CPD

A 16-year-old female cross-country runner presents to your office for follow-up of a right hip injury. The team physician at her high school recently diagnosed her with a stress fracture of the right femoral neck and recommended that she follow-up with you for ongoing management. She has been using crutches to ambulate and reports occasional mild hip pain. The patient and her family ask your advice on management of her current symptoms. Of the following, the BEST medication regimen for this patient is A. acetaminophen orally as needed B. hydrocodone and ibuprofen orally every 6 hours as needed C. ibuprofen orally every 6 hours for 1 week D. naproxen orally every 12 hours as needed E. topical diclofenac gel applied to the anterior hip every 6 hours CPD 17

A

A 17-month-old boy presents for his health supervision visit. You last saw him at 12 months of age. The parents have no concerns, but remark that his left eyelid has looked droopy for "awhile" (Item Q121). Reviewing his old chart, you find that he was born at term by repeat cesarean delivery, had an uncomplicated perinatal course, and a normal examination without ptosis at 12 months of age. His growth and development are unremarkable. His physical examination is notable for left-sided ptosis, anisocoria, and a paler pupil on the left than the right. You also palpate a 3 cm left-sided lower cervical lymph node. He has normal movement of his upper and lower extremities. Of the following, the MOST appropriate management for this child is to A. obtain imaging of the head, neck, chest, and abdomen B. refer him to neurology for an edrophonium (Tensilon) test C. refer him to an ophthalmologist for vision evaluation D. refer him to physical therapy for a brachial plexus injury E. treat the lymphadenopathy with amoxicillin-clavulanate Picture 10 CPD 52

A

A 30-month-old girl is brought to the pediatric urgent care center for evaluation of fever, cough, and rhinorrhea. Her mother is concerned that her daughter has an ear infection because she has been crying frequently. The girl is a well-appearing, well-developed, active child in no distress. Her vital signs include a temperature of 38.4°C, heart rate of 115 beats/min, respiratory rate of 22 breaths/min, and pulse oximetry of 100% on room air. Physical examination is remarkable only for clear rhinorrhea from both nares and a swollen, tender right wrist with bruising over the dorsal aspect. When you inquire about any history of trauma, the mother explains that the girl is extremely active and "very accident prone," but that she recalls no specific injury. You order a right wrist radiograph (Item Q76). A review of the urgent care records show that she was seen for a left humerus fracture at 9 months of age. The mother denies any family history of musculoskeletal disorders. Of the following, the MOST likely explanation for her current radiologic finding is A. child abuse B. leukemia C. osteogenesis imperfecta D. osteomyelitis E. rickets Picture 11 CPD 61

A

A 5-year-old, previously healthy boy presents to the emergency department with a 2-cm laceration above his left eyebrow, sustained after hitting his head on a granite countertop. His vital signs include a temperature of 37°C, heart rate of 140 beats/min, blood pressure of 90/50 mm Hg, respiratory rate of 30 breaths/min, and oxygen saturation of 100% on room air. He is awake, alert, and anxious appearing. The repair requires sedation because of the boy's age, anxiety level, and proximity of the laceration to the eye. He was given a dose of intravenous (IV) midazolam 0.1 mg/kg, but he remains awake, screaming, and thrashes his head when approached. He is given a second dose of IV midazolam 0.1 mg/kg and falls asleep. His vital signs after the second dose are a temperature of 37°C, heart rate of 90 beats/min, blood pressure of 68/40 mm Hg, respiratory rate of 20 breaths/min, and oxygen saturation of 95% on room air. Upon verbal stimulation, the boy opens his eyes, mumbles a few words, and falls back asleep. His extremities are warm with a capillary refill time of 1 second. Of the following, the MOST appropriate next step is the IV administration of A. 0.9% normal saline bolus, 20 mL/kg B. atropine, 0.01 mg/kg C. epinephrine infusion, 0.05 µg/kg per min D. flumazenil, 0.01 mg/kg E. naloxone, 0.01 mg/kg CPD 75

A

A 6-week-old female infant is brought to your office for concern for an eye infection. Her parents report that her left eye is "more watery" than the right. Her mother saw some golden-colored crust on her eyelashes this morning. Her eye has never appeared red, and the parents have seen only clear fluid from the eye. She is otherwise well, eating appropriately, and not excessively fussy. Of the following, the BEST next step in management for her condition is A. nasolacrimal duct massage B. referral to an ophthalmologist C. systemic antibiotics D. topical antibiotics E. warm compresses to the affected eye CPD 3

A

A previously healthy 2-year-old boy presents to your office with several days of tactile fever and nasal congestion interfering with sleep, clear rhinorrhea, and cough. On physical examination, his temperature is 39°C, heart rate is 120 beats/min, and respiratory rate is 24 breaths/min. He is fussy, rubbing his eyes and ears, but is consolable. His voice is hoarse and his posterior oropharynx is erythematous without exudates. You note clear rhinorrhea and erythema of the nasal mucosa. The tympanic membranes are mildly hyperemic and retracted. There is shotty, bilateral cervical lymphadenopathy. Auscultation of the lungs reveals diffuse coarse upper airway sounds. The remainder of the physical examination is unremarkable. Of the following, the MOST appropriate therapy to recommend for this child is A. acetaminophen B. dextromethorphan C. diphenhydramine D. guaifenesin E. pseudoephedrine CPD 83

A

The mother of a 4-year-old girl calls poison control after finding the child playing with a bottle of eye drops. The girl told her mother she thought it looked like a little baby bottle when she was discovered holding it to her lips. The eye drops are a common over-the-counter brand used to treat allergy symptoms. The bottle is now empty, and the mother is unsure of the quantity of liquid it had contained. The girl is alert and well appearing. Her heart rate is 65 beats/min based on the mother's report. Of the following, the BEST next step in the management of this possible ingestion is A. activated charcoal administration within 2 hours B. close observation by the parents at home C. hemodynamic monitoring for 4 hours D. naloxone administration urgently E. vomiting induced immediately CPD 13

A

You are reviewing the list of infants to be screened by the pediatric ophthalmologist for retinopathy of prematurity (ROP). It includes an infant born at 34 weeks of gestation that is now 4 weeks of age. He was born to a 32-year-old woman with a history of substance abuse who presented with placental abruption. He weighed 1.6 kg at birth, required surfactant administration for respiratory distress syndrome, and remained intubated for the first 3 weeks of life. He received antibiotics until blood cultures were negative for 72 hours and a red blood cell transfusion. A nurse in your neonatal intensive care unit questions his inclusion for screening. Of the following, the clinical factor that MOST qualifies this infant for ROP screening is A. duration of intubation B. gestational age C. maternal history of substance abuse D. placental abruption E. red blood cell transfusion CPD 5

A

You are seeing a 12-year-old girl in your office with complaint of generalized pain and back pain that is worsened by exercise. The girl has muscle aches and joint pain that she is not able to localize well. She has noticed recurrent ankle swelling that lasts a few hours with each episode. She rates the pain as a 3 out of 10 at its mildest, and 7 out of 10 at its worst. The girl has pain daily, which is not associated with time of day, and is worsened by exercise. Her review of symptoms is positive for fatigue, headache, difficulty sleeping, abdominal pain with cramping, alternating loose stools and constipation, and occasional mouth sores. She has missed several days of school because of pain, but has kept up with her schoolwork. When asked about changes at home, the girl states that her parents are going through a divorce. Of the following, the BEST next step in the evaluation and management of this girl would be a(n) A. erythrocyte sedimentation rate B. human leukocyte antigen-B27 test C. referral to a cognitive behavioral therapist D. referral to a gastroenterologist E. referral to a physical therapist CPD 65

A

You are seeing a 4-year-old boy, diagnosed with juvenile idiopathic arthritis, for a health supervision visit. His arthritis, which affects his wrists and knees, has been well controlled with medication for the last 6 months. He has had 1 previous disease flare. He is meeting his developmental milestones. The boy's parents are concerned and ask for guidance about how his chronic condition will affect his health, development, and school performance. Of the following, the MOST appropriate recommendation for this boy's family is to A. apply for a 504 modification plan when the boy starts school B. apply for an individualized educational plan when the boy starts school C. apply for supplemental security income D. enroll the boy in an early intervention program E. investigate services available through the Americans with Disabilities Act CPD 58

A

You have been taking care of a 10-year-old boy for most of his life, along with his 3 siblings. Unfortunately, this young boy developed acute myelogenous leukemia around 8 years of age. Throughout his treatment, you have continued to be in close contact with his family. Today, you received a notice from the local oncology team that he died from complications of his disease. In addition to dealing with your own internal reactions to this loss, you begin to wonder how best to interact with his family going forward. Of the following, the MOST appropriate action for you to take with this family is A. ask if the family would come in to see you in about a month B. avoid bringing up any reminders of this boy at future appointments with his siblings C. explain how the Kübler-Ross grief stages will be occurring for each of his siblings D. offer the advice that children younger than 5 years of age should not attend a funeral E. refrain from expressing any tearful emotions when interacting with his parents CPD 63

A

A 16-year-old adolescent boy presents to your clinic for evaluation of nose pain and swelling after he was hit in the face while playing basketball. His nose bled immediately after the incident, but this was controlled quickly with pressure to his nasal bridge. He complains of swelling, difficulty breathing through his nose, and pain when his nose is touched. On physical examination, the distal portion of the patient's nasal bone is deviated to the right. He has dried blood at the edge of each naris. Inspection of his intranasal cavity reveals a tense red mass on each side of his nasal septum (Item Q110). Of the following, the BEST next step in management of this patient's condition is A. closed reduction of the fracture B. drainage of the mass C. follow-up visit in 2 weeks D. intranasal phenylephrine E. oral clindamycin Picture 6 CPD 38

B

A 3-year-old girl is brought to your office for a health supervision visit by her father. The girl has been your patient since birth. You are aware that her parents divorced when she was 18 months of age, and that they share custody. A review of the girl's chart indicates that she has been healthy and that she has had no recent visits for any acute concerns. She has expressed no somatic complaints to either parent. The father states that the girl is very active and seems to be developing appropriately. She recently started preschool and is adjusting well. The girl's vital signs and growth parameters are all within normal ranges for her age. She is very interactive and cooperative with you throughout the visit. A complete physical examination, including inspection of her genitalia, reveals no abnormalities. You begin providing age-appropriate anticipatory guidance to the father while a nurse walks with the girl so that she can pick out some stickers. When the girl leaves the room, the father asks whether you can tell based on your physical examination if his daughter could have been sexually abused. He is concerned about this because the girl's mother recently became engaged to her boyfriend, whom the father does not trust. When you ask him whether the child has made any statements related to being abused by the mother's boyfriend, he denies this but states: "You just never know." He is also concerned because he has noticed the girl intermittently "touching her own private parts" when she is playing in the bathtub over the past 2 to 3 months. Of the following, the MOST accurate statement related to this father's concern is that A. a forensic examination for sexual abuse is indicated B. the girl's recent behaviors can be normal for her age C. the mother's boyfriend should be reported to child protective services D. sexual abuse is unlikely because the girl has a normal physical examination E. sexual abuse should be suspected because of the girl's recent behaviors CPD 27

B

A 4-day-old newborn presents for his newborn check. His mother, who has not breastfed before, reports that she is having a lot of pain with breastfeeding despite assistance from a lactation consultant. She has heard that tongue-tie can cause breastfeeding problems and wonders whether the baby needs to have his frenulum clipped. Of the following, the MOST appropriate information to provide this mother is that A. ankyloglossia is common, affecting about one-quarter of all babies B. frenulotomy may be useful in improving maternal nipple pain during breastfeeding C. strong evidence exists that newborn frenulotomy improves the baby's long term speech outcome D. there are reliable tools for determining which infants may benefit from frenulotomy E. there is clear evidence that frenulotomy is not helpful in supporting breastfeeding CPD 81

B

An 8-year-old boy presents to the emergency department with a 3-day history of right facial swelling and poor oral intake. On physical examination, his temperature is 39°C and vital signs are normal for age. His right cheek is markedly swollen and firm, with mild erythema and moderate tenderness to palpation. Examination of the oropharynx reveals dental caries, malodorous breath, and right mandibular gingival swelling with erythema. There is purulent fluid observed near the base of the first molar and palpation of the tooth elicits pain. The remainder of the physical examination is unremarkable. Of the following, the BEST antimicrobial therapy for this patient is A. ampicillin-sulbactam B. cefotaxime C. metronidazole D. tetracycline E. vancomycin CPD 92

B

A 10-year-old girl has a 2-year history of poor attention. At school, she stares out the window, often unresponsive to her teacher's directions, occasionally wanders around the playground, and fails to come in on time at the end of recess. Her parents have noticed episodes of similar behavior at home. One time, they noticed that the girl's eyes were "beating" side-to-side for about 10 min and she wouldn't respond to them. The girl reports that she was awake during that episode and could hear her parents, but didn't feel like answering "stupid" questions. Her physical examination is unremarkable. Of the following, the BEST next step to establish the diagnosis is A. administration of a Vanderbilt Assessment scale B. begin a trial of methylphenidate C. obtain an electroencephalogram D. referral to an ophthalmologist E. referral to a psychologist CPD 54

C

A 14-year-old adolescent is seen for a routine preparticipation evaluation to play volleyball. She has no significant past medical history and has no current concerns. On physical examination, she has multiple enlarged cervical lymph nodes (1 to 2 cm) on the left side of her neck that are firm and fixed. She also has a 3 to 4 cm, firm, fixed anterior neck mass just left of midline (Item Q32). The remainder of the physical examination is unremarkable. Of the following, the test MOST likely to establish the diagnosis is A. complete blood cell count B. computed tomography of the neck C. fine-needle aspiration of the neck mass D. thyroid-stimulating hormone level E. ultrasonography of the thyroid gland and regional lymph nodes Picture 5 CPD 33

C

A 14-year-old adolescent presents to the emergency room with the chief complaint of having cola-colored urine for 1 day. He had a mild sore throat without fever 4 weeks ago. Vital signs show a respiratory rate of 26 breaths/min, heart rate of 110 beats/min, and blood pressure of 138/90 mm Hg. He has normal growth parameters. On physical examination, he has facial puffiness, but the remainder of the examination is unremarkable. A urine test strip analysis demonstrates a specific gravity of 1.015, pH of 5.5, 3+ blood, 2+ leukocyte esterase, and no protein or nitrites. Of the following, the MOST appropriate anti-hypertensive agent for this patient is A. chlorothiazide B. enalapril C. furosemide D. hydralazine E. nifedipine CPD 71

C

A 5-month-old male infant presents to the infectious diseases clinic for follow-up. He has a history of herpes encephalitis treated with a 3-week course of parenteral acyclovir as a neonate. He has been receiving oral acyclovir for herpes suppression since that time. Of the following, the adverse effect that is most likely to require monitoring in this infant is A. arthritis B. dermatitis C. myelosuppression D. nephropathy E. transaminitis CPD 15

C

A 6-year-old boy comes for evaluation after he was diagnosed with amblyopia at a recent optometry evaluation. He was born at term with no complications, has only had a few minor childhood illnesses, and has had no eye trauma. On past routine physical examination, he had a normal cover-uncover test and pupillary light reflex. Of the following, the MOST accurate statement about this child's amblyopia is that it A. can only be treated with eye patching B. is most likely to be related to a lesion that obstructs vision C. is often not detectable prior to routine vision screening D. is unlikely to respond to treatment at this age E. only occurs in patients with strabismus CPD 56

C

A 6-year-old boy presents to your office with a several month history of worsening nasal congestion, thick nasal discharge, and cough disrupting sleep, despite multiple courses of antibiotics. The boy has asthma and uses an inhaled steroid appropriately for maintenance therapy, but recently has been having frequent exacerbations. Although recent testing did not reveal allergies, he has been using nasal steroid sprays and oral antihistamines. He has a history of multiple upper respiratory tract infections and foul smelling stools. On physical examination, the boy's temperature is 37°C, heart rate is 110 beats/min, respiratory rate is 20 breaths/min, blood pressure is 95/65 mm Hg, and weight is 22 kg (tenth percentile). Examination of the head and neck reveals deviation of the nasal septum to the right, hypertrophy of the nasal turbinates with mucopurulent discharge, and nasal polyps in the left naris. The tympanic membranes are normal. The posterior oropharyngeal mucosa has a cobblestone appearance and the tonsils are enlarged without exudates. Auscultation of the lungs is significant for a prolonged expiratory phase with mild, intermittent wheezing throughout. Of the following, the MOST likely cause of this patient's prolonged symptoms is A. adenoidal and tonsillar hypertrophy B. defective phagocytosis C. dysfunction of a transporter protein D. HIV infection E. poorly controlled asthma CPD 85

C

A 6-year-old previously healthy, fully immunized boy is brought to your office by his mother. He has had a cough and runny nose for 1 week and developed fever yesterday. Today, the boy is complaining of neck pain, resists turning his head to the side, is refusing to eat, and will only take small sips of water. On physical examination, the boy is tired appearing with a temperature of 40.3°C, heart rate of 130 beats/min, respiratory rate of 45 breaths/min, and oxygen saturation of 98% by pulse oximetry. His lung fields are clear with good aeration. He has tender anterior cervical lymphadenopathy, torticollis, and his posterior oropharynx appears erythematous. The remainder of his physical examination is within normal limits. Of the following, the test MOST likely to confirm this boy's diagnosis is A. anteroposterior and lateral chest radiographs B. blood culture C. lateral neck radiograph D. lumbar puncture E. throat culture Picture Slide 4 CPD 29

C

A 7-year-old boy is admitted for evaluation and treatment of swelling and redness around his left eye. His illness began with a 9-day history of fever to 38.9°C, cough, congestion, and runny nose. On the evening prior to admission, he complained of mild pain in his left eye, but was able to watch television without difficulty seeing the screen. On the morning of admission, he woke up with marked swelling, redness, and increased pain in his left eye. He is now unable to open the eye. The boy's temperature is 38.7°C, pulse rate is 110 beats/min, blood pressure is 107/75 mm Hg, and respiratory rate is 22 breaths/min. Examination shows swelling and erythema surrounding the left eye. He is unable to open the eye and complains of pain on attempts to move the eye. You are unable to assess extraocular movements because of the swelling. His nose is congested, and his pharynx is unremarkable. His neck is supple and the remainder of the examination findings are unremarkable. Of the following, the BEST initial treatment for this patient is A. cephalexin and clindamycin B. clindamycin and gentamicin C. vancomycin and ceftriaxone D. vancomycin and gentamicin E. vancomycin and rifampin CPD 97

C

You have just diagnosed a 9-year-old boy with attention-deficit/hyperactivity disorder, following your usual data-gathering steps from both school and home that helped characterize the problem. After discussing the treatment options, the parents have elected to initiate methylphenidate and plan a follow-up appointment with you in 4 weeks. Of the following adverse effects, the MOST likely to occur in this patient is A. dysphoria B. hallucinations C. headaches D. hypertension E. tics CPD 79

C

A 20-month-old girl is brought to your office with complaints of fever and right ear pain. On physical examination, her temperature is 38.5°C. The right ear shows a bright red tympanic membrane, which is bulging with a purulent effusion. The left ear is normal. You note that this is her fourth episode of otitis media in the last 7 months. Her last ear infection was 3 weeks ago and she was treated with amoxicillin. Of the following, the BEST approach for management of this patient is to initiate a A. 5-day course of amoxicillin and refer for insertion of tympanostomy tubes B. 5-day course of amoxicillin and refer to audiology for a hearing screen C. 5-day course of amoxicillin-clavulanate and follow-up in 3 weeks D. 10-day course of amoxicillin-clavulanate and refer for insertion of tympanostomy tubes E. 10-day course of amoxicillin-clavulanate followed by a daily prophylactic low dose of amoxicillin for 3 months CPD 43

D

A 3-month-old infant presents to your practice with a physical examination remarkable for the finding shown in Item Q50. Of the following, the MOST appropriate next step in the management of this patient would be A. reassure her mother that this will self-resolve with time B. refer her to a geneticist out of concern for Sturge-Weber syndrome C. refer her to a pediatric oncologist out of concern for malignancy D. refer her to a pediatric ophthalmologist out of concern for amblyopia E. refer her to a pediatric ophthalmologist out of concern for strabismus Picture 9 CPD 49

D

A 4-month-old male infant comes to your office for a scheduled health supervision visit. He was born at term, has been growing and developing appropriately, and has had no medical problems. His father has noticed that the infant sometimes looks "cross-eyed." On ophthalmological examination, a red reflex is present bilaterally and the corneal light reflex is central bilaterally. The infant fixes on your face and tracks in all directions without ocular misalignment. The remainder of his physical examination is unremarkable. Of the following, the BEST recommendation for this infant is A. follow-up at the 6-month health maintenance visit B. magnetic resonance imaging of the brain C. pediatric neurology referral D. pediatric ophthalmology referral E. pediatric vision therapy referral CPD 99

D

A 4-year-old girl presents to your office for evaluation of left ear pain and drainage. She has had at least 5 episodes of acute otitis media in her lifetime, the most recent of which was 3 months ago. The girl has been complaining of ear pain since this morning. She has not had a fever. This morning, her parents noted yellow crusting at the edge of her ear canal and on her pillow. The family returned yesterday from a weeklong camping trip during which the girl swam daily in a lake. On physical examination, the girl is well appearing with a temperature of 37.4°C. She cries when you touch the pinna or tragus of her left ear. Her left tympanic membrane cannot be visualized because of purulent material that fills the canal. The portion of the left ear canal that is visible is erythematous. Of the following, the MOST helpful factor for making the diagnosis in this patient is A. absence of fever B. history of recurrent acute otitis media C. history of recent swimming D. pain with manipulation of the ear E. presence of purulent debris in the ear canal CPD 35

D

A 4-year-old, previously healthy boy presents to the emergency department with a facial laceration that requires 4 simple, interrupted sutures. His vital signs are normal for age, and other than the laceration, his physical examination is unremarkable. The boy has no allergies and there is no family history of adverse reaction to anesthetic or sedative medications. Despite local anesthesia, distraction, and reassurance, the boy is uncooperative and sedation is required to perform the repair. He receives a dose of intranasal midazolam, 0.5 mg/kg. Five minutes later, he is calm and has a normal response to verbal stimuli. Of the following, while this boy is sedated, it would be MOST appropriate to continuously monitor his A. arterial blood pressure B. electrocardiogram C. exhaled tidal volume D. pulse oximetry E. pupillary response CPD 73

D

A 6-year-old boy develops a fever to 39.4°C, cough, and rhinorrhea. After 2 days of symptoms, his parents notice a mass in the middle of his neck and bring him to your office for evaluation (Item Q243). Upon further reflection, his parents recall that the mass presented once before when the boy had a similar infection, but then disappeared after his infection resolved. On physical examination, the neck mass moves upwards with protrusion of the tongue. Of the following, the MOST likely diagnosis is A. branchial cleft cyst B. cystic hygroma C. ectopic thyroid gland D. thyroglossal duct cyst E. thyroid nodule Picture 12 CPD 90

D

A 6-year-old boy with acute lymphoblastic leukemia in consolidation therapy is admitted to the hospital because of fever and neutropenia associated with shock. He has an indwelling central venous catheter. Vital signs show a temperature of 39°C, heart rate of 160 beats/min, blood pressure of 70/40 mm Hg, and respiratory rate of 30 breaths/min. On initial physical examination, he is tired appearing and in moderate respiratory distress. Lungs are clear to auscultation bilaterally. His heart is regular with no murmurs, and capillary refill time is 4 seconds. His abdomen is soft, nontender, and non-distended. He is given three 20 mL/kg boluses of normal saline. Blood cultures are drawn, and vancomycin and cefepime are started. Ten minutes after the infusion of vancomycin is started, he develops itching, flushing, and an erythematous rash covering his trunk and upper extremities. There is no change in his breathing or hemodynamics. Of the following, the MOST appropriate course of action is to A. administer clindamycin, 10 mg/kg intravenously B. administer diphenhydramine, 1 mg/kg intravenously C. administer hydrocortisone, 2 mg/kg intravenously D. decrease the rate of the vancomycin infusion E. discontinue vancomycin CPD 7

D

An 18-month-old girl who is new to your practice presents for evaluation of right wrist swelling, which her mother initially noticed approximately 1 week ago. There is no reported history of trauma. The girl has had no recent fevers, and she displays no other symptoms of illness. The mother tells you that the girl has been healthy, takes no medications, and that she is adopted and came to live with her new family only 3 months ago. Few details were provided to the adoptive family regarding the child's birth history, past medical history, and family medical history. The girl reportedly began walking around 14 months of age, although the mother notes that "she always seems bow-legged when she walks." The girl's vital signs are within normal limits; her height and weight are both at the fifth percentiles for her age. She is playful and appears well. On physical examination, you note that the girl has a prominent forehead, but no facial dysmorphisms. Her right wrist seems slightly swollen when compared to the left wrist, but there is no overlying bruising, warmth, or erythema, and the girl is able to flex and extend both wrists without pain. You agree with the mother's observation that her legs seem "bowed," but both lower extremities physical examination is unremarkable. You order plain radiographs of the girl's right wrist, which reveal widening of the distal radius and ulna with cupping of the right radial metaphysis, in addition to generalized osteopenia (Item Q111). Of the following, the MOST likely cause of this child's wrist swelling is A. Caffey disease B. child abuse C. osteogenesis imperfecta D. rickets E. scurvy CPD 101

D

An 8-month-old female infant is brought to your office 1 day following discharge from the hospital. She had been growing and developing well until she was hospitalized 3 days ago following 3 seizures at home without fever. She had no prior history of seizures. She was started on phenobarbital on the day of admission. During the hospital stay, her brain magnetic resonance imaging was normal, but her electroencephalogram showed epileptiform discharges and generalized slowing. She has not had any more seizures. Her phenobarbital level on the day of discharge was 10 μg/mL (43 μmol/L) (therapeutic range 15-40 μg/mL). Today, she is sleepy but arousable. Her mother reports she is drinking her usual amount of formula. The physical examination is otherwise unremarkable. Of the following, the BEST next step today for this infant is A. add levetiracetam B. check a serum ammonia level C. increase the phenobarbital dose D. provide reassurance E. recheck the serum phenobarbital level CPD Slide 9

D

An 8-year-old, previously healthy, fully immunized boy presents to your office with bilateral facial swelling that developed over the last 24 hours. Throughout the past week, the patient had a subjective fever, myalgias, and a mild cough. On physical examination, his temperature is 37.5°C, heart rate is 100 beats/min, and respiratory rate is 18 breaths/min. The boy's voice is hoarse. There is bilateral, tender, firm, nonerythematous swelling of the pre-auricular area that extends to the angle of the mandible. His teeth and gingiva are normal, with mild erythema of the buccal mucosa. His posterior oropharynx is erythematous with enlarged tonsils without exudates. He has clear rhinorrhea, erythema of the nasal mucosa, and mildly hyperemic and retracted tympanic membranes. There is shotty bilateral cervical lymphadenopathy. The remainder of the physical examination is unremarkable. Of the following, the MOST likely etiology of the patient's illness is A. HIV B. Klebsiella species C. mumps D. parainfluenza virus E. Staphylococcus aureus CPD 87

D

You are called to the nursery to see a male neonate born at 38 weeks of gestation to a 24-year-old gravida 1 para 0 woman who received routine prenatal care. Ultrasonography performed at 30 weeks of gestation because of poor fetal growth revealed hyperechogenic bowel and periventricular intracranial calcifications. At delivery, the small-for-gestational age neonate was noted to have a diffuse petechial rash and hepatosplenomegaly. Of the following, the condition MOST commonly associated with this neonate's condition is A. cerebral palsy B. learning disability C. seizures D. sensorineural hearing loss E. vision impairment Picture 7 CPD 40

D

You are evaluating a 15-year-old female adolescent with the chief concern of hoarseness of voice. Two weeks prior to presentation, the patient's father reports a history of acute and near complete absence of voice for 1 to 2 days. Although she can now speak, her voice is still abnormal with lower volume, lower pitch, and a persistent hoarse quality. There has been no stridor, cough, wheezing, or fever. Symptoms of gastroesophageal reflux are denied. Nasal symptoms have been notably absent. The patient is an avid cheerleader. On physical examination, the patient is well appearing in no acute distress. Her voice is "raspy" and low pitched. There is no stridor or respiratory distress. A head, eyes, ears, nose, and throat examination is unremarkable. Nasal mucosa is normal in appearance. The oropharynx is clear. Her neck is supple without palpable lymphadenopathy. Lungs are clear bilaterally without wheezing, crackles, or differential aeration. Cardiac, abdominal, extremity, and neurologic examinations are unremarkable. Of the following, the MOST likely etiology of this patient's hoarseness of voice is A. allergic rhinitis B. gastroesophageal reflux disease C. laryngeal papillomatosis D. vocal abuse E. vocal cord paralysis CPD 95

D

You are meeting with the parents of a 15-year-old adolescent boy and 8-year-old boy for a parents-only visit. They inform you that they are getting a divorce. They are planning on selling their current home and will both find new homes within a reasonable travel distance. The children will continue to attend the same schools. They have been careful to refrain from arguing in front of the children, but state that they are having a difficult time agreeing on custody arrangements. Of the following, the BEST recommendation is to have A. the children decide with whom they wish to live B. custody decisions determined by the courts C. joint custody with equal division between parents D. a regular schedule with flexibility for change E. weekdays at one home and weekends at the other home CPD 21

D

A 13-year-old adolescent is brought to your office for a health supervision visit. When you ask if there are any changes at home, she tells you that her parents are getting a divorce. She does not know with whom she will live and is worried about how things will change. She is concerned that she may need to change schools and move to a new home. Her younger brother has been acting out and her parents have been arguing more. Things have been quite tense at home. Of the following, your patient is MORE likely than her unaffected peers to have A. fewer household responsibilities B. a higher perception of self-efficacy C. later sexual experiences D. a less active dating life E. a marriage that will end in divorce CPD 25

E

A 15-year-old adolescent is brought to the office for vomiting. He describes effortless postprandial regurgitation after at least 1 meal daily for 1 month. He occasionally reswallows food. He complains of frequent abdominal pain and nausea, but no diarrhea or bloating. He has lost 2 kg over the last month. He has taken an over-the-counter H2 blocker without improvement. Of the following, the MOST likely diagnosis is A. cyclic vomiting B. eating disorder C. functional abdominal pain D. Helicobacter pylori infection E. rumination disorder CPD 23

E

A 2-year-old boy is brought to your office for a health supervision visit. He has developmental delay and microcephaly. He is cruising but not independently walking, and his parents report that he is difficult to feed, spits out his food, and seems to have difficulty swallowing. At times, they have to hold him down during meals. He has lost 1 kg since his most recent visit 6 months ago, and his weight is now less than the third percentile. You have referred them to an early intervention program, but his father refused to let the early intervention providers in their home. You have referred them to a gastroenterologist, a feeding specialist, and a neurologist, but they missed these appointments and have not rescheduled. Cab vouchers have been provided to the family for travel to their specialty appointments. The parents state they understand that you are recommending specialty care, but his father says they will not go to that hospital "because they hurt children there." Of the following, the MOST appropriate next step in management is to A. ask the family to consider your recommendations again and follow-up in 3 months B. give the family handouts on feeding and developmental delay C. offer to arrange a multidisciplinary evaluation at a different hospital D. offer to connect the family to the parents of another child with similar problems E. report the family to the state child welfare agency for suspected medical neglect CPD 19

E

A 3-week-old full-term newborn, with fever and decreased oral intake over the past 24 hours, is admitted to a teaching hospital where you are the supervising pediatrician. Her plan of care includes obtaining blood, urine, and cerebrospinal fluid cultures, and initiating empiric intravenous antibiotic therapy. As you discuss this plan with the admitting resident, you ask how she will manage the newborn's procedure-related pain. The resident replies that she generally does not use any pain management modality when performing procedures in newborns, as they are much less affected by these procedures than older children. Of the following, the MOST accurate statement about pain management for patients of this age is that A. a single modality should be used to manage procedure-related pain B. their level of procedure-related pain is overestimated by parents and health care providers C. they do not have the cognitive ability to remember painful experiences D. they typically display a less pronounced physiologic response to pain than older children E. undergoing painful procedures may result in long-term changes in pain response CPD 69

E

A 4-month-old infant with a history of neonatal hypoxic ischemic encephalopathy and seizure disorder is hospitalized for pertussis. Since being initially discharged from the hospital at 2 weeks of age, she has not had any seizures. She is on phenobarbital as prescribed by a neurologist, and her last level was 20 μg/mL (86.2 μmol/L) (therapeutic range, 15-40 μg/mL) 2 weeks prior to admission. For the current illness, she presented with rhinorrhea, paroxysmal cough, and perioral cyanosis. She has been treated with supportive care, oxygen as needed, and was started on erythromycin. Between the coughing episodes, she is otherwise at her baseline, taking feeds by mouth, and has continued to be seizure-free. On the fourth day of hospitalization, she becomes increasingly lethargic. She has not had seizure activity or fevers. Vital signs show a temperature of 37°C, heart rate of 110 beats/min, blood pressure of 65/30 mm Hg, and respiratory rate of 15 breaths/min. On physical examination, she is hypotonic and difficult to arouse. Pupils are 3 mm equal and reactive. Heart is regular rate and rhythm with no murmurs. Capillary refill time is 1 second. Breath sounds are clear and equal. Abdomen is soft, nontender, and non-distended with no organomegaly. Of the following, the test MOST likely to reveal a cause of her lethargy is A. ammonia level B. electroencephalogram C. lumbar puncture D. magnetic resonance imaging of the brain E. phenobarbital level CPD 11

E

A previously healthy 4-year-old boy was brought to your office for evaluation of fever, irritability, and poor oral intake for 3 days. Today, he began drooling and his mother noticed sores in his mouth (Item Q195). In the office, his temperature is 40°C, heart rate is 112 beats/min, and respiratory rate is 24 breaths/min. He is ill appearing and irritable, but consolable. Physical examination reveals numerous vesicles with red halos on the buccal mucosa. The gingiva is intensely erythematous and edematous. He appears mildly dehydrated. The remainder of his examination is unremarkable. Of the following, the MOST likely diagnosis is A. acute necrotizing gingivitis B. aphthous ulcerations C. hand-foot-mouth disease D. herpangina E. primary herpetic gingivostomatitis Picture 8 CPD 46

E

You are caring for an 8-year-old hospitalized boy who is receiving chemotherapy for acute lymphoblastic leukemia. He was admitted for fever, neutropenia, and septic shock 5 days ago and has improved after receiving fluid resuscitation, stress dose steroids, intravenous vancomycin and cefepime, and a dopamine infusion. He was weaned off the dopamine after 24 hours. His indwelling central line culture grew Pseudomonas aeruginosa, and after 48 hours, based on sensitivity results, the vancomycin was discontinued. Today, the boy had 8 loose, watery, foul-smelling stools. Stool studies have been sent. Of the following, the MOST appropriate next step is A. discontinuation of cefepime B. fluconazole, 12 mg/kg intravenously every 24 hours C. ganciclovir, 5 mg/kg intravenously every 12 hours D. linezolid, 10 mg/kg orally every 8 hours E. metronidazole, 10 mg/kg orally every 6 hours CPD 77

E

You are seeing a 7-year-old boy in your office, which is a medical home with comprehensive care systems available. The boy, recently diagnosed with Becker muscular dystrophy, was referred to neurology 2 weeks ago for a positive Gower sign and elevated muscle enzymes. He has normal intelligence and is able to walk and perform activities of daily living normally. The family is struggling to deal with this new diagnosis. They have concerns regarding his prognosis, educational needs, and care planning. Of the following, the MOST accurate statement regarding this child is that A. the family should contact the Department of Health for community resources B. he is not disabled enough to qualify for educational modifications C. he will need monthly health maintenance visits D. his neurologist should be his primary medical provider E. your office will coordinate specialist referrals for disease management CPD 67

E