Aquifer Peds

Which immunization(s) should be given today? (Select ALL correct answers.)

23-valent pneumococcal polysaccharide vaccine Meningococcal conjugate

A 6-week-old infant is brought to the emergency room by his mother due to sleepiness, constipation, and yellow skin for the past 3 weeks. The mother and the baby recently immigrated to the United States. No medical records from the delivery are available. The infant has been breast-fed since birth. Vital signs are normal. Physical examination reveals jaundice, large anterior and posterior fontanelles, a large tongue, and abdominal distension. Which of the following is the most appropriate next step in management of this patient?

Thyroid function studies

Dr. Harris explains that breast milk jaundice is the most likely diagnosis. He challenges you to consider what labs, if any, are absolutely essential to draw at this point: Which of the following seems critical?

Total serum bilirubin

Which of the following do you think are possible causes of unresponsiveness in a child Ian's age? Select all that apply.

Toxic ingestion Seizures Syncope Head Trauma Intracranial process - brain tumor intracranial hemorrhage, etc. Intussusception Infection

At the age of 16 months, which of the following developmental milestones should Ian have reached? Select all that apply

Uses 4-6 words consistently Uses a spoon and cup, spilling occasionally Follows simple commands Stoops and recovers

Based on the history you have already gathered (recognizing you have not yet examined him), what is the most likely cause of these symptoms? (Select the ONE best answer.)

Vasovagal syncope

List items in your broad working differential diagnosis for Caleb's symptoms

Viral gastroenteritis, bacterial gastroenteritis, surgical process (small bowel obstruction, appendicitis, inflammatory bowel disease)

What supplements are recommended for exclusively breastfed infants younger than 6 months of age? Select all that apply.

Vit D

A 16-year-old previously healthy girl comes to the Pediatrics Urgent Care Clinic having "almost fainted" at soccer practice. She says that she had not eaten much earlier in the day and it was very hot and muggy outside. She felt light-headed and sick to her stomach. She denies losing consciousness and did not fall to the ground. She denies any chest pain. When you examine her, her eyes are sunken and he is tachycardic. What would be your next step in her management?

Administer fluids and fluids and recheck vital signs

What are the key points of the history that help narrow the differential diagnosis?

Atopic family history, comes and goes, dog exposure, pruritic, diphenhydramine (Benadryl) may help. Lauren's family history of atopy suggests the possibility of an allergic reaction. Dog saliva exposure could initiate an allergic reaction—it is a more significant allergen than dander. The fact that when Lauren took an antihistamine her symptoms were alleviated also supports a theory of an allergic reaction.

What is the inheritance pattern for sickle cell disease?

Autosomal recessive

A 5-year-old boy is brought to his pediatrician with two days of right ankle pain and rash over both lower extremities. He has not had any fever and is previously healthy. He recovered from an upper respiratory infection two weeks ago. Vital signs are normal. His right ankle is swollen and mildly tender. He has palpable purpura over both lower extremities. Which of the following statements is true about his likely diagnosis?

This disease is classified as a small vessel vasculitis

Which one of Mr. Murphy's statements below would be most relevant to Ian's presentation today? Choose the single best answer

"I had a convulsion during a fever when I was about 2 years old"

Calculate Jimmy's BMI

25.4; 97th percentile; obese

Of the following, which do you think are the more likely causes of Holly's illness? Select all that apply.

A Bacterial meningitis F Roseola (Exanthem subitum) G Sepsis/bacteremia H Urinary tract infection J Viral meningitis

What congenital heart defects are more likely to be detected in school-age children than in neonates? Select all that apply.

ASD, bicuspid aortic valve

Select the tests you wish to perform initially. (Select all that apply.)

Acetaminophen level Blood gas Calcium EKG Electrolytes Serum glucose Toxicology screen

Based on your summary statement which of the following would be included in the differential diagnosis at this point?

Acute chest syndrome CHF Pericarditis Rib infarction Sepsis

How do you interpret the glucometer reading?

Adam's glucometer reading is above the target value of > 45 mg/dL.

Which of the following are the next best steps in management? (Check all that apply.)

Administer bolus of dextrose Administer bolus of normal saline Start O2

What are some of the potential effects of a chronic disease—such as sickle cell disease, asthma, or cystic fibrosis—on a child's development?

All

Aside from teaching Isabella and her mother how to administer insulin, choose the other educational priorities that need to be addressed prior to discharge. Select all that apply.

All except long term complications, benefits of insulin pump, differences b/w type 1 and 2 diabetes

How would you describe and diagnose her right ear? Choose the single best answer.

Amber, nonmobile, retracted position, opaque (OME)

Based on your findings from Mandy's history, what do you think are the five most likely causes of her illness?

Appendicitis Ectopic pregnancy Ovarian cyst PID UTI

How might you assess Gerardo's pain?

As the mother to assess Use a faces pain scale

A 10-month-old infant is brought to the pediatrics emergency department by her parents, who say she has been coughing persistently for the past three hours. The parents were watching a movie at home when they first noticed their daughter coughing. Patient is a vaccinated, well-nourished infant in moderate distress with retractions, nasal flaring, and grunting. Physical examination reveals diminished breath sounds in the right lung with normal breath sounds on the left. What other associated physical exam findings are expected on auscultation?

Asymmetric wheeze

Based on the key findings reflected in the summary statement, select the top four diagnoses on your differential from the following list:

Brain tumor Migraine headache Sinusitis Tension headache

What physical finding that could contribute to hyperbilirubinemia might you see on Meghan's head if she had suffered birth trauma

Bruising, Cephalohematoma

Important reasons to perform a GU exam during a preparticipation sports evaluation include which of the following?

Check for undescended testicles Hernia check Show the patient how to do a testicular self-exam

What are the critical history and physical items you will be looking for in these children?

Contact with animals Scaling appearance with raised border Pruritis Otherwise well child

A 10-year-old boy presents to his pediatrician with a history of hypopigmented non-pruritic "dots," mostly located on his face and neck. His mother complains that lesions get worse during the summer when her son plays outside. On exam, they are slightly scaly, hypopigmented lesions approximately 0.5 cm in diameter. What is the most likely etiology of his rash?

Decreased number of active melanocytes and decreased number and size of melanosomes

What information would you like to gather from Ian's parents and the ambulance personnel to help determine the etiology of this episode? Select all that apply.

Detailed description of the event Behavior immediately before and after seizure Presence of fever or other signs of illness Potential for toxic ingestion Recent history of injury

By what ages should an infant double and triple his/her birth weight?

Double by 5 mo, triple by 12 mo

Which of the following are possible sequelae of obesity?

Dyslipidemia, HTN, Obstructive sleep apnea, Slipped capital femoral epiphysis, steatohepatitis, type 2 DM

Based on your understanding of the pathophysiology of Kawasaki disease, which studies should be performed to screen for complications related to the disease? Choose the single best answer.

Echo

A 3-year-old female comes to the clinic with a chief complaint of fever (40 C) for over a week. Her mother reports that she has been fussy and inconsolable since she became febrile. She has a red tongue with large papillae, conjunctivitis, a palmar rash, unilateral cervical adenopathy, and swollen feet. Given the most likely diagnosis, what is the most important follow-up for this girl over the next few weeks?

Echocardiogram to look for coronary artery aneurysm

What is the etiology of Benjamin's rash?

Eczema (atopic dermatitis)

What are the key results from Holly's CBC, and what do they suggest about Holly's illness?

Elevated WBCs with a "left shift" (increased numbers of polys and bands), raising a concern for a serious bacterial infection.

A 3-day-old infant is evaluated in the nursery for poor feeding since birth. The infant takes 1 ounce of formula every 4 hours. Each feed takes about 40 minutes because the patient falls asleep during the feed. The patient has vomited twice today and stooled once yesterday. Physical exam reveals a lethargic infant who is difficult to arouse by exam. The liver is enlarged and muscle tone is decreased. Serum ammonia level is elevated. Which of the following laboratory results would be expected in this patient?

Elevated urine orotic acid

What pertinent information have you obtained from this quick chart review? Choose the single best answer.

Emily has normal growth and development to date

Which of the following terms describe Jason's rash? Select all that apply.

Erythematous Macular

Which of the following hemoglobin (Hgb) patterns are associated with a diagnosis of sickling disorders on the newborn screen (NBS)? Select all that apply.

FS FSA FSC

You have completed Holly's physical exam and you still are unable to identify an etiology. What is the correct term for this situation?

Fever without source

Which of the following additional pieces of information help you interpret today's CBC results? (Select all that apply.)

History of transfusions Several recent CBCs (baseline values)

Considering the information Benjamin's mother has just given you, what do you believe are the most important nutritional issues for Benjamin?

Inadequate veggie and iron intake, excess milk and juice intake, using a bottle at sleep greatly increases risk for early childhood caries; sipping on juice throughout the day

A 9-month old comes to the clinic for a well-child visit. The child is at the 50th percentile for weight, length, and head circumference and is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit?

Influenza, Hep B, IPV

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Jason is a 4-year-old male with a 7-day history of fever and increased irritability, recently treated for presumptive strep pharyngitis. He now presents with a diffuse, erythematous, blanching macular rash, and red eyes.

Given the key findings from Emily's history, select the SEVEN most likely or most concerning diagnoses you are considering at this junctur

Juvenile idiopathic arthritis, leukemia, lyme arthritis, osteomyelitis, septic arthritis, transient synovitis, trauma

Based on your suspicion of what and where Nick's lesion is, Dr. Moran asks you which of the following is the most appropriate next test. Choose the single best answer.

MRI of the brain

How do you interpret Meghan's total bilirubin level from the Bhutani nomogram?

Meghan's total bilirubin of 17.0 mg/dL is in the high-intermediate risk zone.

What is the most common cause of chest pain in an adolescent?

Musculoskeletal

Based on the summary of findings, select items from the list below to create your refined differential diagnosis:

Neonatal sepsis RDS TTN

Given what you know so far about Adam, which of the following are on your initial differential diagnosis?

Neonatal sepsis/pneumonia Pneumothorax Respi distress syndrome (RDS) Transient tachypnea of newborn (TTN)

Based on the history you have gathered so far, is it appropriate for Rebecca to be receiving antihistamines/decongestants for her symptoms? Choose the single best answer.

No

Does Meghan's weight concern you?

No

What management would you recommend at the two-week visit? Please choose the best option below.

Order total and direct bilirubin levels

A 5-day-old infant presents with a chief report of jaundice. As you obtain a careful history, which of the following would NOT be a risk factor for neonatal jaundice?

Phenylketonuria

Dr. Lowery asks if you would like to order any labs. Which of the following would you recommend? Choose the single best answer.

Rapid testing for influenza

What studies, if any, would you order to be done in the next several weeks to follow up on this first episode of pyelonephritis? Select all that apply.

Renal and bladder ultrasound

A 16-year-old female with a history of irregular menses presents to the ED with severe abdominal pain. She has regular unprotected sexual intercourse with multiple male sexual partners. She has experienced fevers, nausea, vomiting, right shoulder pain and reports no vaginal bleeding or discharge. Vitals are T 38.0 C, BP 90/60 mmHg, P 120 bpm, R 20 bpm. Qualitative ß-hCG is positive, and hemoglobin is 7 g/dL. Physical exam reveals that she has difficulty answering questions due to pain. Auscultation of the chest is notable for tachycardia, a murmur, and clear lungs bilaterally. The abdomen is rigid with tenderness throughout, but more so in the right lower quadrant. There is guarding and rebound tenderness. On pelvic exam, there is cervical motion tenderness but no bleeding or masses noted. What is the most likely diagnosis?

Ruptured ectopic pregnancy

In addition to sending a newborn screen, which of the following lab tests are now indicated?

Serum ammonia Serum glucose Serum potassium Serum sodium T4 Total and direct bilirubin TSH

Of the following, which are developmental milestones that you expect to see in a developmentally appropriate 9-mo infant?

Sits without support, waves bye-bye

How would you interpret Emily's lab results? Choose the single best answer.

The results do not show a degree of inflammation consistent with septic hip. Emily can be given a diagnosis of transient synovitis.

What do Holly's CSF results indicate?

There is no evidence that Holly has meningitis.

Based on this dipstick result, what is the most likely diagnosis for Holly?

UTI

Has Asia performed the expected developmental milestones for a 6-mo infant?

Yes

which of the following conditions are important causes of school failure?

conduct disorders, learning disability, mood disorders, sensory impairment, sleep disorders, anxiety disorders

The following conditions either predispose to hyperbilirubinemia or reflect a condition that can cause hyperbilirubinemia. Which do you identify in Meghan's medical record? Select all that apply.

ABO Mismatch, Breastfeeding, Mediterranean ethnicity

Based on your differential diagnosis, what diagnostic workup would you recommend? Select all that apply.

Abdominal U/S w/ attention to pylorus, BMP, Pediatric gastroenterology consultation for upper endoscopy, pediatric surgery consult, UA and urine culture

With the key findings from Olivia's history in mind, what diagnoses would you include in your differential at this point?

Abusive head trauma Congenital adrenal hyperplasia (CAH) Congenital hypothyroidism Genetic conditions such as Down Syndrome Inborn error of metabolism

At this point, which of the following would be reasonable to include in your differential diagnosis for Jason? Select all that apply.

Adenovirus infection Enteroviral infection Kawasaki disease Multisystem inflammatory Syndrome in Children (MIS-C) following COVID-19 infection

Which of the following defines the best fluid management plan for Ben? Choose the single best answer.

Administer repeated IV normal saline boluses (20 mL/kg) until there is significant clinical improvement, then continue IV fluids (dextrose, normal saline, and potassium) until after surgery

A 2-year-old girl is brought to the clinic by her mother for a health maintenance visit. While waiting for the pediatrician, her mother reads her a short book. When you enter the room, her mother asks her to take the book and return it to a bookshelf. Developmental history reveals that the patient can scribble with a pencil but cannot write her name. She can kick and throw a ball, but cannot jump in place. Which of the following best describes this child's development?

Age approprite development

Of the following, how would you arrange for treatment for Mandy's boyfriend? Select all that apply.

All of above

Which of the following signs or symptoms would indicate a need for urgent intervention? Select all that apply.

Altered mental status Delayed capillary refill Respiratory distress Respiratory depression Cyanosis

A previously healthy 10-year-old boy comes to the clinic with a chief concern of progressive cough for three days that began gradually. His cough is described as productive with whitish sputum. His mother reports that he has been febrile up to 101.5 F daily. She thinks he is fatigued and has not eaten well in the past several days. He has no throat pain, vomiting, or diarrhea on review of systems. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. Which of the following would you likely find in your evaluation?

Alveolar consolidation in the right lower lobe on chest radiograph

Of the following, which treatment option would be best for Rebecca? Choose the single best answer.

Amox

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Anna is a 10-month-old female with a one-week history of respiratory illness and an acutely worsening cough. She has mild respiratory distress and asymmetric breath sounds with unilateral wheezing in the right lung fields in the absence of fever and cyanosis.

You are notified that a 10-day-old patient in your practice had a newborn hemoglobin screen positive for sickle cell disease. Pregnancy and delivery were uncomplicated. Mother is 19 years old and works as a nurses' assistant at a nursing home. When questioned, she says she remembers her grandmother died of chest pain and a lung infection. Which of the following should be ordered next for the baby?

Antibiotics

Which of the following medications could cause mydriasis (dilated pupils)?

Antidepressant Antihistamine Decongestant Sedative-hypnotic

Which of the following may elevate BP measurements?

Anxiety over being at the clinician's office; Pt is in pain; Taking BP below the level of heart

Based on what you know about the patient so far, write one- to three-sentence summary statement to communicate your understanding of the patient to other providers

Asia is an asymptomatic, thriving 9-mo old girl incidentally noted to have RUQ mass and pallor on routine WC exam. She has no lymphadenopathy, splenomegaly, or jaundice.

Based on your understanding of the pathophysiology and complications of Kawasaki disease, which of the following therapies would be appropriate in the acute management of Jason's illness? Select all that apply.

Aspirin IVIG

Now that you have completed Sunita's physical exam, you consider what information you will present to Dr. Law. Based on Sunita's history and physical findings, what do you think are the most likely diagnoses? Select all that apply.

Asthma, allergies

You begin to formulate a preliminary list of differential diagnoses based on your history to guide your physical examination. Which of the following diagnoses would you consider in Anna? Select all that apply.

Asthma, bronchiolitis, croup, foreign body aspiration, community-acquired pneumonia, viral URI

In the box below, develop a list of some of the possible causes of unilateral cervical lymphadenopathy.

Bacterial cervical adenitis, cat scratch disease, reactive node from an oral inflammatory or infectious process, Kawasaki disease, mycobacterial infection.

Integrating the new information about Nick's symptoms into your previously obtained history and physical examination, select the diagnoses that you are now considering on your differential.

Basilar migraine Intracranial mass Medication side effect

Among the following, which laboratory studies should be ordered or performed on Holly? Select all that apply.

Blood culture CBC with differential Lumbar puncture Urinalysis Urine culture

Of the following tests, which are appropriate to order? Select all that apply.

CBC w/ differential CXR Continuous pulse ox

Select the laboratory tests that would be most helpful to confirm your diagnosis and guide further management

CBC w/ differential UA

A 7-year-old male presents to the clinic with reports of headaches and episodes of feeling sweaty and flushed. He also reports that at times he feels as if his heart is racing. He was full-term, had an uncomplicated birth, and has been otherwise healthy until now. On exam, his BP is 120/80 mmHg and is the same in his upper and lower extremities. His weight and height are in the 50th percentile for his age. What is the most likely cause of this patient's hypertension?

Catecholamine excess

Which intravenous antibiotic regimen would you choose to treat Holly?

Ceftriaxone

Which of the following treatment regimens would be appropriate? Select ALL that apply:

Ceftriaxone 500 mg IM in single dose + Azithromycin 1 g PO once Ceftriaxone 500 mg IM in single dose + Doxycycline 100 mg PO BID x 7 days

Based on the information above, which of the following formulations and dosing would be acceptable for Holly? Select the 3 best options.

Cephalexin 25 mg/mL Give 7 mL by mouth twice daily Cephalexin 25 mg/mL Give 3.5 mL by mouth 4 times daily Cephalexin 50 mg/mL Give 3.5 mL by mouth twice daily

Gerardo's chart shows that he has never had surgery. Which of the following are the two most common surgeries in children with sickle cell disease? (Select all that apply.)

Cholecystectomy Tonsillectomy

Based on the key findings from the history, select the top five diagnoses to consider at this point. What do you think are the most likely possibilities for Alex's problem? Select all that apply.

Coagulation disorder IgA vasculitis (Henoch-Schonlein purpura/HSP) Idiopathic thrombocytopenic purpura (ITP) Leukemia Viral infection

Based on Meghan's total serum bilirubin result and the likely diagnosis of breast milk jaundice, which one of the following management plans is most reasonable?

Continue breastfeeding and recheck total bilirubin level in 24h

A 2-year-old female presents to the urgent care clinic with a 7-day history of high fever to 38.5 C, a maculopapular rash that began on the palms and soles of her feet, red eyes without discharge, and unilateral cervical adenopathy. What other symptom/sign might you discover on further history and exam?

Erythematous and edematous feet

Think about the order in which you will conduct your examination of Rebecca to achieve the best results. Which of the following will be the last step in your exam sequence? Choose the single best answer.

Eyes/oral cavity

Which evaluations are appropriate today? Choose the single best answer.

Fingerstick hemoglobin/hematocrit

Which of the following would you order for this child? (Choose the single best answer.)

Fluids at maintenance rate Generally, it is vital to: Correct dehydration Provide replacement for insensible losses (increased with fever and tachypnea), and Give maintenance fluids.

Which one of the following disorders meets the ideal criteria for universal newborn screening?

Galactosemia

Based on the information that you have obtained, what is your assessment of the success of breastfeeding? Select the single best response.

Good

A 3-year-old boy is brought to the clinic by his parents for follow-up of iron deficiency anemia. His diet consists mostly of sweet, bland, low-texture foods. He drinks 32 ounces of milk daily from a bottle. In addition to prescribing oral iron supplementation, what is the best advice to give the parents concerning this patient's diet?

Gradually introduce new foods and slowly decrease his old favorites

An 18-month-old girl is brought to her pediatrician by her mother who notes that she has been fussy for the past three days and has been pulling on her ears. The child is up to date with her vaccines. Her temperature is 39 C (102.2 F). Otoscopic exam of her left ear shows a yellow, opaque, and bulging tympanic membrane. Which of the following organisms is the most likely cause of the child's condition?

H influenzae

What are Jimmy's weight age and height age?

Height age is 9; weight age is 13

Which of the following are on your differential diagnosis?

Hepatic neoplasm, Hydronephrosis, Neuroblastoma, Teratoma, Wilms' tumor

A 6-week-old infant is brought by her parents to the clinic for increased sleepiness for the past 2 weeks. The patient is not easily aroused for feedings and is not as alert as she was previously. The infant was born abroad and the family recently immigrated to the United States. Neonatal screening was not performed. Vital signs are normal. Physical exam reveals jaundice, an enlarged fontanelle and an umbilical hernia. Which of the following laboratory abnormalities would most likely in this patient?

High TSH, low T4

Which of the following are risk factors for childhood obesity?

High birth weight, lower socioeconomic status, obese parent, Prader-Willi syndrome

Based on what you know about Sunita, what other elements in the history would you like to specifically ask about?

History of eczema, nasal congestion, palpitations, presence of fever, vomiting

What do you hear in the audio of Tyler's heart sounds? Choose the single best answer.

Holosystolic murmur

A 5-week-old infant is brought to the pediatrician for failure to thrive with a history of prolonged feeding time and tachypnea. What other features does this infant most likely have?

Hyperdynamic precordium with holosystolic murmur

A 6-month-old vaccinated infant arrives in the ED with a 12-hour history of poor feeding, emesis, and irritability. On exam, she is ill-appearing with T 39.2 C, P 160 bpm, R 40 bpm, BP 80/50 mmHg. CBC shows WBC 11.2, Hgb 13.5, Plt 250. Urinalysis shows > 100 WBC per hpf, positive leukocyte esterase, and positive nitrites. She has no history of prior urinary tract infection. Chest x-ray is negative. Urine and blood cultures are pending. After bringing her fever down, she is still uninterested in drinking, but her exam improved, and you are confident she does not have meningitis, so an LP is not performed. Which of the following is the best next step in management?

IV ceftriaxone

As you are about to report your final diagnosis to Dr. Sectish and show him what you know about IgA vasculitis, he asks, "What would your diagnosis be if everything were the same except a platelet count of 20?"

Idiopathic thrombocytopenic purpura (ITP)

What if Kevin's lesion seemed "weepy" and had honey-colored crusts on it? What diagnosis should you consider? How would this differ from a contact dermatitis rash?

Impetigo, a bacterial infection.

List your differential diagnosis for a two-year-old with acute onset altered mental status.

Infection (sepsis, meningitis, encephalitis) Toxic ingestion Trauma Seizure

What is the most likely cause of Benjamin's anemia?

Iron deficiency

Looking back at the differential you had created based on Jason's history, which of the entities is now your leading diagnosis?

Kawasaki disease Jason has had fever for 7 days and meets all 5 diagnostic criteria. Thus a diagnosis of Kawasaki disease best fits his clinical presentation.

A 7-year-old male with a past medical history of headaches presents with increased frequency and severity of headaches along with new onset vomiting. When the boy was walking into the room, he had a wide stance and nearly tripped twice. Which of the following is the most appropriate next step?

MRI

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers

Madelyn is a previously healthy 2-year-old female who presents with acutely altered mental status and suspected accidental ingestion. She initially presented with hypoglycemia, hypotension, tachycardia, and hypoxemia. She has slightly improved with initial treatment, but mental status is still not at baseline. Exam is significant for agitation, tachycardia, mydriasis, decreased bowel sounds, and warm, flushed skin

Your history thus far is significant for prolonged fever and irritability. Which of the following is the most worrisome potential cause of Jason's fever and irritability? Choose the single best answer.

Meningitis

Given this information and considering your initial differential diagnosis, which of the following diagnoses are most likely? Choose up to 4 answers.

Meningitis/encephalitis Seizure Systemic infection/sepsis Toxic ingestion

Based on the physical exam findings, assign a level of dehydration. Choose the single best answer.

Mild to moderate

Is Jimmy too young to have type 2 DM?

No

What are additional differential diagnostic possibilities for the tinea infections we have been talking about? Select all that apply.

Nummular eczema Psoriasis Pityriasis alba Pityriasis rosea

Here is a list of treatments that many patients try on warts before seeing a dermatologist. Which of the following do you think has the best data to support its use? Choose the single best answer.

OTC salicylic acid

A mother brings her 8-year-old son to his primary care physician for pain in his knees and ankles that has been present for the past three days. She also notes that he has had a rash since yesterday, but otherwise feels well. The patient has no chronic illnesses, but he was brought in three weeks ago for an upper respiratory infection. Exam is significant for pain elicited on passive movement of the ankles and knees. Additionally, the patient is found to have an erythematous, slightly raised, non-blanching rash over his legs, buttocks, and posterior portion of his elbows. CBC shows WBC 8.9, Hgb 12.5, Hct 36.1, and Plt 327. Urinalysis is unremarkable. Which of the following is the best next step in management?

Observation

A 2-year-old male is brought into the ED by his mother because of vomiting and altered mental status. He has pinpoint pupils and seems to be drooling and sweating uncontrollably. His pulse is 60 bpm, his respiratory rate is 45 bpm, and he seems to have difficulty breathing. Which ingestion is the most likely cause of his symptoms?

Organophosphates

A 3-year-old female presents to the ED with sudden onset difficulty walking. She does not have a fever, headache, nausea, or vision changes, but two weeks ago she had a runny nose, a fever, and a rash. Musculoskeletal exam reveals no abnormalities of lower extremities. Neurologic exam reveals bilateral horizontal nystagmus, wide based stance and swaying, and bilateral overreaching on finger to nose test. An LP is performed which reveals a normal CSF. Which of the following is the most likely diagnosis?

Post-infectious cerebellitis

A previously healthy 8-year-old male is found to have a mildly elevated blood pressure during a routine health maintenance visit. Review of systems is negative. Vital signs are otherwise within normal limits. His physical exam is significant for obesity and is otherwise within normal limits. What is the most likely diagnosis?

Primary HTN

How would you describe Gerardo's height and weight?

Proportionate Impairment of height and weight

A 30-minute-old infant is evaluated in the nursery for tachypnea. He was born at 30 5/7 weeks gestation by vaginal delivery. Labor was induced due to severe maternal pre-eclampsia. Mother received no prenatal care. Apgars were 6 and 7 at 1 and 5 minutes, respectively. One dose of betamethasone was given prior to delivery. A chest x-ray reveals decreased lung expansion. Which of the following diagnoses is most consistent with this patient's presentation?

RDS

Which of his vital signs is abnormal? Choose the single best answer.

RR

Claire is a 16-year-old girl who presents for birth control management. Her review of symptoms is unremarkable except for chest pain. Upon further questioning, she reveals the pains are intermittent, on and off for the past couple months. It is not associated with exertion, and is described as sharp, and well localized at the left sternal border. It is very brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in. She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and physical exam are normal. Which is the next best step in management?

Reassurance

What is the most likely diagnosis? Choose the single best answer.

Seborrheic dermatitis

A one-hour-old newborn male is evaluated in the nursery. He was born to a G2P1 mother at 36 weeks gestation via spontaneous vaginal delivery. The mother did not receive prenatal care because she did not have insurance. She thinks that her water broke about two days ago, but she did not have any contractions after that, so she decided not to come to the hospital. She did not start having contractions until 19 hours before she delivered. No meconium was noted at delivery. The infant did not cry vigorously and was tachypneic and cyanotic. His temperature is 38.1 C (100.5 F). His chest x-ray is normal. Which of the following is the most likely cause of this patient' symptoms?

Sepsis secondary to prolonged rupture of membranes

An 8-year-old girl comes to the clinic with two weeks of nasal congestion. Three days ago, she developed a fever of 38.7°C, purulent nasal secretions, malodorous breath, and a nocturnal cough. Examination of the nose reveals bilateral purulent nasal drainage and mild facial tenderness. Which of the following is the most likely diagnosis?

Sinusitis

What diagnoses do you consider when you first see a patient with pustules on any part of his or her body? Select all that apply.

Staphylococcal folliculitis/furunculosis Acne vulgaris Hydradenitis suppurativa Rosacea Perioral dermatitis

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Sunita is a 6-year-old girl with chronic nasal congestion and a history of eczema who presents with a chronic cough that is often worse at night, with exercise, and with exposure to cold air. She has no fever, shortness of breath, or history of wheezing, but has a family history of asthma.

A 3-year-old presents to the ED with altered mental status for the past six hours. Her mother reports that the babysitter called her at work today after the patient started acting agitated and "looking very sick." The mother also reports that the patient feels warm and may be dehydrated. On exam, the patient is agitated and anxious with dilated pupils. Her skin is warm and dry. Vitals reveal tachycardia and hypotension. You suspect the child may have accidentally ingested a family member's medication. An overdose of which of the following medications could cause this patient symptoms?

TCA

Which of Olivia's growth parameters and vital signs are concerning?

Temp and weight

Why is penicillin given to children with sickle cell disease on a prophylactic basis? (Choose the single best answer.)

To prevent infections that can lead to sepsis

A 3-year-old child is found to have a dry, pruritic rash on his face. Physical exam is notable for confluent areas of erythema and scaling. There are mild excoriations surrounding some areas and mild lichenification of the extensor surfaces of both elbows. What is the next best step in management of this child's problem?

Topical steroids and emollients

At this point, based on Emily's history and exam, which of the following is your leading diagnosis? Choose the single best answer

Transient synovitis

A 7-year-old male presents with a five-year history of intermittent vomiting, vertigo, and throbbing unilateral headaches that seem to be induced by emotional stress and when his teacher wears perfume. The headaches occur 1-2 times a month and interfere with his school attendance and lifestyle. He reports that the pain is not worsened by long naps or coughing. His mother reports that she has a history of headaches that started as a child and wonders if her son inherited this from her. His neurological exam shows no focal deficits. What is the next step in diagnosis or treatment?

Trial of prophylactic medication for migraine headaches

A 5-year-old boy presents to the emergency department with two days of abdominal pain and one day of rash. He has not had any vomiting or diarrhea. Medical history is significant for an upper respiratory tract infection one week ago. He is otherwise healthy and takes no medications. Vital signs are normal. On examination he has petechiae and purpura on his buttocks and lower extremities. Palpation of the abdomen reveals mild tenderness. The remainder of the exam is normal. Laboratory studies are normal. A clinical diagnosis is made. Which of the following is most important to monitor at this patient's follow-up visit in two days?

UA

A 6-month-old female is brought into the pediatrician's office for three days of high fever, fussiness, and decreased appetite. The patient has not had any upper respiratory tract symptoms, vomiting, diarrhea, or rash. On physical exam the patient is fussy, has a RR of 28 bpm and a pulse of 160 bpm. She is febrile to 102.8 F (rectal). The patient is alert, not toxic appearing, and fully moving all extremities. Apart from her vital signs, no other significant exam findings are noted. A CBC demonstrates leukocytosis of 17.0 cells x 103 / µL with elevated bands. Of the following, which diagnosis is most likely?

UTI

A 6-month-old female presents to the Emergency Department because of decreased appetite and fussiness for four days and fever for one day. She had two episodes of non-bilious, non-bloody emesis today with decreased urine output. She was born at 40 weeks gestation. Pregnancy was uncomplicated and this is her first illness. Her vaccinations are up to date. She is non-toxic appearing but fussy. Temperature is 101 F. Her physical examination is non-focal. Which of the following is the most appropriate to evaluate her risk of urinary tract infection at this time?

Urinary catheterization

Which of these sounds most like Tyler's murmur? Choose the single best answer.

VSD

How would you recommend that Dr. Jones address the issue of home safety with Madelyn's family? (Select one response. There is no single best answer.)

all

Isabella weighs 22 kg and is approximately 10% dehydrated. How much fluid will she need over the next 24-48 hours in order to replace her current fluid deficit?

2440 mL

You've calculated the total amount of fluid needed and an hourly rate of administration to replace Isabella's deficit. She also needs maintenance fluids. What should the hourly rate be for her maintenance fluids? Choose the single best answer below

62 mL/hour

Given that Emily weighed 17 kg today, which of the following would be appropriate dosing instructions for ibuprofen? Choose the single best answer.

8.5 mL q6h

Besides further HPI questions, what additional information would you like to obtain in your history? Select all that apply.

All of above

In which position(s) could the child rest while you examine her ears? Select all that apply.

All of above

Which of the following would you expect to find on the rest of Isabella's lab results? Select all that apply

All of above

What other common congenital heart defects can present with signs of congestive heart failure and a murmur? Select all that apply.

Aortic stenosis, Coarctation of Aorta, PDA

A 15-year-old female is brought to the ER with a chief concern of abdominal pain for three hours. She rates her pain at 8/10 and describes it as constant and located mainly in the middle of her abdomen. It is worse with coughing and moving. She had two episodes of nonbilious, non-bloody vomiting. She is sexually active with her boyfriend of three months and always uses condoms. Her last menstrual period was two weeks ago. Vital signs are normal. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Laboratory studies reveal normal complete blood count and c reactive protein. Which of the following is the most likely diagnosis in this patient?

Appendicitis

You find similar findings for Rebecca's left ear, consistent with bilateral OME. You explain to her mother that the fluid in her middle ear has most likely persisted since her episode of bilateral AOM four months before.

Assess language development, order hearing assessment

Dr. Whitman agrees with you that Caleb is mildly to moderately dehydrated. She asks how you would like to provide rehydration. Choose the single best answer.

Begin oral rehydration w/ a commercially prepared solution while monitoring Caleb in the pediatric clinic

First, are there any issues left from Benjamin's previous visit that should be reviewed?

Behavior, nutrition, dental hygiene, history of maternal depression

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Ben is an 8-week-old formula-fed baby male with a one-week history of repeated, non-bilious, now blood-streaked emesis, with fatigue and weight loss. He's had no fever or diarrhea, but urine output has decreased.

From the following, which labs and imaging tests would you like to order (while also trying to minimize costs)? Select all that apply

Blood culture, CBC, CRP, ESR, lyme antibody

Based on the history, it sounds as if Tyler is having some real difficulties with his feeds. Which of the following might be causing Tyler's difficulty feeding, respiratory distress, and diaphoresis? Select all that apply.

CHD/CHF, respiratory infection, sepsis, metabolic disorder

With your summary statement in mind, what etiologies now remain in your differential diagnosis?

CHF

Which of the following safety issues are important to discuss with the parents of a 3-year-old? Select all that apply.

Car accidents, falls, firearms, fire safety, poisonings, swimming-pool safety

Which of the following findings is NOT associated with the etiology listed? Choose the single best answer.

Carditis: Transient synovitis

A 4-year-old female with a history of type 1 diabetes mellitus was admitted to a local hospital for treatment of DKA. A few hours after the treatment, she develops grunting, irregular respirations, and has vomited twice. On exam, when asked to gaze forward, her left eye is pointing downward and out. Her diastolic blood pressure is 90 mmHg. What is a likely diagnosis?

Cerebral edema

A 4-year-old male who lived internatinally presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). He does not have high fevers, rhinorrhea, congestion or night sweats. Which of the following are the next best diagnostic tests?

Chest X-ray and tuberculin skin test

After reviewing the chart, what are some of the important details that you already know about Sunita?

Chronic cough, Sunita's age, new to the practice and presently on no meds, appropriate growth parameters, normal vitals

Which of these diagnostic tests should you order to help you assess Tyler's clinical status? Select all that apply.

ECG, Echo, CXR

Which two of the pathogens below are the most prevalent causes of AOM? Choose the two best answers.

H. influenzae, nontypeable and Strep pneumo

A 5-year-old girl is brought by her mother to the clinic for a well-child visit. Medical history is significant for three upper-respiratory infections in the past year. She does well in preschool, is toilet trained, and enjoys eating mostly pasta, bread, and milk. Review of systems is otherwise unremarkable. She lives with her mother and father in a home built in 1985. Her height is at the 50%tile, weight is at the 50%tile and BMI is at 60%tile. Vital signs are normal. Physical examination is normal. Lab studies today show a hemoglobin of 10.0 g/dL. Her hemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anemia?

Iron deficiency

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Isabella is a 7-year-old female with vomiting, diffuse abdominal pain, and dehydration who also has polydipsia and enuresis. On exam she is lethargic, tachypneic, and tachycardic, but normotensive and without peritoneal signs.

A 3-year-old female is at the pediatrician's office for continued right knee pain after a ground-level fall six weeks ago. The patient is UTD on all immunizations, has no significant PMH, and no recent illnesses. The patient's mother reports the patient complains of pain mostly in the morning when going to daycare but doesn't seem to be bothered by it while playing outside in the afternoon. On exam, the patient's vitals are all within normal limits. Her physical exam reveals a well-appearing toddler who walks stiffly and avoids bending her right knee. The knee has a mild effusion but no obvious erythema. There is pain with passive flexion and extension of the right knee. During the exam she tells you her left ankle also hurts, which her mother had forgotten about but says started hurting the same time as the right knee. Her CBC is normal, while her ESR and CRP are mildly elevated. Which of the following is the most likely cause of this child's condition?

JIA

A 6-year-old female comes to the clinic because of worsening right knee pain over the past month. On exam, you note generalized lymphadenopathy and splenomegaly. She coughs intermittently throughout the visit, and her mother explains that she is just getting over a cold. You note absence of tenderness, erythema, effusion or warmth over the hip, knee, and ankle joints. Her vitals are unremarkable except for a low-grade fever (100.8 F). Reviewing her chart, you note that she has lost 5 lbs since her visit 2 months ago. She sits with her right leg externally rotated but appears to be in pain despite trying several different positions, refusing to bear weight on that side. What is the most likely diagnosis?

Leukemia

What other topics will be important to cover at this health maintenance visit?

Nutrition, exercise, sleep, toileting, social environment, dental care, and safety are all topics that are important to cover.

An 18-month-old presents with yellow and poorly mobile tympanic membranes. Four months prior he presented then with several days of nasal congestion, cough, decreased eating, and ear tugging. His exam then revealed a red, nonmobile tympanic membrane and he was treated with amoxicillin. Based on the history and physical exam, what is the most likely diagnosis now?

Otitis media with effusion

You realize that Isabella is quite sick and needs additional interventions quickly. Given your leading diagnosis, what will you suggest to Dr. Sato that you do next? Select all that apply.

Random glucose test, UA, IV access, IV fluid bolus with 0.9% saline, continuous CV monitor, STAT electrolytes, Blood gas

An 18-month-old girl presents to the clinic with nasal congestion and fever for three days. She is previously healthy. She is receiving acetaminophen for fever. Temperature is 101.2 F (38.4 C), pulse is 100 beats/minute, respirations are 24 breaths per minute. Oxygen saturations are 98% on room air. She is alert and well perfused with clear mucus coming from both nostrils and no increased work of breathing. Both turbinates show erythema. Her oropharynx is erythematous. No crackles or wheezing are heard. Her immunizations are up to date. Which of the following infectious organisms is most likely cause of this patient's presentation?

Rhinovirus

A 9-year-old boy presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He has struggled with these concerns over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him?

Short acting inhaled beta agonist PRN with daily low dose inhaled corticosteroid

What is your assessment of Tyler's feeding? Choose the single best answer.

The feeding history suggests a problem with Tyler's ability to feed adequately.

While Tyler was in the newborn nursery, his parents were told that the initial exam was normal, with no murmur noted. They ask why the murmur was not noted in the nursery.

There is elevated pulmonary vascular resistance in a newborn

A 5-year-old boy is noted to have a grade II systolic murmur and a widely split S2 murmur on cardiac exam. His vital signs are stable and he has been asymptomatic. Which of the following statement is accurate regarding this child's presentation and likely condition?

This patient's murmur is caused by excessive flow through the pulmonary outflow tract and should be evaluated

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Tyler is a 6-week-old former term infant who has recent onset of progressive dyspnea with feedings, diaphoresis, and poor weight gain (having only gained 300 grams from his birth weight). He is acyanotic with a normal temperature, but exam reveals tachypnea, an active precordium, Grade III holosystolic murmur, and hepatomegaly.

Which aspects of the physical exam help you to determine the level of dehydration?

Weight, Vital signs, HEENT exam, skin turgor, character of pulses, cap refill, mottling of skin, mental status/level of activity

What advice would you give about guns in the home?

he only way to completely prevent accidental injury due to the gun is to remove the gun from the house as recommended by the American Academy of Pediatrics. For families that choose to have guns, either for work or protection, the recommendation is to keep the gun locked, unloaded, and with ammunition locked separately from the gun.

What vaccines should Mike have received at the 11-year-old well-child visit? Select all that apply.

HPV Meningococcal ACYW Conjugate Vaccine Tdap

Based on your physical exam findings, including the possibility of a palpable spleen, which three diagnoses now are most likely?

IgA vasculitis ITP Leukemia

What is your final diagnosis?

IgA vasculitis is a self-limited, IgA-mediated, small vessel vasculitis that typically involves the skin, GI tract, joints, and kidneys.

Which of the following images correlates with a lice infestation? Choose the single correct answer.

Image 3 (black and red image) depicts nits, or lice ova. Nits are firmly attached to the hair shaft and difficult to remove. These are hatched (empty) nits. Unhatched nits may be more gray or yellow in color and are generally found 1-2 mm from the scalp.

What is the device shown above? Choose the single best answer.

Incentive spirometer

This is the chest x-ray you ordered on Tyler. What do you think this film shows? Choose the single best answer.

Increased heart size, increased pulmonary vascular markings

A 12-year-old boy presents to the ED with reports of anorexia, weight loss, persistent cough, with nocturnal coughing fits that have been waking him from sleep for the past three weeks. He reports no fever, chills, myalgia, sore throat, or rhinorrhea. The patient presented to his primary care clinician one week prior with the same report, and was treated with amoxicillin and bronchodilator therapy. His chest x-ray was negative for infiltrates at that visit. The patient's symptoms did not improve with this regimen. The cough became more frequent, sometimes causing emesis. Which of the following is the most likely diagnosis?

Infection w/ Bordetella pertussis in paroxysmal

What is the most common cause of a murmur in childhood? Choose the single best answer

Innocent murmur

A 9-year-old male presents to the emergency department in an ambulance after he was found unconscious at a local playground. In the ED he is lethargic and difficult to arouse. He is able to minimally verbalize that his head and stomach hurt. He vomits clear liquid twice over the course of 30 minutes. Vital signs are as follows: T 37.6 C, HR 66 bpm, BP 155/80 mm Hg, RR 18 bpm. His respirations are irregular with brief episodes of apnea. On physical exam you are unable to reproduce the abdominal pain and there is no rebound tenderness or guarding. The rest of the physical exam is unremarkable. Which of the following is the most likely diagnosis?

Intracranial hemorrhage

A 5-week-old infant presents to clinic with 4 days of repeated, non-bilious, non-bloody vomiting with non-bloody diarrhea. He has 8 to 9 episodes of vomiting per day immediately following breastfeeding. The episodes started 4 days after the entire family suffered from severe viral gastroenteritis. His birth history is uncomplicated (full term, NSVD, unremarkable 30-week ultrasound) and birth weight was 3.6 kg (50th percentile). On exam, his vitals are: T 36.7°C, HR 185, BP 85/45, RR 36, Wt 4.1 kg (25th percentile). On exam, his eyes are moderately sunken without production of tears, his lips are cracked, and his throat is without erythema. His capillary refill is ~3 seconds, and his pulse is thready. He appears lethargic. What is your first step in management?

Intravenous lactated Ringer's solution of 20mL/kg boluses until baseline clinical status is achieved, then either oral hydration or IV fluid hydration if not tolerating PO. E. Observe for 6 hours with normal PO intake and administer 60-120 mL of oral rehydration solution for every episode of vomiting.

List three causes of diaper rash.

Irritant dermatitis Diaper candidiasis Bacterial infection, especially caused by perianal Group A streptococcus

A 3-year-old male presents with fever to 39.4 C for the past week, injected eyes, and a refusal to walk for the past two days. On physical exam, you note conjunctival injection without exudates bilaterally, prominent papillae of his tongue with redness as well as redness of his hands and feet. He also has a new diffuse maculopapular rash on his torso that becomes more prominent with fever. On examination of the swollen extremities, you are unable to elicit any tenderness or effusions in any joints. Which of the following is the most likely diagnosis?

Kawasaki disease

What is the most serious problem that can result when a newborn infant has high levels of unconjugated bilirubin?

Kernicterus, neurologic impairment, brain damage, or encephalopathy

Remember, these are not Anna's films but are from teaching files. These films are consistent with a foreign body lodged in which lung?

LEFT lung

From the data plotted on the growth chart, how would you classify Adam? Select the single best answer.

Large for gestational age (LGA)

An 11-year old boy presents to the clinic with wheezing. His mother states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. His mother also reports that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy at this time?

Low dose inhaled corticosteroids and albuterol rescue inhaler as needed

A 6-year-old boy presents to the clinic with a chief complaint of acute onset of bruising. He is afebrile, and his mother reports that he recently had a URI. He was born full-term and has never been hospitalized. He was circumcised at birth with no problems with bleeding. No one in his family has any chronic medical problems. There have been no serious childhood illnesses or deaths. No one has a history of easy bruising or bleeding. On exam you find that he has a purpuric rash on his buttocks and legs. His urinalysis reveals 15 to 20 RBCs/hpf. Which of the following additional findings would be inconsistent with a diagnosis of IgA vasculitis?

Low platelets

There are many mistaken or unproven beliefs about what can cause or aggravate acne lesions. Which of the following are known to worsen acne? Select all that apply.

Makeup Mechanical factors such as manipulation Overzealous cleaning

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Mandy is a sexually active 16-year-old girl with fever, vomiting, tachycardia, and acute onset progressive diffuse abdominal pain. She also reports dysuria and dyspareunia. On exam she has cervical motion tenderness and purulent cervical discharge.

An 8-year-old female presents to your clinic for follow-up after being hospitalized for status asthmaticus. She is completing a five-day course of systemic steroids. Given her history of moderate persistent asthma, her outpatient regimen includes daily use of inhaled fluticasone/salmeterol. She was also diagnosed with ADHD one year ago and was started on Adderall XR daily. Her BMI today is at the 83rd percentile for her age, and her blood pressure is at the 98th percentile for her age. What is the most likely cause of her stage I hypertension?

Meds

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Meghan is a vigorous, 6-day-old, exclusively breastfed term infant of partial Greek descent with two days of jaundice and an otherwise normal physical exam. She has had no significant weight loss and is voiding and stooling normally. There is an ABO set-up.

The father of a 15 year-old-girl calls the on-call provider with concerns of fever, headache and mental status changes over the past 12 hours. She has a fever of 39.4 C (103 F) and is acting dazed and difficult to arouse. On further questioning, the father states that she is breathing heavily, has decreased urine output, and decreased oral intake. He wants advice about whether she should be taken to the Emergency Department. Given the limited history, which of the following is highest on the differential?

Meningitis

Based on your reading about asthma and thinking about the history and exam findings from your time with Sunita, how would you classify her asthma?

Moderate persistent

Does the history suggest that Olivia is getting enough breast milk?

No

Holly had her 6-month immunizations 21 days ago. Could her fever be explained by an adverse reaction to one of her vaccines?

No

Is this typical speech development for an 18-month-old? Choose the single best answer.

No

Should you refer Jimmy to an endocrinologist at this time?

No

If Mike's cardiac and neurologic physical examination are normal, and the prior ECG is confirmed to be normal, what additional evaluation do you think is appropriate? (Select the ONE best answer.)

No further testing indicated

A 2-year-old male presents to the ED with a 2-day history of vomiting and diarrhea. The patient's father relays a history of abrupt onset of vomiting that started yesterday around 1 pm. He has had 6 episodes of emesis since yesterday and 3 episodes of diarrhea. The emesis is non-bilious and the diarrhea is described as watery. There are no sick contacts in the home. Vital signs: T 37.1, P 102, R 20, BP 90/60. Abdomen is soft, non tender, normoactive bowel sounds, and no masses. Pulses are normal and capillary refill is 2 seconds. He has still been tolerating some PO feeds without instant vomiting. What is the most immediate intervention for this patient?

No immediate intervention is necessary

What additional tests or procedures would you recommend at this time? Choose the single best answer.

No tests are necessary

An asymptomatic, healthy 9-month-old is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child?

Non-amplification of the n-myc gene is a favorable prognostic factor

Olivia's mom is concerned that her baby is sleepy. Which of the following best describes Olivia at this point?

None of the above

Febrile seizures are classified as simple or complex. Given the characteristics of Ian's simple febrile seizure, what do you think might be some features of a complex febrile seizure? Select all that apply.

Occurrence more than once in a 24-hr period Focal seizure

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Olivia is a non-dysmorphic 2-week-old female presenting with decreased activity and poor feeding. Physical exam is notable for weight still below birthweight, a slightly low temperature, otherwise normal vital signs, enlarged fontanelles, mild hypotonia, jaundice, and an umbilical hernia. She was born post-term AGA at home and had no newborn screen.

While the ED team is administering your initial therapy, you and Dr. Jones begin to obtain more history. Given your current differential diagnosis, what information do you think would be most important to gather from Mrs. Kowalski?

Onset of symptoms: When did you notice she was sick? Recent Medical Hx: Any recent illnesses? Any fever? Any medications given? Any trauma? Any possibility of an ingestion? Past Medical Hx: Admissions to hospital or ED visits? Any chronic medications?

A 3-year-old male presents to clinic with an annular, well-circumscribed, scaly plaque with a raised erythematous border and central clearing on the left thigh. The mother reports that the lesion is highly pruritic and that the patient has been exposed to other children with a similar rash at day care. Upon further examination, a similar lesion with boggy borders is also found on the posterior aspect of his scalp. Which of the following is the most appropriate treatment for this child's problem?

Oral griseofulvin

Considering the key findings in the history, which of the following would you include in your differential diagnosis at this point? Select all that apply.

Otitis media, pneumonia, sinusitis, URI

What seven characteristics will you ask about to better define Mandy's pain?

P = Position (be exact) Q = Quality (dull, sharp, burning) R = Radiation (be exact) S = Severity (scale from 1 to 10, if the patient can do this) T = Timing (when it happens) A = Alleviating factors A = Aggravating factors A = Associated symptoms

Given Mandy's history and physical examination, which of the following is the most likely diagnosis? Choose the single best answer.

PID

A 16-year-old female presents with acute onset of diffuse abdominal pain with intermittent sharpness in the epigastrium that radiates to her back. She has had some episodes of vomiting and has a low grade fever. She is sexually active and has used alcohol in the past. Which of the following is most likely to present with epigastric abdominal pain?

Pancreatitis

Based on the physical exam and key features of the history, which of the following diagnoses are in your differential? Select all that apply.

Papular urticaria Streptococcal infection Erythema multiforme Urticaria due to type 1 hypersensitivity Drug eruption

Which of the following signs indicates the most severe respiratory distress? Choose the single best answer.

Paradoxical breathing

Which of the following statements regarding stimulant medications are true?

Patients may develop insomnia. Stimulant medication may cause decreased growth velocity. Stimulant medications may decrease appetite.

A mother brings her 20-day-old male infant to your clinic for the child's first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been vomiting 2 to 3 times per day, and the mother reports that her son seems fussier than her friends' infants. On exam, you note an eczematous rash and a musty odor to the infant's skin and urine. Which enzyme deficiency would you expect the infant to display?

Phenylalanine hydroxylase

Based on Mike's description of his chest pain (recognizing you have not yet examined him), what do you think is the most likely cause? Select the single best answer.

Precordial catch syndrome

A 16-year old female presents to the ED with abdominal pain. Upon questioning, the patient notes that the pain is consistently in the RLQ without radiation. She reports no dysuria, hematuria, diarrhea, or hematochezia. She has a history of multiple sexual partners and inconsistent condom use. She does not use any other contraceptive measures. She believes her last menstrual period was 3 weeks ago, but she is unsure. She has no history of abdominal or pelvic surgeries. Her temperature is 100.8 F, pulse is 85 bpm, respiratory rate is 12 bpm, and blood pressure is 110/70 mmHg. Her abdominal exam is notable for involuntary guarding, tenderness to palpation in the RLQ without rebound tenderness, and no CVA tenderness. Her pelvic exam is notable for cervical motion tenderness with some discharge. What is the best NEXT step in management?

Pregnancy test

A 2-year-old male presents to the ED with a 5-hour history of hyperactivity, fever, and sweating. His BP is 160/90 mmHg, HR 130 bpm, RR 30 bpm. On exam, he has dilated pupils, cool skin, and hyperreflexia. What is his most likely accidental medication ingestion?

Pseudoephedrine

Which of Jason's vital signs are abnormal for a healthy 4-year-old? Select all that apply.

Pulse Temp

Assuming Gerardo has SS hemoglobin, what information would you give him as he heads off to college? Please select the response that seems most appropriate to you. More than one may be appropriate. In each instance, you begin by reviewing the inheritance pattern (i.e., "If you have Hgb SS and your potential partner has Hgb AS, your infant would have a 50% chance of having sickle cell disease and a 50% chance of having sickle cell trait").

"There is no single best answer"

Review the chart at the following link. What would be your clinical estimation of degree of dehydration for Isabella? Choose the single best answer.

10%

A healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate this child's age to be based upon his developmental milestones?

18 mo

A 2-year-old patient with sickle cell disease presents for a well child evaluation. She has a history of three sickle cell vaso-occlusive crises in the past, including dactylitis and bone pain. She has been symptom-free for a few months and today she is feeling well. She is meeting her developmental milestones. She had an upper respiratory infection recently, but seems to be getting better now. She is up to date on her standard vaccinations up to 2 years including a full course (four doses) of Prevnar. What would you do for her today?

A dose of pneumococcal polysaccharide vaccine (Pneumovax).

A 7-year-old male frequently gets in trouble at school for being disruptive and talking inappropriately in class. He does not follow directions and does not work well with classmates during group exercises. His mother relates that at home, he is always on the go, sleeping only six to seven hours each night, and he does not follow the rules at home. He often skips his homework and sometimes puts himself in danger, such as by running away unaccompanied. Which of the following is the most likely diagnosis?

ADHD

A 5-month-old is brought by her parents to the clinic because of decreasing oral intake over the past 4 days. The patient has been sleeping more than previously and seems to tire out when feeding. The patient breastfeeds and eats homemade pureed vegetables. The patient has not had a bowel movement in three days. She has no fever or respiratory symptoms. Physical examination reveals a weak cry and decreased strength. What additional physical examination findings would be expected with this patient's presumptive diagnosis?

Absent deep tendon reflexes

A previously healthy 4-year-old girl is brought to her clinician because her parents have noticed that she has been less active than usual for the past three weeks. Her father explains that it is difficult to get his daughter out of bed in the mornings and that she no longer plays outside with her older brother. Physical examination is notable for a temperature of 38.4 C, heart rate of 125 bpm, pallor, truncal bruising, and diffuse lymphadenopathy. The remainder of the exam, including a thorough neurologic assessment, is unremarkable. Which of the following is the most likely diagnosis?

Acute lymphoblastic leukemia

A 12-year-old male with obesity comes to the clinic with a chief concern of right knee pain. On exam the right knee is neither swollen nor erythematous but he is noted to have limited ROM of the right hip. In addition, when he lifts his right leg, it externally rotates. The patient did not have a URI or any trauma preceding the onset of pain. The vital signs are normal at the time of the visit and he is well appearing and afebrile. What is/are the best next step(s) in management?

AP and lateral x-ray of hip

A 6-week-old infant presents to your office for a check-up. The baby was born full-term by NSVD to a 29-year-old G1P0 mother with no complications. Mother states the baby was feeding well until a week ago, when he developed increased sleepiness, prolonged feeding, and greater duration between feeds. His mother notes he stops to take breaks during feeds because he seems to be trying to catch his breath. He has four to six wet diapers per day and stools three or four times per day. Vital signs: Temperature is 37.6 C (99.7F), respiratory rate is 68 breaths/minute, pulse is 138 beats/minute, blood pressure is 88/58 mmHg, and oxygen saturation is 98%. The physical examination is notable for increased respiratory effort and retractions, and, upon cardiac examination, a murmur with a hyperactive precordium and no cyanosis. Abdominal exam reveals a liver edge palpable to 4 cm below the right costal margin. Which condition would be LEAST LIKELY to be the cause of the infant's symptoms?

ASD

A woman brings her 8-year-old son to the pediatrician after witnessing him stare blankly into the distance at dinner the previous week. He was unresponsive to her calling his name or any other stimuli, and it lasted for about 10 or 20 seconds. His teacher reports he does seem to daydream often in class but is able to keep up with schoolwork and excels in his studies. She doesn't note him being disruptive or impulsive in class. His mother is concerned about these blank stares and unresponsive episodes. Which of the following is the most likely diagnosis?

Absence seizure

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Adam is a late preterm, LGA infant of a diabetic mother who presents with tachypnea at two hours of life following C-section delivery through clear amniotic fluid. Exam is significant for normal oxygen saturation, normal and symmetric breath sounds, and mild respiratory distress.

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Alex is a well-appearing, afebrile, 6-year-old boy with recent URI who presents with acute onset of lower extremity petechiae, palpable purpura, and bilateral arthralgia.

Based on the information you have so far, which of the following medications do you think Madelyn might have taken?

All of the above

Based on your classification, which of the following medications could be used in treatment?

All of the above

Dr. Clark asks you, "After I confirm your physical exam, if I agree with what you have found, how do you suggest we break this potentially terrible news to the family?

All of the above

How do you bring up the issue of obesity?

All of the above

Which of the following causes of hemolysis (and possible jaundice) may be hereditary?

All of the above

Which of the following vital signs in a child of Nick's age with headaches would make you concerned about a possible life-threatening cause for the headaches? Select all that apply.

All of the above

If you had been the physician who saw this patient on the initial visit what would you have done? (There is no single "correct" answer for this question.)

All of the above No single correct answer

A 14-month-old female presents to the clinic with a fever of 39.2 C and irritability. According to mom, the patient was initially sick one week ago with a runny nose and cough, but these symptoms had resolved. She started pulling at her ear and becoming increasingly irritable last night. She has had several prior ear infections and was most recently treated one month ago with amoxicillin. She is up to date on immunizations. Physical examination reveals a red, opaque, bulging tympanic membrane with bubbles and limited mobility of her left ear. The exam of the right ear is normal. Which of the following is the next step in the management of this patient?

Amox/Clav

At this point, which approach would you suggest in communicating your concerns to Nick's parents? (There is no single correct answer.)

Any answer

A 2-year-old male with sickle cell disease is brought to the ER by his parents because he is not feeling well. His mother reports that he has been very tired for the past week. Vitals show a temperature of 39°C, BP of 120/75 mmHg, RR of 24 bpm, and pulse of 104 bpm. On physical examination he is ill appearing. His conjunctivae appear pale, and his sclerae are anicteric. Lungs are clear to auscultation. His abdominal exam is benign (nontender, nondistended, with no organomegaly). His extremities are nontender upon palpation. His nailbeds appear pale. Stat CBC reveals Hgb: 4.5 g/dL, Hct 15%, WBC 1800, and platelets 88,000. Mother is concerned as she has never seen him so ill before. What is the most likely cause of his new symptoms?

Aplastic anemia

A 15-year-old female presents with three hours of abdominal pain and two episodes of nonbilious, nonbloody vomiting. She rates her pain at 8/10 and describes it as constant, diffuse, but most severe in her periumbilical region. It is worse with coughing and moving. She has never had pain like this before and has had no appetite since the pain started. She is sexually active with her boyfriend of three months, always uses condoms, and has not been tested for STIs. She is due to start her menstrual cycle next week. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mmHg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but there are no masses and no cervical motion tenderness. Her WBC and CRP are both mildly elevated. Based on the information above, what is the most likely diagnosis?

Appendicitis

A 16-year-old homeless female presents with low-grade fever and abdominal pain. The patient reports recent unprotected sex. Abdominal examination reveals tenderness to palpation in the lower abdominal region, but no masses are felt. Pelvic examination reveals whitish cervical discharge and cervical motion tenderness. The discharge is sent for culture, and a pregnancy test is negative. What is the next best step in management?

Arrange for hospitalization

What should be the steps in your initial assessment? (Select the top five.)

Assess the patency of her airway Check for evidence of circulatory compromise Check the vital signs Observe the cyanosis or respiratory depression Obtain a fingerstick glucose test

Considering Rebecca's signs, symptoms, and physical exam findings, now select the most appropriate diagnosis. Choose the single best answer.

B/L AOM

Which of the following positions is most appropriate for Asia at this stage?

Back seat, facing the rear

With foreign body aspiration as your provisional diagnosis, which options of the following would be the most appropriate initial tests for Anna? Select all that apply.

Bilateral decubitus or inspiratory/expiratory chest films, PA and lateral chest films

What are the findings in this x-ray? You should be able to note at least two. Select the findings below.

Bilateral infiltrates Cardiomegaly

A 3-week-old infant is brought to his pediatrician with a chief report of light tan-colored stools and worsening jaundice. He is exclusively breastfed and has six to eight wet diapers per day. On exam, he appears to have scleral icterus and jaundice. Upon further workup, he is found to have an elevated direct bilirubin. What is his most likely diagnosis?

Biliary atresia

Based on your summary statement, select the conditions that would be on your differential diagnosis from the list below. Select all that apply.

Breast milk jaundice, Hypothyroidism

A concerned mother brings her 7-day-old infant to your office after noticing yellowing of his skin for two days. Mother reports she is feeding the baby six times per day for 10 minutes each time, but admits her breasts often feel full and are not relieved by nursing. The baby was born full term by spontaneous vaginal delivery. On exam, the infant appears to have jaundice of the face and chest. He has also lost > 10% of his birth weight. What is the most likely cause of his jaundice?

Breastfeeding jaundice

Based on your findings so far, select the five most likely causes of Ian's seizure:

CNS infection (meningitis/encephalitis) Febrile seizure Head injury/post-traumatic seizure Ingestion/poisoning Idiopathic seizure/epilepsy

Which of the following features are characteristic of tension headaches in children? Select all that apply.

Can be triggered by stress May feel like a band around the head May involve tenderness of the muscles of posterior neck

Besides home safety, what are additional topics you could discuss with Asia's mom regarding anticipatory guidance at this age?

Car seat placement, avoid using a walker, dietary changes, expected developmental changes, and sleep patterns

Based on your summary statement, select the most likely diagnoses remaining on your differential at this point.

Congenital adrenal hyperplasia Congenital hypothyroidism Inborn error of metabolism

A two-month-old infant is brought to clinic by her mother for a well-baby checkup. Mom says that her daughter is easy to care for because "she rarely cries and sleeps most of the time." On exam, the patient has a yellow tint to the skin, decreased muscle tone, and a large anterior fontanel. What is the most likely diagnosis in this patient?

Congenital hypothyroidism

A 2-week-old infant is brought by her mother to the clinic because of concerns for jaundice, constipation, sleepiness, and poor feeding. She has not had any vomiting. The patient was born at home and received no medications or lab studies. Physical exam reveals enlarged anterior fontanelle, jaundice, hypotonia, and an umbilical hernia. The remainder of the examination is normal. While obtaining confirmation of the diagnosis, which of the following is the most appropriate pharmacotherapy in this patient?

Consult with pediatric endocrinologist and start treatment with 10 to 15 mcg/kg/day of crushed levothyroxine in liquid, and follow up labs in 2 weeks

How would you approach Anna's mother about prevention of foreign body aspiration? Choose the single best answer.

Counsel the mother now in ways to prevent ingestions, choking, and foreign body aspiration.

What practical steps would you take today in addition to oral iron treatment (given as 2 to 4 mg/kg/day of elemental iron divided once or twice daily)?

Counseling Benjamin's mother abotu decreasing his milk intake. Milk can cause anemia through multiple mechanisms including microscopic GI bleeding as well as poor iron availability from milk. Vitamin C increases absorption of iron so recommending that he take supplements with either Vitamin C supplement or Vitamin C rich foods can help

A 3-year-old girl is brought into the clinic by her mother because she has a gradually worsening cough and she has been having trouble breathing. Her mother says the patient sounds like she is barking when she coughs. She is up to date with her vaccinations. Her mom always watches her when she's playing. Physical examination of the child reveals inspiratory stridor. She does not have wheezing, there are no retractions, and she has symmetrical breath sounds. No pseudomembranes are appreciated. What is the most likely diagnosis?

Croup

An erythematous tongue with prominent papillae has the marbled appearance of the flesh of a strawberry, and is thus often referred to as a "strawberry tongue." Which of the following conditions have been associated with a finding of a "strawberry tongue?" Select all that apply.

Scarlet fever Kawasaki disease Toxic shock syndrome

A 7-year-old male is brought by ambulance to the ED because of decreased mental status for two hours. His parents say that he has been tired for the past three days. Six hours ago, he began vomiting, but has not had diarrhea. He is difficult to arouse and moans with stimulus. Temperature is 98.6, pulse is 124 beats/minute, respirations are 28 breaths/minute, blood pressure is 96/68 and oxygen saturations are 99% on room air. Physical exam findings include dry mucous membranes and moaning on palpation of the abdomen. The remainder of the exam is normal. What is the most likely cause of his condition?

DKA

Based on the information you have so far, choose the most likely diagnosis from the differential listed below. Choose the single best answer.

DKA

Which of the following vaccines will you give Asia today at her 2-month visit?

DTaP, HepB, HiB, IPV, PCV13, RotaV

Of the following factors that you discovered while taking Rebecca's medical history, which are considered risk factors for developing acute otitis media? Select all that apply.

Daycare attendance, exposure to cigarette smoke, possible allergies

How will you respond to Mike in order to discourage him from using steroids? Select all that apply.

Discuss physical side effects, including acne and change in testicular size Ensure he know that steroids can be detected on drug testing Review examples of cases where use of steroids has problems for professional athletes

Ms. Mason says, "I really want to breastfeed. Will that be possible?" How would you respond?

Dr. Martin tells Mrs. Mason, "We can have you try feeding soon. Adam might have some difficulty initially because he is breathing fast. If that turns out to be the case, we can have you start pumping milk. When we head back to the nursery, we'll see how he's doing and try to get him out to you as soon as we're sure he's ready."

John is a 17-year-old presenting today for a preparticipation physical exam. During the interview, he reports a low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a temperature of 101.3° F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His participation would be most likely affected by which of the following tests?

EBV serologies

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Emily is a 4-year-old previously healthy female who presents with acute right leg pain, refusal to walk, low-grade fever in the setting of URI symptoms a couple of days ago, and a recent minor fall. The only musculoskeletal finding on exam is limited internal rotation of the right hip, and she is otherwise well appearing.

A 5-year-old female, previously healthy, presents with an erythematous, vesicular rash on her palms and soles and a high fever for several days. Upon examination, she is also found to have ulcers in her mouth. A few days later, the fever and rash resolve. What is the most likely pathogen?

Enterovirus

Based on your initial differential diagnosis, what further questions do you need to ask Caleb's mother when you return her phone call

Has he been around anyone else who has been ill? Has he had any travel history or new exposures? Has he had significant abdominal pain? What is the character and frequency of the emesis (stomach contents, bilious, bloody)? What is the character and frequency of the stool (bloody, watery, mucus-containing)? Has he had a fever? Is he eating and drinking? How much? Is he urinating? When was his last urination? What is his level of activity?

At this time, which of the following is the most appropriate step in Nick's management? Select the one best answer.

Have Nick and his mother complete a two-week headache diary and follow up shortly thereafter

Which of the following symptoms would raise concern for a life-threatening cause of Nicholas' headaches? Select all that apply.

Headache accompanied by projectile vomiting Headache associated w/ fever and photophobia Headache occurring early in the morning Headache that awakens one from sleep Headache that worsens with cough or Valsalva maneuver Sudden onset of severe headache

Which of the following are common signs and symptoms of cerebral edema? Select all that apply.

Headache, recurrence of vomiting, inappropriate slowing of heart rate (bradycardia) rising BP (HTN), irregular respirations, restlessness/irritability, increased drowsiness (lethargy), CN 6 palsies, abnormal pupillary responses

A 3-year-old female comes to the clinic with a limp and a slightly externally rotated right hip. Which of the following signs/symptoms would you expect in the history or exam if a diagnosis of transient synovitis were made?

History of recent upper respiratory tract infection

What are three important pieces of information you already know about Holly from her chart, even before you begin to take your history?

Holly is a 6-month-old female. She has a fever (rectal temp of 39.8 C (103.6 F)). She has had a fever for two days. She has a rapid heart rate (tachycardia). She has a mildly increased respiratory rate (tachypnea).

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Holly is a former full-term, previously well, fully immunized, 6-month-old girl with a two-day history of high fever and poor appetite. On exam she is tachycardic, appears dehydrated, and is poorly consolable without an apparent source for her fever.

A 4-year-old boy is brought to the clinic by his mother for developmental evaluation. She is concerned that he is delayed when compared to the children of her friends. Although he can throw a ball and copy a circle, he cannot brush his teeth on his own, tie his shoes, or hop on one foot. Which of the following set of developmental milestones most closely matches those expected of a 4 year old child?

Hop on 1 foot, copy cross, brush teeth

A 2-year-old female with normal birth and developmental history presents with increased agitation and decreased arousability. A family member who lives in the home suffers from chronic pain secondary to a back injury, and her mother found an open container of pills on the bed. Vitals reflect bradycardia, bradypnea, hypotension, and slight hypothermia. On physical exam, she exhibits somnolence, constricted pupils, hypoactive bowel sounds, and hyporeflexia. What substance was most likely ingested?

Hydromorphone

A 17-year-old girl presents for a sports preparticipation physical. She reports that she occasionally gets short of breath and feels light-headed with exercise, and sometimes she experiences chest pain as well. She lost consciousness once last season during a playoff basketball game, but attributed it to feeling sick at the time. Her grandfather died suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis?

Hypertrophic cardiomyopathy

A 1-month-old infant who is < 3rd percentile for weight presents to the clinic. He is breastfed every 2 hours and latches on well. However, he has frequent non-bilious episodes of vomiting that have been increasing over the past week despite his mother instituting "reflux precautions." He does not have mucus or blood in his stool. Physical exam reveals a small, olive-sized mass in his abdomen. What is the most likely diagnosis?

Pyloric stenosis

You have accepted a part-time tutoring job for first-year medical students. One of your students asks if you would please clarify the details of normal fetal circulation. Which of the following best describes the path oxygenated blood takes to reach the fetal brain?

RA > foramen ovale > LA > LV > systemic circulation

A 3-hour-old infant, born by C-section at 36 weeks to a 30-year-old G1P1 with Apgars of 8 and 9 at 1 and 5 minutes, respectively, is found to be tachypneic in the newborn nursery. His mother has a history of type II diabetes that was poorly controlled during her pregnancy. She took prenatal vitamins and no other medications during her pregnancy. Prenatal labs, including GBS, were negative. The mother's membranes ruptured 9 hours prior to delivery, she was afebrile, and the amniotic fluid had no meconium. On physical exam, the infant is large for gestational age. He has good air movement through the lungs bilaterally, without retractions or nasal flaring. He appears well perfused with a normal cardiac exam. He has decreased muscle tone and a weak suck reflex. Cutaneous blood glucose measurement is 39 mg/dL. What is the most likely diagnosis?

Hypoglycemia

What would you tell the mother now, in answer to her question? Choose the single best answer.

I am concerned that Tyler's feedings do not seem to be going well. Can I ask you a few more questions about Tyler to help us find out if there is a problem?

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Ian is a previously healthy, developmentally normal 16-month-old male who was observed to have a brief, self-limited generalized seizure and was subsequently unresponsive. There is a family history of febrile seizures and no history of trauma. On presentation he is responsive but irritable with significant fever.

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Gerardo is a 2-year-old male with sickle cell disease who presents with acute fever, chest pain, and respiratory distress. Exam is significant for hypoxemia; rhonchi and decreased basilar breath sounds with dullness to percussion bilaterally; and increased splenomegaly.

The first priority is to establish the relationships between you and Benjamin and his mother in order to have a productive well-child visit. How would you proceed? Select all that apply.

Give a toy to Benjamin, Smile and ask Benjamin, Tell Benjamin's mother

What is your immediate management plan? Choose the single best answer.

Give an IV bolus of normal saline (20 mL/kg) 100 mL immediately

An 8-year-old boy is brought to clinic by his parents because they are concerned that he has not been doing his homework. His teacher recently called the parents to say that their son seems distracted in class, constantly interrupts other children when they are speaking, and is very fidgety. When you speak with the boy, he tells you that he did not know about the homework assignments and that he tries hard to pay attention in class. What is the next best step in management?

Find out more about his behavior at home and at school

A 9-year-old female is brought to clinic by her mother because of two days of abdominal pain and vomiting. She has vomited six times today and has had decreased appetite, but no diarrhea, fevers, sick contacts, or changes in her diet. Her mom states that she has been otherwise healthy apart from increased thirst and occasional bedwetting over the last few weeks. Of note, the patient's maternal grandmother suffers from celiac disease. On exam, the patient is afebrile, has a heart rate (HR) of 180 bpm, BP 90/60 mmHg, RR 50 bpm, and O2 saturation of 98%. She is lying in bed appearing slightly drowsy, taking rapid, deep breaths, and is slow to respond to questions. Her heart and lung exams are normal apart from being tachycardic, and her abdominal exam reveals mild diffuse tenderness to palpation with no rebound or guarding. Which of the following would be the most appropriate next step in management?

Fingerstick blood glucose

Which of the following should be included in a discharge plan for Jason? Select all that apply.

Follow up with cardiology in 1-2 weeks Prescription for low-dose aspirin Influenza vaccine

A 12-month-old previously healthy girl presents with cough and mild subcostal retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest x-ray demonstrates unilateral air trapping. What is the most likely diagnosis?

Foreign body aspiration

A previously healthy 11-month-old male with 5-day history of a "cold," is brought to the ED by his mother for one day of acute worsening cough and intermittent wheezing. Per the mother, the cough was initially dry but has become more "phlegmy," making it difficult for the infant to breathe, particularly when he is feeding or more active. His immunizations are up to date, and he has no known allergies. His family history is significant for a 6-year old sister who was diagnosed with asthma four years ago. On exam, the infant is afebrile, mildly tachypneic with normal O2 saturation. He has prominent nasal flaring and mild subcostal retractions. He has clear rhinorrhea but no evidence of oropharyngeal erythema. Lung exam reveals decreased breath sounds and wheezes on the right. What is the most likely diagnosis?

Foreign body aspiration

Now, with your summary statement in mind, what is the one most likely diagnosis?

Foreign body aspiration

Based on these x-rays, choose the single most likely diagnosis of Anna's acute condition:

Foreign body in large airway (RIGHT side)

A 4 day old term infant presents for his first newborn visit. He was born via spontaneous vaginal delivery without complications. Mother reports that the baby appears "yellow" since leaving the hospital. He is exclusively breastfed and latches for 1-5 minutes per feed every 2-3 hours. He has had 2 wet diapers in the last 24 hours. Which of the following would most aid in narrowing the differential diagnosis?

Fractionated bilirubin

What medications might be effective at improving Tyler's symptoms of heart failure?

Furosemide, digoxin, elanapril

A 6-month-old infant comes to clinic because of several weeks of vomiting after feedings. The vomiting has become blood-streaked, which is when the mom became concerned and brought him in. The baby's PO intake has decreased and he has been losing weight. Abdominal exam is normal, with no masses palpated. What is the most likely diagnosis?

GERD with esophagitis

Select the items from the following list that should be included in your differential diagnosis for Ben's vomiting and dehydration at this point

Gastroesophageal reflux, inborn error of metabolism, intussusception, malrotation w/ or w/o volvulus, milk protein allergy, pyloric stenosis, UTI, viral gastroenteritis

How would you describe this seizure? Select all that apply.

Generalized tonic-clonic seizure

A 2-hour-old infant is evaluated in the nursery for progressively worsening tachypnea. He was born at 32 weeks gestational age via spontaneous vaginal delivery to a mother with diabetes and negative group B streptococcus status. His Apgar scores were 8 at one minute and 9 at five minutes. On physical examination he is large for gestational age. His vital signs are respiratory rate 75 breaths/minute, temperature 36.5 C (97.7 F), and pulse is 130 beats per minute. His lung exam is remarkable for intercostal and subcostal retractions, grunting, and equal breath sounds. His heart exam reveals normal rhythm, normal S1 and S2, no murmurs, and normal peripheral pulses and capillary refill. Which of the following is the most likely cause of the patient's condition?

RDS

A 5-year-old male comes to the clinic with a chief complaint of four days of progressively worsening fever that has been minimally responsive to acetaminophen. The patient complains of sore throat and decreased appetite. His sister had a positive rapid strep test and is now being treated with amoxicillin. Your concern is for Group A strep. What is the next best step in management?

Rapid strep test with back-up culture if negative

A 4-year-old child is refusing to walk over the course of a week. Her mother recalls that she fell off her bike yesterday. On exam, she is afebrile, but has decreased range of motion of her hip. You review her file and note that she is up-to-date on her immunizations and she was last seen three weeks ago for a self-limited episode of diarrhea that she developed while visiting family in rural Mexico. Aspiration of her affected hip joint reveals slight increase in inflammatory cells but normal chemistries and a negative gram stain. Culture is pending. Which of the following is the most likely diagnosis?

Reactive arthritis

A 36-month-old presents for a well child visit. The parents would like to know if the child's development is progressing appropriately. The child passed a hearing test at birth, and other than a few URIs, has been generally healthy. The child has not had any hospitalizations or serious illnesses. The child is able to run well, walk up stairs, walk slowly down stairs, uses more words than the parents are able to count, but can only use them in short, two or three-word sentences. The child's speech is understandable and the child can draw a circle, but not a cross. Neurological examination reveals normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the next best step in management of this child?

Reassure the parents that the child's development appears normal

Based on what you know about the patient so far, write a one-to-three sentence summary statement to communicate your understanding of the patient to other providers.

Rebecca is a fully immunized 18-month-old girl with acute onset of fever and ear tugging following three days of URI symptoms who has a history of language delay, past otitis media, daycare, and smoke exposure

A 16-year-old boy presents to your office requesting clearance to play football. You begin by taking his medical history. He says that he feels very well, but admits that he recently experienced one episode of syncope that occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while playing basketball. Physical examination reveals no abnormalities. What is the next best step in management?

Refer to Cardiology

A 3-month-old male presents to the ED with a fever that started the previous day. Mother reports that he is fussy and has decreased oral intake. He has had five fewer diaper changes than usual. He has no vomiting, diarrhea, or respiratory difficulty. On physical exam his temperature is 101.6 F, pulse 110 bpm, RR 24 bpm, and BP 95/67 mmHg. The baby seems irritable and is not consolable by the parent. HEENT exam is significant for dry mucous membranes. Other than his irritability, the rest of the physical exam is unremarkable. CBC shows WBC 3.5, but is otherwise normal. BMP is within normal limits. Urinalysis shows positive leukocyte esterase, positive nitrite, and WBCs > 10/hpf. An LP is performed, and urine and CSF culture results are pending. The patient is placed on IV fluids and is started on cefotaxime. What is the next best step in evaluation?

Renal bladder U/S

Although Holly is only 6 months old, which of the following would be consistent with Kernig's sign if she were older? (Select the ONE best answer.)

Resistance to extension of the knee

Which of these findings is of the greatest concern in this case? Choose the single best answer.

Respiratory rate

A 5-year-old male with sickle cell disease presents to clinic with a chief concern of severe chest pain for the past day. His mother notes that he has been breathing quickly and that she measured his temperature this morning to be 100.5 F. He describes the pain as an 8/10 on the faces scale. He is tachypneic on exam and has an oxygen saturation of 97% on room air. Chest exam reveals normal lung sounds bilaterally, and he has some reproducible tenderness over his chest wall. A chest x-ray is performed and demonstrates clear lung fields and a cardiac silhouette that is within normal limits. What is the most likely cause of the chest pain?

Rib infarction

A 10-day-old boy is brought to the ED by his mother because of fever. Mother describes that the baby has been "sleepy" and feeding less vigorously than in the previous two days. She believes his urine output has also decreased. His birth history is notable for prolonged membrane rupture (about 32 hours), and maternal fever at the time of delivery. Prenatal and neonatal ultrasound revealed bilateral hydronephrosis. On exam, the infant is sleepy with a temperature of 38.5 C. A blood sample is sent for CBC, BMP, and culture. Attempts are made to obtain CSF and urine for analysis and culture, but only very small volumes of these fluids are obtained. Volume resuscitation is started. Chest x-ray is performed with indeterminate results. What is the most appropriate next step?

Send samples for culture and begin parenteral antibiotic treatment

You see a 6-year-old male in the ED who presents with a history of a 10-second episode of jerking movements of his extremities with unresponsiveness, observed by both of his parents. His parents claim he has had abdominal pain and small quantities of bloody diarrhea for two days. The child has no significant past medical history, has taken no medications recently, has no pets, and has not traveled outside of California in the past year. He attends kindergarten. Which organism is the most likely cause of the child's symptoms?

Shigella sonnei

A 16-month-old male is brought to the urgent care clinic by his father because of a seizure 30 minutes ago. The child dropped to the floor with loss of consciousness and had sporadic twitchy movements of his legs and arms that lasted for five minutes. He had URI symptoms for the past two days, with a fever to 39.4 C (103 F) today. He is previously healthy and had normal developmental screening at his last visit. Neither parent has a seizure disorder, but the child's mother had a single seizure as a young girl after developing a high fever with a cold. Which of the following is the most likely diagnosis in this patient?

Simple febrile seizure

A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis?

Small round blue cells with dense nuclei forming small rosettes

Which one of the following is true about colds and wheezing in infants and children? Choose the single best answer.

Some children w/o asthma may have wheezing associated w/ upper respi symptoms

Which of the following tests would be most useful in establishing a diagnosis of asthma for Sunita? Choose the single best answer.

Spirometry

What if, on Nick's neurologic examination today, you'd found that he had papilledema, paresis and sensory loss over the right leg with 4+ reflexes at the patella and ankle also on the right-and that the rest of his neurologic examination was normal. With those findings, where would you think the lesion might be? Choose the single best answer.

Supratentorial, on L side of brain

A male infant weighing 3200 grams is born to a G1P1 female at 39 weeks' gestational age via planned C-section. Maternal PMH is unremarkable, and GBS status is negative. Apgars are 7 and 8 at 1 and 5 minutes of life, respectively. The delivery was uncomplicated, and the infant initially appeared in good condition. However, one hour following delivery the infant develops increasing respiratory distress. Respiratory rate is assessed as 90 breaths/min. All other vital signs are within normal limits. On exam, the infant is acyanotic with rapid respirations and robust capillary refill. Chest x-ray shows bilateral lung fields with the appearance of "a radio-opaque line of fluid in the horizontal fissure of the right lung." No air bronchograms are noted. What is the most likely etiology of the infant's respiratory distress?

TTN

List the findings that are most relevant in refining the differential diagnosis.

Temperature of 104 F Non-purulent conjunctivitis Mucosal changes of the oropharynx Unilateral cervical adenopathy Erythema and swelling of the extremities Erythematous macular rash Irritability

A 12-year-old female presents to her pediatrician complaining of a headache of gradual onset x 3 hours, non-provoked and described as a "big rubber band around my whole head" and a 5 out of 10 on the pain scale. The pain is not throbbing, and there is no associated photophobia, nausea or vomiting. The patient is afebrile, and there are no neurologic deficits during physical exam. Her mother states her pain is typically relieved with ibuprofen, but her mother is concerned that the patient may have migraines because she has a few headaches every month after school. The child is otherwise healthy. What is the most likely cause of her headaches?

Tension-type headache

Review Madelyn's electrocardiogram. What do you see?

The EKG shows an irregularly irregular rhythm. P waves are not distinctly seen. There is a wide QRS. The QT interval is prolonged. Madelyn is showing signs of cardiotoxicity on her EKG, which makes ingestion with tricyclic antidepressants likely.

A 15-month-old male presents to the ED with a 3-day history of vomiting and diarrhea. His current weight is 11 kg. He was born at 39 weeks, without any perinatal complications. There is no significant history of travel, sick contacts, or recent changes in diet. The mother notes that he has had only 2 urine diapers over the last day. Physical exam is remarkable for an irritable but consolable infant with tachycardia and normal blood pressure. He is crying with minimal tears and his mucous membranes are dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds. He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the following statements is true?

The patient is moderately dehydrated and should be managed with 50-100ml/kg of oral rehydrating solution over 2-4 hours.

Given that the medical assistant was unable to check the vision and hearing for the patient, what would be your next steps in this assessment?

While vision screening is recommended to start at 3 years, many patients cannot yet do chart based screening. All children should be given two tries at separate visits before referring them to a specialist for an exam. So in this case, the vision testing can be repeated at the next visit as long as the parents don't have any specific vision concerns today.

Of the descriptions below, which best describes Rebecca's left ear? Choose the single best answer.

White/red, reduced mobility, opaque, bulging

A 5-month-old male is brought to the urgent care clinic with a 3 day history of rhinorrhea and non-productive cough. At birth the baby was large for gestational age and exam at the time was notable for macrocephaly, macroglossia, and hypospadias. Vital signs are stable on physical exam at this time. There is copious nasal discharge, but lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass?

Wilms' Tumor

A 3-year-old boy presents to the ED 20 minutes after his parents witness an episode of convulsions at home. His parents report that Charlie was in his usual state of good health until three days ago when he developed fever, cough, and rhinorrhea. This evening they found him in bed with his eyes rolled upward, jerking all four of his extremities uncontrollably. He was unarousable from this state, which self-resolved after about two minutes. This has never happened before. Currently, Charlie is sleepy but arousable and complains of nausea. His vitals include T 103.2 F, P 112 bpm, BP 100/60 mmHg, RR 22 bpm, O2 sat 99% on room air. Aside from rhinorrhea and erythematous mucous membranes, the remainder of his physical exam is unremarkable. What is the next best step in management?

Workup for source of fever

A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would most likely be characteristic of the cough that this patient would present with?

Worse at night

Is Jimmy up to date on his immunizations?

Yes

How would you respond?

You thank the sister for offering to translate and explain that you have an interpreter available by tablet

Which of the following systemic illnesses commonly have diaper rash as one of the features?

Zinc deficiency Langerhans cell histiocytosis

Given what you have learned about decontamination, which of the following would be appropriate for Madelyn?

none