour of life after an accidental home birth.
The labor was precipitous and the child’s mother is currently in the operating room for postpartum hemorrhage while the father is in transit from work. The mother was followed by the obstetric team at your hospital, and records indicate this was a healthy and uncomplicated first pregnancy for her. The infant appears robust and healthy on exam.
Which of the following will occur during the infant’s hospitalization?
Options:
A: Administration of hepatitis B vaccine.
B: Hearing screen.
C: Ortolani and Barlow measures.
D: Warming of the child, if necessary, and monitoring of vital signs.
E: Screening for hyperbilirubinemia.
F: All of the above.
| F | |
A 14-year-old adolescent girl presents with a history of low-grade fevers for 1 week, a rash on her face, painful swelling of her knee, and calf swelling.
She reports chest pain when she takes a deep breath. On exam she has oral ulcers on the hard palate and butterfly-shaped redness on her cheeks and the bridge of her nose. Her knee is swollen, warm, and painful to move. The cardiac exam is normal. (See Figure 7–1 .)
Figure 7-1
Malar rash of systemic lupus erythematosus. Classic butterfly rash of systemic lupus erythematosus covering both cheeks and the bridge of the nose. The nasolabial folds are spared. (Reproduced with permission from Wolff K, Johnson RA, and Saavedra AP, eds. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology . 7th ed. New York, NY: McGraw-Hill Education; 2013, Fig. 14-33.)
What is the diagnosis?
Options:
A: Acute rheumatic fever.
B: Influenza.
C: Systemic lupus erythematosus.
D: Fibromyalgia.
E: Endocarditis.
| C | |
You attend the delivery of an infant girl who was noted to have a cleft lip on prenatal ultrasound.
On your initial exam, she is found to have a complete unilateral cleft lip and palate. (See Figure 9–4 .) The family has lots of questions regarding this diagnosis.
Figure 9-4.
This infant has a complete unilateral cleft lip that extends into the nasal sill. (Reproduced with permission from Lalwani AK, ed. Current Diagnosis & Treatment in Otolaryngology: Head and Neck Surgery . 3rd ed. McGraw-Hill Education; 2011, Fig 20-4.)
All of the following are true regarding cleft lip and palates EXCEPT:
Options:
A: Cleft lip occurs most often on the left side.
B: Right-sided clefts are more commonly associated with syndromes.
C: There is no association between a bifid uvula and a cleft palate.
D: Cleft lip is more common in males and cleft palate in females.
E: Almost all children with cleft lip and palate require myringotomy and tympanostomy tube placement due to eustachian tube dysfunction.
| C | |
A 16-year-old adolescent girl initially presented to your clinic with cough, generalized lymphadenopathy, and fever.
Onset of symptoms was 6 months ago, with increasing pruritus, flushing, and night sweats. She occasionally felt increasing pressure in her chest while lying down, and was having difficulty taking deep breaths. Physical examination was remarkable for posterior cervical lymphadenopathy, 10 cm on the right and 5 cm on the left. Coarse crackles were appreciated in the lower lung fields bilaterally. Saturation of peripheral hemoglobin by oxygen (SpO2) was 86% on room air. A CBC revealed hemoglobin of 10.6 g/dL, white blood cell count (WBC) 15 ×103/mm3 (differential: neutrophils 15%, lymphocytes 73%, monocytes 8%, eosinophils 4%), and platelets 382 ×103/mm3. An excisional lymph node biopsy reveals the finding shown in figure below.
This finding was noted on excisional biopsy of the patient’s enlarged lymph node (Case 6). (Reproduced with permission from Kaushansky K, Lichtman MA, KBeutler E, et al: Williams Hematology, 8ed. McGraw-Hill Education, Inc., 2010. Fig 98-34.
Of the following, the most likely diagnosis is:
Options:
A: Acute lymphoblastic leukemia.
B: Hodgkin lymphoma.
C: Infectious mononucleosis.
D: Diffuse large B-cell lymphoma.
E: Systemic lupus erythematosus.
| B | |
A 15-year-old boy comes to the clinic because of concern about increased urination and thirst.
His teachers have noticed that he leaves class frequently at school, and he has also been getting up at night to urinate. He is obese but tells you he is pleased to have lost several pounds over the last several weeks. On exam, his height is at the 80th percentile, weight is at the 99th percentile, blood pressure is 130/80 mm Hg, and heart rate is 90 bpm. In general, he is obese but otherwise appears healthy. On exam, you note thickened and darkened skin on his posterior neck and axillae (see Figure 11–10 ), pink striae on his abdomen, and well-muscled legs and arms. You suspect that he could have type 2 diabetes mellitus but are smart enough to also consider type 1.
Figure 11-10.
Acanthosis nigricans on the back of the neck. (Reproduced with permission from Hoffman BL, Schorge JO, Schaffer JI, et al, eds. Williams Gynecology. 2nd ed. New York, NY: McGraw-Hill Education; 2012, Fig. 17-6.)
Which of the following features would support a diagnosis of type 2 versus type 1 diabetes mellitus?
Options:
A: Recent weight loss.
B: Low C-peptide level.
C: Signs of insulin resistance (acanthosis nigricans).
D: Blood glucose of 280 mg/dL.
E: Polyuria and polydipsia.
| C | |
An 8-year-old girl presents to the emergency department because of lumps on the right side and back of her head.
Her parents first noticed them several weeks ago and thought they were “zits” because they were soft and painless. Now, the lumps have grown and are still soft and painless. The patient has previously been healthy, although the parents report that she has been getting up five to eight times each night to void, and is drinking more than usual for the past 2 to 3 weeks. Vital signs are within normal limits. Physical exam is remarkable for soft, nontender nodules over the right temporal bone and right occipital scalp. You also notice a rash on the right pinna, which is scaly and erythematous, and which the patient reports has been there for months; it is occasionally pruritic. A skeletal X-ray series is performed, and reveals a 1.5 × 1.5 cm round, lytic lesion in the right temporal bone and another 2.5 × 3 cm similar lesion in the right occipital bone, the latter of which is shown in Figure 4–5 .
Skull finding in Langerhans cell histiocytosis (LCH). This plain film exhibits a large lytic lesion in the right occipital bone. There is minimal sclerosis and no periosteal reaction. This appearance is consistent with skull lesions common in LCH. (Used with permission from Adam D. Wolfe, MD, PhD.)
Which of the following is the most likely diagnosis for this patient?
Options:
A: Ewing sarcoma.
B: Osteosarcoma.
C: Non-Hodgkin lymphoma.
D: Trauma with contusion of the skull.
E: Langerhans cell histiocytosis.
| E | |
A 6-year-old girl is brought by her mother for evaluation of a new rash in August.
Her mother noted an approximately 2-cm red circular lesion a week ago. It has increased in size slowly over the last week and now has central clearing. (See Figure 20–6 .) The girl has been outside a lot this summer but does not remember any tick bites. She is afebrile and has no other symptoms. You suspect Lyme disease.
Erythema migrans is the hallmark of Lyme disease. It starts as a small red bump then grows to form a large annular erythematous lesion. Central clearing may occur to form the classic “bull’s eye”. (Used with permission from Nathan Price, MD.)
Your next step should be to:
Options:
A: Obtain Lyme serologies.
B: Prescribe amoxicillin.
C: Prescribe doxycycline.
D: Observe, only, since she is otherwise asymptomatic and has no reliable history of tick exposure.
E: Perform a lumbar puncture.
| B | |
A mother comes to the emergency room in labor at 35 weeks' gestation and delivers immediately.
Intrapartum antibiotics are not administered. She is from out-of-state and does not have a copy of her prenatal records. She denies any known abnormalities with her prenatal records but admits that she did not go very often. The baby is vigorous and crying. Apgar scores of 8 and 8 are given. The baby weighs 2,500 g and has the appearance of a late-premature infant. Mother reports her "water broke" a few hours ago. Hepatitis B vaccine is given. Vitamin K prophylaxis and erythromycin ointment is applied. STAT prenatal labs are obtained from the mother.
What is the recommended clinical management of the well-appearing late-preterm newborn whose mothers received inadequate GBS prophylaxis?
Options:
A: Well-appearing infants do not routinely require further diagnostic evaluation or special observation
B: Well-appearing infants born less than 37 weeks' gestation whose mothers did not receive adequate intrapartum GBS prophylaxis do not routinely require further diagnostic evaluation, but should be observed for ≥48 hours
C: All newborns born less than 37 weeks' gestation, regardless of intrapartum antibiotic use, should undergo full diagnostic evaluation and treatment pending cultures results with observation for ≥48 hours
D: Well-appearing infants born less than 37 weeks' gestation without adequate intrapartum GBS prophylaxis should undergo limited evaluation and observation for ≥48 hours
| D | |
You are seeing a 13-year-old adolescent boy who was admitted to the local community hospital for chronic fatigue and significant iron deficiency anemia with hemoglobin of 5.8 g/dL.
The history reveals that he has had no recent illnesses, fever, or travel history. He has decreased appetite and nausea without abdominal pain. He is fatigued after sleeping 10 hours at night, and has trouble staying awake at school. He wakes to void several times at night. He complains of generalized weakness, having withdrawn from his soccer team this past month. Growth parameters are significant for weight at the 10th percentile and height at the 50th percentile. Vital signs are temperature 36.7°C, heart rate 100 bpm, respirations 24 breaths per minute, and blood pressure 137/82 mm Hg. Upon admission, lab results are Na 135 mEq/L, K 5.2 mEq/L, Cl 101 mEq/L, CO2 16 mEq/L, glucose 102 mg/dL, albumin 3.2 g/dL, calcium 6.8 mg/dL, phosphate 8.2 mg/dL, BUN 85 mg/dL, and creatinine 5.2 mg/dL. Urinalysis is negative for blood, but positive for 1+ protein. You recognize that this patient has renal failure and consider the next steps in his treatment.
Which of the following should NOT be part of your management plans for him?
Options:
A: Renal ultrasound.
B: IV maintenance fluids D5 ½ NS.
C: IV calcium chloride to correct for hypocalcemia.
D: Low-phosphate and low-potassium diet.
E: Pediatric nephrology consult at a tertiary care hospital for transfer of care to determine modality of renal replacement therapy.
| C | |
A 2-year-old boy is brought to your clinic for evaluation after an episode of painless gross hematuria.
His mother reports that he had a red-tinged void in his diaper last night, although his void this morning was normal colored. The patient is otherwise healthy, on no medications, and appears to be in no pain. His physical examination reveals a painless, left-sided abdominal mass palpated toward the flank, which does not move with respiration. Urinalysis in clinic today reveals trace heme and no red blood cells. You decide to order an abdominal ultrasound to evaluate the mass further and eventually arrive at a diagnosis of Wilms tumor (WT).
What is a potential complication of Wilms tumor?
Options:
A: Tumor rupture with internal hemorrhage
B: Hypercalcemia
C: Tumor lysis syndrome
D: Adrenal insufficiency
E: Thrombocytopenia
| A | |
The triad of epiphora, blepharospasm, and photophobia with corneal clouding on exam is consistent with what pediatric ophthalmologic emergency?
Options:
A: Congenital nasolacrimal duct obstruction
B: Orbital cellulitis
C: Primary congenital glaucoma
D: Endemic keratoconjunctivitis
E: Congenital Horner syndrome
| C | |
A neonatologist sees a neonate in the level 2 neonatal intensive care nursery for feeding difficulties. The 7-day-old newborn was born at 32 weeks' gestation and had been doing well on increasing nasogastric feedings of breast milk. In the previous 6 hours the nursing staff report emesis of two feedings and decreased activity. On physical examination the temperature is 36.6°C (97.9°F), heart rate is 165 beats per minute, and respiratory rate is 35 breaths per minute. The newborn is awake and appears uncomfortable. The head is normocephalic with flat fontanel. The chest is clear with good air movement and equal breath sounds. The heart has normal S1 and S2 without murmur. Abdomen is tense and distended with decreased bowel sounds. A grossly bloody stool is noted in the diaper. The plain film of his abdomen is shown. Which of the following is the most appropriate next step?
Options:
A: Obtain a surgical consultation for an emergent exploratory laparotomy.
B: Continue feeding of the newborn, as gastroenteritis is usually self-limited.
C: Culture the stool culture to identify the etiology of the bloody diarrhea and obtain an infectious disease consultation.
D: Stop feeds, begin intravenous fluids, order serial abdominal films, and initiate systemic antibiotics.
E: Remove the nasogastric tube, place a transpyloric tube, and after confirmation via radiograph of tube positioning, switch feeds from nasogastric to nasoduodenal.
| D | |
A 15-year-old boy presents to your office with a 1-day history of unilateral facial weakness. On exam, he is unable to fully close his right eye. He also cannot raise his right eyebrow. The nasolabial fold on the right side is less prominent compared with the left side. His extraocular movement is full bilaterally, and he has normal pupillary responses. Strength in the arms and legs is full bilaterally.
Where do you localize the lesion?
Options:
A: Motor cortex
B: Facial nerve
C: Neuromuscular junction
D: Facial muscles
| B | |
An 8-month-old girl is brought to the clinic for evaluation of a fever.
She has been healthy and this is her first illness. She has no known drug allergies. Her mother reports that several members of the family “had a cold” last week and the patient had several days of coughing and rhinorrhea that seemed to improve. Physical exam reveals an ill-appearing infant with a temperature of 39.2°C (102.5°F) and a right tympanic membrane (TM) that is erythematous and bulging with white fluid present behind the TM. You perform pneumatic otoscopy and do not appreciate any movement of the TM. (See image below). You explain to the mother that the child has a right-sided acute otitis media (AOM).
Which of the following is the most appropriate initial treatment for this patient?
Options:
A: Clindamycin
B: Cefuroxime
C: Cefdinir
D: Amoxicillin and clavulanic acid (Augmentin)
E: Amoxicillin
| E | |
A boy born after 38-3/7 weeks’ gestation by spontaneous vaginal delivery cries immediately with good respiratory effort.
His heart rate is strong, at 160 bpm. No murmurs are heard on exam. You notice that he is cyanotic and administer supplemental oxygen through a face mask. No change in color is noted. As the infant is otherwise stable, he is transferred to the neonatal intensive care unit (NICU). He is trialed off oxygen, resulting in an oxygen saturation of 72%. He is placed back on supplemental oxygen by nasal cannula, with an increase in saturation to 78%.
Which of the following is the most likely possible diagnosis?
Options:
A: VSD
B: D-transposition of the great arteries
C: Cor triatiatum sinister
D: Cor triatriatum dexter
E: Scimitar syndrome
| B | |
Which of the following infant reflexes will not be present at day of life 7?
Options:
A: Palmar grasp
B: Parachute
C: Moro
D: Tonic neck
E: Rooting
| B | |
A 6-month-old boy presents with a 2-day history of worsening cough, congestion, and increased work of breathing. On physical examination, the patient is noted to have nasal flaring, intercostal retractions, diffuse rales, and expiratory wheezes. The patient is diagnosed with acute bronchiolitis. What finding would have you seriously consider hospitalization?
Options:
A: Respiratory rate of 60 bpm
B: Appropriate oral intake to maintain hydration status
C: Oxygen saturation of 97% on room air
D: Accessory muscle use
E: Identified sick contacts in the home
| D | |
A 16-year-old boy presents to the emergency center with a 2-day history of an abscess with spreading cellulitis. While in the emergency center, he develops a high fever, hypotension, and vomiting with diarrhea. On examination, you note the erythematous rash along with injected conjunctiva and oral mucosa, and a strawberry tongue. He is not as alert as when he first arrived. This rapidly progressive symptom constellation is likely caused by which of the following disease processes?
Options:
A: Kawasaki disease
B: TSST-1–secreting S aureus
C: Shiga toxin–secreting Escherichia coli
D: α-Toxin–secreting Clostridium perfringens
E: Neurotoxin-secreting Clostridium tetani
| B | |
A male infant born at 25 2/7 weeks' gestation (birth weight 800 g) develops tachycardia and abdominal distension prior to passing a blood-tinged stool. His physical examination reveals decreased tone and activity, tenderness on palpation of the abdomen, and a paucity of bowel sounds. His abdominal x-ray shows diffuse pneumatosis without pneumoperitoneum or portal venous air. His parents arrive during initial stabilization of their infant and ask to speak to the attending neonatologist.
Which of the following statement regarding this infant's condition is correct?
Options:
A: Because of his abdominal findings, the infant likely has hypersensitivity to mother's breast milk, and she should stop pumping.
B: Unless intestinal perforation occurs, their infant's risk for growth failure is not significantly increased as a result of this condition.
C: Their infant is unlikely to develop an intestinal stricture if there is no bowel perforation.
D: This condition puts their infant at increased risk for neurodevelopmental impairment.
E: The incidence of this condition is inversely related to gestational age and birth weight, but these characteristics do not increase the risk of mortality.
| D | |
Which of the following accurately describes systemic onset juvenile idiopathic arthritis (JIA)?
Options:
A: Gradual onset
B: Girls affected more than boys
C: Diffuse lymphadenopathy
D: More than four joints involved
E: HLA-B27 positive
| C | |
Which is NOT a sign of neonatal hypoglycemia?
Options:
A: Hypothermia
B: Respiratory distress
C: Strong suck
D: Lethargy
E: Exaggerated Moro reflex
| C |