Board Review Quiz #3 - 2019
Correct Answer: D
A 12-year-old boy is brought to the emergency department following a motor vehicle collision. He complains of headache, but has had no vomiting or seizure activity. He is awake and conversant, but cannot remember the details of the accident. His Glasgow coma scale score is 15. He has a history of myringotomy tube placement for frequent ear infections at 2 years of age. On examination, he has bloody otorrhea on the left. Of the following, the MOST likely reason for this patient's symptoms is A. basilar skull fracture B. chronic otitis externa C. chronic otitis media D. middle ear trauma E. traumatic brain injury
Correct Answer: D
A 12-year-old boy is seen for a preparticipation sports physical evaluation. He has no concerns and is excited to play football in the upcoming fall season. His medical history is significant only for generalized joint hypermobility. He takes no medications and has no known allergies. His mother also has joint hypermobility; the family history is otherwise not significant. Of the following, compared with his teammates, this boy is at INCREASED risk for A. bone fracture B. concussion C. hyperthermia D. joint dislocation
Correct Answer: B
A 10-month-old male infant is brought to the office with 6 days of fever and a new rash. His mother states that he has been difficult to feed for 2 days because he is so irritable. He usually breastfeeds for 20 min every 3 hours, but has only been feeding for 5 min every 2 hours. He has had 2 wet diapers in the last 24 hours. He has not been given any medication. No one else is ill at home. The infant's family is Asian American and he is in day care 3 days a week. Vital signs show a temperature of 39.5°C rectally, respiratory rate of 30 breaths/min, heart rate of 160 beats/min, and a blood pressure of 90/65 mm Hg. Physical examination shows an alert, but very fussy infant. His conjunctiva are injected, but there is no purulent drainage. The lips are red and cracked. There are no mouth ulcers. His tongue is red with white papilla. The neck, chest, and cardiac examinations are unremarkable. The liver edge is at the right coastal margin. No spleen is palpated. His hands and feet have mild edema. There is an erythematous maculopapular rash on his trunk and arms. Laboratory results are as follows: White blood cells, 10,500/µL (10.5 x 109/L) with 65% neutrophils, 25% lymphocytes, 10% atypical lymphocytes Hemoglobin, 9.5 g/dL (95 g/L) Hematocrit, 30.1% Erythrocyte sedimentation rate, 60 mm/h C-reactive protein, 4.5 mg/L Urinalysis shows white blood cells Alanine aminotransferase, 50 U/L aspartate aminotransferase, 45 U/L The patient is admitted to the hospitalist service. Of the following, the BEST next combination of diagnostic and therapeutic maneuvers is A.blood culture and intravenous azithromycin B.echocardiogram and intravenous immunoglobulin C.lumbar puncture and intravenous ceftriaxone D.throat culture and intravenous penicillin E.urine culture and intravenous ampicillin
E
A 10-year-old boy with a 2-week history of fever up to 38.9°C, cough, malaise, and fatigue is brought to your office. He has experienced a 1-kg weight loss and reports left-side chest pain. The patient and his family returned from a camping trip in the Grand Canyon 4 weeks ago. The boy appears fatigued. He has mild tachypnea and splinting of respiratory effort. Auscultation of the chest is significant for decreased breath sounds and a pleural rub at the left lung base. A chest radiograph confirms a small left-sided pleural effusion. Examination of the heart, abdomen, and oropharynx are unremarkable. You suspect acute coccidioidomycosis. Of the following, the finding MOST supportive of this diagnosis is A.centrilobular nodules with "tree in bud" pattern on computed tomography of chest B.cutaneous involvement with finding of erythema nodosum C.detection of coccidioides antigen in urine by enzyme immunoassay D.detection of serum complement fixation antibody E.eosinophilia on complete blood cell count
Correct Answer: C
A 10-year-old girl is brought to the emergency department by her parents because she cannot walk. Her symptoms started 2 days ago with tripping on stairs and curbs. Yesterday, she could not stand up from a sitting position, and this morning she could not get out of her bed. Her physical examination shows an anxious-appearing girl with a soft voice, lying on a stretcher. She can wiggle her legs, but cannot lift them off the stretcher. Her hands have a weak grip, but she can raise her arms off the stretcher, her pupils are reactive, and her facial movements are strong. You cannot elicit any deep tendon reflexes. Of the following, the BEST next step in evaluation is A. computed tomography of the head B. magnetic resonance imaging of the spine C. negative inspiratory force measurement D. serum botulism toxin assay E. serum lead level
Correct Answer: B
A 10-year-old girl is brought to your office by her parents for evaluation of clumsiness. She had met all the early developmental milestones on time, but over the past year, her parents have noticed that she falls over small obstacles like steps or curbs. They have seen occasional quick jerks of her eyes, especially when she turns her head. Over the past month, she has been coughing when she drinks fluids. The mother reports that she had a cousin who died at 20 years of age of a progressive neurological disorder. Her neurological examination shows an alert girl with upper extremity dysmetria, diffuse areflexia, lower extremity weakness, and an ataxic gait. A brain magnetic resonance image is performed and is normal. Of the following, the MOST likely test to show the correct diagnosis is A. 15q11 methylation study (Angelman syndrome) B. frataxin gene sequencing (Friedreich ataxia) C. leukocyte lysosomal enzyme panel (leukodystrophy) D. neurofibromin gene sequencing (neurofibromatosis type 1) E. serum α-fetoprotein level (ataxia telangiectasia)
Correct Answer: B
A 10-year-old girl presents with progressive fatigue without pain. Physical examination reveals edema and a pink-to-violet discoloration of the upper eyelids and malar areas (Item Q97A). Scaly, red papules (Item Q97B) are observed over the knuckles. Of the following, the MOST appropriate laboratory investigation to support the diagnosis is A. antinuclear antibody assay B. creatine phosphokinase concentration C. epicutaneous patch testing D. erythrocyte sedimentation rate E. skin biopsy
Correcr Answer: D
A 13-year-old adolescent is transferred into your practice and comes for an initial visit and physical examination. He was full term, has never been hospitalized or had surgery, and takes no medications. He has a history of a heart murmur and the family brings you a copy of his last cardiac evaluation done 5 years ago. The report states that he has a bicuspid aortic valve. He plays baseball and soccer without any symptoms. On physical examination today, he has a heart rate of 72 beats/min, respiratory rate of 18 breaths/min, and blood pressure of 115/65 mm Hg in the right arm and 105/65 mm Hg in the right leg. He has no jugular venous distension. His lungs are clear to auscultation. His cardiac examination reveals a regular rhythm. His S1 and S2 are normal. There is a 1/6 systolic murmur at the left mid sternal border, which does not radiate into the neck. There is no rub or gallop. His abdominal examination is normal. His femoral pulses are brisk. He has been invited to participate in a rugged 2-week survival course and his parents want your opinion as to whether it is safe for him to participate and what his long term prognosis is. Of the following, the MOST accurate advice or assessment for them at this time is A.the gradient across his aortic valve is likely 5 to 30 mm Hg B.he has a 75% risk of developing aortic stenosis during his lifetime C.he will need lifelong endocarditis prophylaxis D.his blood pressures suggest an associated coarctation E.the presence of a murmur means that he will need exercise restriction
Correcr Answer: C
A 13-year-old adolescent with trisomy 21 who underwent surgery at 4 months of age for an atrioventricular canal defect is brought to your office for a school physical examination. He has not been seen by you for 4 years. He has not been on any medications. He is in special education class and would like to participate in the Special Olympics. On review of symptoms, his mother states that he has not had the same level of energy for the last 2 weeks. He has been sleeping during the day on the weekend and has been too tired to do his school work. On physical examination, his heart rate is 56 beats/min, his respiratory rate is 32 breaths/min, and his blood pressure is 92/45 mm Hg. He has mild intercostal retractions. His pulse oximetry is 90% on room air. He is alert but not talkative today. His chest examination shows decreased breath sounds bilaterally with crackles. His cardiac examination reveals a slow regular heart rate with a 2/4 diastolic murmur and a 2/6 systolic murmur at the left midclavicular line at the fourth intercostal space. No hepatosplenomegaly or lymphadenopathy is noted. Given the combination of history and physical findings, the MOST likely etiology of his current fatigue is A.hyperthyroidism B.leukemia C.mitral stenosis D.pericardial effusion E.tricuspid valve regurgitation
Correct Answer: D
A 14-year-old African American adolescent presents to your office for evaluation of severe headaches for the past 7 months. The headaches began shortly after the start of the school year. She had never experienced a headache before that. The headaches involve the left side of her head, are described as throbbing, and last 2 to 3 hours. During the headache, she feels nauseated and sometimes vomits. Her symptoms are somewhat relieved if she lies down in a dark room. The patient does not have any vision changes or weakness associated with the headaches, and they do not worsen with coughing, sneezing, lying down, or sitting up. They do not wake her up from sleep. She has not gained or lost weight recently. She does not take any medications other than occasional ibuprofen for the headaches. Her father has migraine headaches and her younger sister has sickle cell disease. Her blood pressure is 102/68 mm Hg, heart rate is 92 beats/min, respiratory rate is 22 breaths/min, and her body mass index is 21. Her physical examination, including neurological examination and fundoscopy, is unremarkable. Of the following, the BEST imaging recommendation for this patient is A. computed tomography of the brain B. computed tomography venogram C. magnetic resonance imaging of the brain D. no imaging indicated at this time E. transcranial Doppler ultrasonography
Correct Answer: C
A 14-year-old adolescent is seen for a routine preparticipation evaluation to play volleyball. She has no significant past medical history and has no current concerns. On physical examination, she has multiple enlarged cervical lymph nodes (1 to 2 cm) on the left side of her neck that are firm and fixed. She also has a 3 to 4 cm, firm, fixed anterior neck mass just left of midline (Item Q32). The remainder of the physical examination is unremarkable. Of the following, the test MOST likely to establish the diagnosis is A. complete blood cell count B. computed tomography of the neck C. fine-needle aspiration of the neck mass D. thyroid-stimulating hormone level E. ultrasonography of the thyroid gland and regional lymph nodes
C
A 15-month-old previously healthy boy is brought to the emergency department with fever, rash, and increasing lethargy. He was in his usual state of health until he developed a runny nose and cough the day before presentation. On the day of presentation, he has felt warm to the touch, had decreased oral intake, and became progressively lethargic and listless. When he woke up in the morning, his mother noticed a few red spots on his skin. Throughout the day, the rash progressed, significantly covering his trunk, arms, and legs. He has no known allergies. The boy's temperature is 39.5°C, heart rate is 180 beats/min, respiratory rate is 50 breaths/min, blood pressure is 70/40 mm Hg, and oxygen saturation is 100% on room air. His physical examination reveals a well-nourished but toxic-appearing, lethargic child. He has a nonblanching, purpuric rash evenly distributed over his face, trunk, and upper and lower extremities. His mucous membranes are dry. He is in moderate respiratory distress, with clear lung fields and good bilateral air exchange. His heartbeat is regular, with no murmur. The boy's extremities are cold, with a capillary refill time of 5 seconds. His abdomen is soft with no organomegaly. The nurse places 2 large-bore intravenous catheters, and fluid resuscitation is rapidly initiated. Of the following, the MOST appropriate antimicrobial therapy in this case is intravenous A.acyclovir B.amphotericin B C.ceftriaxone D.chloramphenicol E.vancomycin
Correct Answer: E
A 15-year-old adolescent is brought to your clinic after he had a convulsion at home 2 days ago. His mother tells you she heard a loud thumping noise, and when she went to check on him, he was convulsing on the bedroom floor. This lasted about 2 minutes. He was seen in an urgent care clinic and no acute abnormalities were found. He tells you he has had quick twitching movements of his shoulders and upper extremities, particularly in the morning for the past year. There is no family history of tremor or seizures. His neurological examination shows an anxious adolescent with bilateral upper extremity tremulousness when his arms are outstretched. There are no other abnormal movements. His physical examination is otherwise unremarkable. He and his mother ask to start a medication to treat this problem. Of the following, the BEST medication to treat this patient's underlying problem is A. fluoxetine B. lorazepam C. phenytoin D. propranolol E. valproate
Correct Answer: C
A 15-year-old girl presents with a 1-week history of pain and swelling in her fingers and wrists. She also complains of generalized fatigue and a rash for the last 3 weeks. Her rash seems to be exacerbated by sun exposure. Her medical history is not significant otherwise. Her family history is significant for an aunt with rheumatoid arthritis and a grandmother with thyroid disease. On physical examination, the girl's temperature is 38°C, heart rate is 66 beats/min, respiratory rate is 16 breaths/min, and blood pressure is 112/60 mm Hg. She is alert and cooperative. She has an erythematous maculopapular rash over the bridge of her nose, erythema of the hard palate, and a few shallow gingival ulcers. There is mild swelling, tenderness to palpation, and pain with range of motion in the proximal interphalangeal joints of several of her fingers and both wrists. The remainder of her physical examination findings are normal. Urinalysis demonstrates a specific gravity of 1.035, pH of 6.0, 3+ blood, 4+ protein, 2+ leukocyte esterase, no glucose, and no nitrites. Urine microscopy shows more than 100 red blood cells/high-power field (hpf), 10 to 20 white blood cells/hpf, no crystals, and no bacteria. Of the following, the MOST likely diagnosis for the girl in the vignette is A. antineutrophil cytoplasmic antibody vasculitis B. juvenile idiopathic arthritis C. systemic lupus erythematosus D. Sjögren syndrome
Correct Answer: B
A 15-year-old previously healthy adolescent boy presents to the emergency department for evaluation of an injury that occurred approximately 30 minutes ago when he was trying to catch a fast-moving ball during a high school baseball tournament. The adolescent reports that he fully recalls being hit directly on his right eye with a baseball. His parents brought him to the emergency department for evaluation immediately afterward because of significant pain, bruising, and swelling in his right periorbital area. There was no loss of consciousness at the time of injury, and he has had no vomiting, epistaxis, or drainage from his right eye. He has been holding a cold compress over his injured eyelid since the injury to help with the swelling, so he is unsure about his vision in the right eye. On physical examination, the adolescent is alert and fully-oriented. He appears uncomfortable, but appropriately answers your questions and follows commands. His vital signs are within normal limits for his age. His physical examination is significant for marked bruising and swelling over his right eyelid and periorbital area. When you ask him to look at you with both eyes open, his right eye seems to sit slightly lower than the left and his upward gaze is limited on the right. His pupils are 3 mm in diameter, equal, round, and reactive bilaterally. You note slight conjunctival injection in the right eye, but no signs of hyphema. His visual acuity is intact in both eyes. A fluorescein examination is negative for corneal injury. No other abnormalities are seen on a complete neurologic examination. Of the following, the injury that is MOST likely to be causing the adolescent's clinical findings is A. fracture of the medial wall of the right orbit B. fracture of the right orbital floor C. fracture of the right superior orbital rim D. traumatic laceration of the right orbital nerve E. traumatic rupture of the right globe
Correct Answer: D
A 15-year-old previously healthy adolescent is brought to the emergency department with a 2-month history of fevers, fatigue, headaches, shortness of breath, and poor appetite. She has developed swelling of her face, in both arms, and around her eyes. She has not had abdominal pain, blurry vision, cough, or vomiting. She has not traveled outside of the United States. Her vital signs show a temperature of 37°C, heart rate of 100 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 100/60 mm Hg. Her oxygen saturation is 100% on room air. On physical examination, she is well developed and well nourished. She has generalized facial and periorbital edema. She has good dentition and no oropharyngeal erythema. Pupils are 2 mm, equal, and reactive. Both jugular veins are fully distended when she is in the upright position. There is no redness or tenderness in the neck. Several enlarged lymph nodes in both axillae and supraclavicular regions are felt. She is slightly tachypneic, but breathing comfortably. Lungs and airway sounds are clear. Heart is regular with no rubs, murmurs, or gallops. Abdomen is soft, nontender, and non-distended with no hepatosplenomegaly. Her extremities are warm and well-perfused. Marked edema of both upper extremities, including the hands, is seen. Lower extremities have no cyanosis, clubbing, or edema. Neurologic examination is normal. Of the following, the MOST likely cause of her swelling is A.congestive heart failure B.lymphedema C.primary pulmonary hypertension D.superior vena cava syndrome E.tuberculosis
B
A 16-month-old girl is brought to your office with fever, bloody diarrhea, and vomiting. She lives on a farm and has been drinking unpasteurized cow milk. No other family members are ill. Her temperature is 38°C. She is pale and has mild dehydration. Laboratory data are shown: Laboratory TestResult Hemoglobin10.6 g/dL (106 g/L) Sodium130 mEq/L (130 mmol/L) Of the following, the MOST likely cause of her illness is A.Bacillus cereus B.Campylobacter jejuni C.enterotoxigenic Escherichia coli D.Mycobacterium bovis E.Shigella sonnei
Correct Answer: E
A 16-year-old Korean girl presents for a 6-month history of fatigue. She has had a 10 kg (22lb) weight loss during this time and reports intermittent fevers. The left brachial pulse is 2+, but the right is 1+. She has a fever in the office to 103.5 F. The blood pressure in her right arm is 95/50, the left arm is 140/99. A bruit is heard over the left shoulder on auscultation. ESR 70 and CRP is 10.2. WBC is 22 and hemoglobin is 9.1. What tested you ordered next? A. PPD and blood cultures B. Bone marrow biopsy C. TSH D. EEG E. Magnetic resonance angiography
Correct Answer: B
A 16-year-old adolescent boy presents to your clinic for evaluation of nose pain and swelling after he was hit in the face while playing basketball. His nose bled immediately after the incident, but this was controlled quickly with pressure to his nasal bridge. He complains of swelling, difficulty breathing through his nose, and pain when his nose is touched. On physical examination, the distal portion of the patient's nasal bone is deviated to the right. He has dried blood at the edge of each naris. Inspection of his intranasal cavity reveals a tense red mass on each side of his nasal septum (Item Q110). Of the following, the BEST next step in management of this patient's condition is A. closed reduction of the fracture B. drainage of the mass C. follow-up visit in 2 weeks D. intranasal phenylephrine E. oral clindamycin
Correct Answer: E
A 16-year-old boy presents with a very swollen, painful right knee (Item Q121A). He is a soccer player, but there is no history of recent injury. During the interview, you notice the boy has injected conjunctivae (Item Q121B). Of the following, further evaluation MOST likely will reveal A. alopecia areata B. Gottron papules C. Kayser-Fleischer rings D. malar rash E. urethritis
Correct Answer: C
A 17-year-old adolescent is brought to your office for follow-up after her first sports-related concussion. She is a competitive soccer player, and last week, she and another player collided, their heads hit together, and the adolescent sustained a concussion. She was evaluated in the emergency department and discharged home. Her father, who has multiple sclerosis, is her coach and has kept her out of practice and games since the concussion. She reports that not being able to play soccer is making her "depressed and irritable." She has been an A student, but is having difficulty concentrating at school. You recommend graded return to academic and physical activity, and mandate complete recovery before returning to play. Her father asks you about long-term cognitive consequences of this concussion. Of the following, the MOST accurate statement about the long-term consequences from this concussion is A. her baseline academic achievement decreases her risk of neurocognitive deficits B. her family history increases her risk of long-term neurocognitive deficits C. it is unlikely that she will have detectable neurocognitive deficits D. neurocognitive deficits are more likely if she keeps heading the ball E. wearing protective headgear during contact sports will decrease her risk of permanent neurocognitive deficits
Correct Answer: D
A 2-day-old newborn is being evaluated for seizures by neurology and has had a computed tomography of the brain that shows findings consistent with tuberous sclerosis. The neonatal intensive care unit nurse tells you that there have been frequent wide complex ectopic beats, but none have been captured on an electrocardiogram. On physical examination, you find a male newborn with weight of 3.8 kg in no distress, heart rate of 130 beats/min, respiratory rate of 34 breaths/min, and blood pressure of 82/55 mm Hg. The heart rhythm is regular. The cardiac examination is unremarkable: there is a normal S1 and S2 without any murmurs, rubs, thrills, or gallops. The point of maximal impulse is not displaced. There is no hepatosplenomegaly and the femoral pulses are normal. An echocardiogram is ordered. Of the following, the MOST likely finding on echocardiogram in this patient is A.atrial septal defect B.atrioventricular canal defect C.dilated cardiomyopathy D.rhabdomyomas E.tetralogy of Fallot
Correct Answer: E
A 2-month-old infant is seen in the emergency department for fever and respiratory distress. The baby had rhinorrhea 1 week ago, has been tachypneic for 3 days, and developed lethargy today. There is no history of a heart murmur. The baby is admitted for probable pneumonia, but after 2 days of antibiotics, is not improving as expected. She continues to fatigue easily with feeding, which her mother states has been the case for the past week. Her birth weight was 2.7 kg and her weight today is 5 kg (38th percentile). Her vital signs show a heart rate of 180 beats/min, respiratory rate of 80 breaths/min, and blood pressure of 65/45 mm Hg taken in the right arm. Her oxygen saturation is 92%. On physical examination, she has intercostal and subcostal retractions, but is not coughing and has no stridor. Her lungs are clear with breath sounds heard well to the bases. Her cardiac examination is significant for a soft S1 and S2 with no audible murmur. Her abdominal examination shows a liver edge that is 4 cm below the right costal margin. Her femoral pulses are palpable, but not strong. She has a capillary refill time of 3 seconds. Of the following, the MOST likely etiology for the infant's clinical symptoms is A.aspiration B.group B streptococcal sepsis C.intussusception D.viral bronchiolitis E.viral myocarditis
Correct Answer: E
A 2-year-old boy is brought to your office for a health supervision visit. His mother reports that he has been healthy over the previous year, with only minor upper respiratory infections, 1 ear infection, and 1 visit to the emergency department for a forehead laceration. His developmental screening results are appropriate for his age. On physical examination, white lines are seen along the bases of several teeth. His mother states that she brushes her son's teeth daily, but he has not yet seen a dentist. The boy has not had any tooth pain or problems with eating. His mother had several cavities when she was a young girl. Of the following, the MOST appropriate next management step for this boy is to A. add daily fluoride rinses to his oral health routine B. continue current management and reevaluate in 3 months C. perform a fluoride wash in your office D. recommend decreasing sugar intake E. refer him to a dentist for evaluation
Correct Answer: D
A 20-month-old girl is brought to your office with complaints of fever and right ear pain. On physical examination, her temperature is 38.5°C. The right ear shows a bright red tympanic membrane, which is bulging with a purulent effusion. The left ear is normal. You note that this is her fourth episode of otitis media in the last 7 months. Her last ear infection was 3 weeks ago and she was treated with amoxicillin. Of the following, the BEST approach for management of this patient is to initiate a A. 5-day course of amoxicillin and refer for insertion of tympanostomy tubes B. 5-day course of amoxicillin and refer to audiology for a hearing screen C. 5-day course of amoxicillin-clavulanate and follow-up in 3 weeks D. 10-day course of amoxicillin-clavulanate and refer for insertion of tympanostomy tubes E. 10-day course of amoxicillin-clavulanate followed by a daily prophylactic low dose of amoxicillin for 3 months
D
A 22-month-old boy is hospitalized in a burn center after a scald injury. The injury was sustained 2 days ago after he pulled a pot of boiling water from the stove top to the floor when his mother stepped away from the kitchen. He has a temperature of 39.1°C, heart rate of 150 beats/min, respiratory rate of 38 breaths/min, blood pressure of 98/66 mm Hg, and oxygen saturation of 100% on 2 L/min of oxygen via nasal cannula. He is distressed. He has decreased breath sounds in both bases, no murmur, abdominal distention, and denuded skin over portions of his right arm, abdomen, and lower legs in a splash pattern. There are newly violaceous edges on the abdominal wound. Of the following, the BEST indication for starting parenteral antibiotics in this patient is A.abnormal respiratory examination results B.discoloration at abdominal wound edges C.heart rate greater than 120 beats/min D.temperature greater than 38.3°C E.wound involving greater than 10% of body surface area
Correct Answer: E
A 24-month-old girl is brought to your clinic for her 2-year health supervision visit. Her father reports she has stopped saying words she used to know, and she twirls her hands a lot. Her occipital frontal circumference growth curve shows a plateau. Her height and weight have increased as expected for age. The remainder of the physical and neurological examination is unremarkable. The father asks if she has autism. Of the following, the MOST likely diagnosis is A. Angelman syndrome B. autism spectrum disorder C. inborn error of metabolism D. Landau-Kleffner syndrome E. Rett syndrome
Correct Answer: B
A 3-year-old boy is being evaluated for fever and rash. He has had daily fevers for the past 15 days; fevers occur in the late afternoon or early evening and his temperatures are routinely between 39°C and 40°C. During the day, the boy has had slightly decreased energy and has occasionally reported fatigue, but he has been well enough to attend daycare. He has an evanescent rash on his trunk that is most notable when he is febrile. On physical examination a rash is noted (Item Q13) as well as small effusions of his right knee and left elbow. His liver edge is palpable 3 cm below the right costal margin. Of the following, the laboratory abnormality MOST likely to be associated with the suspected diagnosis is A. elevated antinuclear antibody titer B. elevated erythrocyte sedimentation rate C. leukopenia D. positive rheumatoid factor
Correct Answer: B
A 3-year-old boy is brought to the emergency department for evaluation. His parents report that he has had a runny nose and cough for several days. Today, his symptoms rapidly worsened. They note that he has a fever and is breathing quickly. His voice and cry sound unusual to them, and he has been refusing to eat. On physical examination, his temperature is 40°C, his heart rate is 125 beats/min, his respiratory rate is 45 breaths/min, and his oxygen saturation is 100% on room air. He appears ill. He has inspiratory stridor and subcostal retractions. He is holding his head midline and refuses to flex, extend, or rotate his neck. He is extremely resistant to examination of his oral cavity, and you cannot clearly visualize the posterior oropharynx. You obtain a lateral neck radiograph (Item Q132). Of the following, the MOST appropriate initial treatment for the boy's condition is A. intravenous ceftriaxone B. intravenous clindamycin C. intravenous penicillin D. oral amoxicillin E. oral cefdinir
Correct Answer: A
A 3-year-old boy is brought to your office for a routine health supervision visit. On a previsit screening form, the boy's mother indicates that he has been well with no recent illnesses and no complaints of pain. She notes that he has recently started to speak in 2-word phrases and that he uses approximately 200 spontaneous words. He seems to understand everything that his family members say to him and will follow a 2-step command. On examination, he is well appearing, cooperative, and interactive. His tympanic membranes are opaque, gray, and immobile on pneumatic otoscopy (Item Q8 ). Of the following, the MOST appropriate next step in this boy's management is A. audiology evaluation B. referral to an otolaryngologist for surgery C. treatment with an intranasal corticosteroid D. treatment with oral amoxicillin E. watchful waiting with follow-up in 3 months
Correct Answer: A
A 3-year-old boy who is well known to your practice is brought in for complaints of not using his left arm or left leg as much over the past 3 days. He has an unrepaired atrial septal defect. He has had occasional seizures since he was 1 year of age, and takes levetiracetam. He has been in the care of grandparents this week while his parents are on vacation. The boy has not had any head injuries or seizures, and has been taking his medications regularly. There is no prior record of hemiparesis in his chart. His neurological examination shows decreased spontaneous movement of his left arm and left leg, with normal tone. His reflexes are brisk and symmetric in the upper and lower extremities. His mental status, speech, and language are normal. Of the following, the study MOST likely to yield the diagnosis in this boy is A. computed tomography of the head B. echocardiogram C. electroencephalogram D. electromyography and nerve conduction study E. magnetic resonance imaging of the cervical spine
Correct Answer: B
A 3-year-old girl has had fever for 6 days. Her father states that for the past 3 days her temperature has been at least 38.9°C, and it is not improving. He indicates that her eyes are red and she has a rash. He says she has been very cranky and that her appetite is decreased. He reports no vomiting, diarrhea, dysuria, cough, or trouble breathing. Her immunizations are up-to-date. The family was on vacation at a crowded amusement park for the first 3 days of her illness. She was seen at an urgent care center near the park where no etiology for her fever was found and no testing was done. Her temperature is now 38.9°C. She is irritable but interactive and cooperates with the examination. She has injected conjunctiva bilaterally without exudate, erythematous and cracked lips, and a polymorphous rash on her trunk and legs. The remainder of the physical examination findings are normal. Of the following, the MOST appropriate next steps in the diagnostic approach for this child include A. chest radiography, complete blood cell count with differential, blood culture, and urine culture B. complete blood cell count with differential, comprehensive metabolic panel, Creactive protein level, and urinalysis C. nasopharyngeal swab for influenza A and B, rapid streptococcal antigen test, and heterophile antibody test D. serum measles IgM antibody, complete blood cell count with differential, and nasopharyngeal swab for viral culture
Correct Answer: C
A 3-year-old girl presents to your office for evaluation of a "lump" in her right neck that was noticed by her mother while she was being bathed. She had an upper respiratory infection 3 weeks ago, with rhinorrhea and cough, which has fully resolved. She has had a normal appetite and energy level. The girl has not had persistent fevers, weight loss, or night sweats. The family has no pets, they have not been in a forest or wooded area, and have not traveled outside the country. The girl is developmentally appropriate, and is at the 40th percentile for both weight and height. On physical examination, a 1.5 × 1.0 cm freely movable and nontender mass is palpable just below the angle of her right mandible. The remainder of her physical examination is unremarkable. Of the following, the BEST next step in management is to A. obtain computed tomography scan of the neck with contrast B. perform a purified protein derivative test C. provide reassurance to the mother D. refer to a surgeon for a biopsy E. treat with oral amoxicillin/clavulanate
Correct Answer: B
A 4-year-old boy is admitted to the hospital with a 6-day history of fever, with a temperature of up to 40°C and a 3-day history of red cracked lips, nonpurulent conjunctivitis, and swollen hands and feet. On physical examination the boy is very irritable. His heart rate is 130 beats/ min and his blood pressure is 90/56 mm Hg in the right arm. The boy has an erythematous, nonvesicular rash on his trunk and a 2-cm left cervical lymph node. On auscultation, his lungs are clear and there is no murmur or gallop. There is no hepatosplenomegaly and he is well perfused. The remainder of his examination is unremarkable. Of the following, the BEST next step in the evaluation and management of this patient is to A. administer intravenous (IV) ceftriaxone after obtaining blood cultures B. administer IV immunoglobulin 2 g/kg over 12 hours C. administer low-dose aspirin orally at 5 mg/kg per day D. administer prednisone orally at 2 mg/kg per day E. restrict fluids to two-thirds of the maintenance rate
Correct Answer: D
A 4-year-old boy presents to your office for evaluation of leg pain. He feels pain behind his knees about once per week, generally at night as he is falling asleep. Occasionally, the pain wakes him from sleep. His parents have been treating the pain with acetaminophen and massage, which generally alleviates the pain within 20 to 30 minutes. The parents deny any history of limp, joint swelling, fevers, or skin changes in their son. The boy occasionally reports leg pain when walking more than 4 blocks, but his activity level is age appropriate. His appetite is normal. His physical examination is unremarkable. Of the following, the BEST next step in evaluation and management for this boy is to A. obtain radiographs of the hips B. obtain radiographs of the knees C. obtain serum C-reactive protein levels and complete blood cell count D. reassure the family that no further intervention is needed E. re-examine him after restriction of physical activity for 4 weeks
Correct Answer: E
A 4-year-old boy with acute lymphocytic leukemia presents to the oncology clinic for laboratory evaluation. He is currently receiving consolidation chemotherapy. His mother informs you that 9 days ago he was in contact with a child who has now been diagnosed with varicella. Her son has not had varicella in the past. His serologic test results are not available. Of the following, the BEST next step in management is to administer A. acyclovir B. ganciclovir C. intravenous immune globulin D. varicella vaccine E. varicella-zoster immune globulin
Correct Answer: B
A 4-year-old girl is brought to the emergency department with decreased level of consciousness. She is hypotensive and in a wide complex tachycardia on arrival. She is cardioverted with 2 J/kg and regains sinus rhythm. Her electrocardiogram shows low voltages with ST segment elevations (Item Q132). Her mother states that she was ill with a diarrheal illness 2 weeks ago and has been tired since that time, but became acutely ill and drowsy today. On physical examination, you see a lethargic child with pallor. Her heart rate is 180 beats/min, her respiratory rate is 40 breaths/min, and her breathing is shallow. Her blood pressure is 75/40 mm Hg. She is cool in her extremities with a capillary refill time of 4 seconds. Her pulse oximetry is not picking up well. You notice that her jugular veins are distended. Her chest examination is significant for rales throughout and retractions. Her cardiac examination is significant for a difficult to palpate point of maximal impulse that is displaced to the left and weak. She has a regular rhythm, but it is rapid. You appreciate S1 and S2 and hear a third heart sound in early diastole but no murmur. Her chest radiograph shows pulmonary edema and an enlarged heart. You are planning admission to the intensive care unit and getting consultations arranged. You place the child on 100% oxygen by non-rebreather mask and establish intravenous access. Of the following, the intervention which would be MOST likely to improve the patient's status now is A.amiodarone, 5 mg/kg intravenous bolus B.dopamine, 10 µg/kg per min C.esmolol infusion, 50 µg/kg per min D.intravenous immunoglobulin infusion, 1 g/kg E.normal saline, 40 mL/kg intravenously
Correct Answer: D
A 4-year-old girl presents to your office for evaluation of left ear pain and drainage. She has had at least 5 episodes of acute otitis media in her lifetime, the most recent of which was 3 months ago. The girl has been complaining of ear pain since this morning. She has not had a fever. This morning, her parents noted yellow crusting at the edge of her ear canal and on her pillow. The family returned yesterday from a weeklong camping trip during which the girl swam daily in a lake. On physical examination, the girl is well appearing with a temperature of 37.4°C. She cries when you touch the pinna or tragus of her left ear. Her left tympanic membrane cannot be visualized because of purulent material that fills the canal. The portion of the left ear canal that is visible is erythematous. Of the following, the MOST helpful factor for making the diagnosis in this patient is A. absence of fever B. history of recurrent acute otitis media C. history of recent swimming D. pain with manipulation of the ear E. presence of purulent debris in the ear canal
Correct Answer: B
A 5-year-old boy is admitted to the hospital with a 2-week history of intermittent fever. He has been having trouble walking today and is complaining of pain in his left knee. He is alert and well perfused. His heart rate is 120 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 100/65 mm Hg. On physical examination, you note that he has conjunctival petechiae, but no conjunctivitis or rhinorrhea. He has small, nontender lymph nodes in the anterior cervical chain; he has no jugular venous distension. His neck is supple. His oropharynx is clear, his chest is clear, his cardiac examination shows a regular rate and rhythm, and a normal S1 and S2 with a 2/6 systolic murmur at the left mid-axillary line and the fourth intercostal space. The abdominal examination shows a palpable spleen, but no hepatomegaly. The femoral pulses are 2+. His left knee is swollen, erythematous, and warm to the touch. He is not able to straighten his leg. He has not had any medications. His laboratory workup shows: White blood cell count is 10,500/µL (10.5 x 109/L), 80% neutrophils, 18% lymphocytes, 2% monocytes Hemoglobin, 13 g/dL (130 g/L) Hematocrit, 39% Platelet count, 390 x 103/µL (390 x 109/L) Erythrocyte sedimentation rate, 120 mm/h Of the following, the MOST important diagnostic test that should be performed to evaluate the etiology of this patient's symptoms is A.abdominal computed tomography B.blood cultures C.C-reactive protein D.chest radiograph E.knee magnetic resonance image
Correct Answer: C
A 5-year-old boy is brought to the pediatric emergency department by his mother for worsening joint pain, fever, and a new onset of rash. The child appears in severe distress due to pain and continues to point at his right knee. Mother mentions that he is complaining of intermittent pain for the past 2 months along with 1-2 fevers a day and she reports seeing a "salmon-colored" rash. His physical exam is pertinent for severe tenderness at the right knee and hip joint with limited range of motion and an evanescent "salmon-colored patch" on the left knee. Lab results show an elevated ESR, CRP, and positive ANA. What is the most likely diagnosis? A. Serum sickness B. Septic arthritis C. Juvenile idiopathic arthritis (JIA) D. Rheumatoid arthritis E. Osteoarthritis
Correct Answer: C
A 5-year-old boy is brought to your office with several months of back pain. The pain is diffuse across his lower back, worsens with activity, and resolves with rest. The pain does not radiate down his legs. On physical examination, he has a lordotic posture, and there is no scoliosis, sacral hair, or skin abnormalities. His lower extremities are thin and weak. He uses the Gowers maneuver to rise from the floor. His patellar deep tendon reflexes are normal; on plantar stroking, his toes go downward. Of the following, the MOST likely diagnosis is A. Becker muscular dystrophy B. spinal muscular atrophy C. tethered spinal cord D. transverse myelitis E. vitamin B12 deficiency
Correct Answer: C
A 5-year-old girl is brought to your office with a complaint of sore throat, headache, and fever for the past 3 days. Her temperature is 39°C, and her examination is notable for pharyngeal erythema, palatal petechiae, and bilateral anterior cervical lymphadenopathy. You obtain a rapid antigen detection test for group A Streptococcus, which is positive. This is her third episode of streptococcal pharyngitis in the last 2 months. Of the following, the MOST appropriate treatment for this patient is A. amoxicillin for 5 days B. benzathine penicillin G for 2 days C. clindamycin for 10 days D. doxycycline for 10 days E. sulfamethoxazole/trimethoprim for 10 days
Correct Answer: B
A 5-year-old girl presents to your clinic for evaluation of fever for 7 days. She recently returned from Pakistan where she travelled with her parents to visit family. She did not receive pre-travel vaccinations. Vital signs show a temperature of 38.7°C, respiratory rate of 30 breaths/min, heart rate of 120 beats/min, and blood pressure of 105/65 mm Hg. On physical examination, she has abdominal tenderness and hepatosplenomegaly. Laboratory data are shown: Of the following, the test that is MOST likely to establish the diagnosis in this child is A. abdominal ultrasonography B. blood culture C. hepatitis panel D. urine culture E. viral nasal wash
Correct Answer: B
A 6-month-old infant is brought to your office for a health supervision visit. She was born at 28 weeks of gestation by emergent cesarean delivery after placental abruption. Her neonatal course was complicated with prolonged oral intubation, treatment for necrotizing enterocolitis, and sepsis. Since discharge from the neonatal intensive care unit at 2 months of age, she has been well with appropriate growth. She is developing appropriately for her corrected age. Her parents have questions about teething. Of the following, the MOST accurate statement is that this infant may have A. anodontia (absence of teeth) B. delayed dental eruption C. early dental eruption D. hypodontia (missing teeth) E. supernumerary (extra) teeth
Correct Answer: A
A 6-week-old female infant is brought to your office for concern for an eye infection. Her parents report that her left eye is "more watery" than the right. Her mother saw some golden-colored crust on her eyelashes this morning. Her eye has never appeared red, and the parents have seen only clear fluid from the eye. She is otherwise well, eating appropriately, and not excessively fussy. Of the following, the BEST next step in management for her condition is A. nasolacrimal duct massage B. referral to an ophthalmologist C. systemic antibiotics D. topical antibiotics E. warm compresses to the affected eye
Correct Answer: E
A 6-year-old boy seen in your office has had chronic nasal congestion and noisy breathing for several months. His parent reports mucoid rhinorrhea that is present every day and worsens intermittently. The boy often has difficulty breathing through his nose, especially when sleeping. Past trials of antihistamines or antibiotics have only provided temporary improvement in symptoms. He has no history of serious bacterial infections, pneumonia, or asthma. His growth and development have been appropriate for his age. He eats a regular diet and has normal stool and urine output. On examination of the nasal passages, you note glistening, bluish-gray, grape-like masses bilaterally. The remainder of the physical examination findings are unremarkable. The most common cause of this condition in children is BEST evaluated by performing Correct Answer: E A. an aspirin sensitivity challenge B. a complete blood cell count with differential C. a human immunodeficiency virus immunoassay D. an IgE level measurement E. a sweat test
A
A 6-year-old girl is brought to your office for evaluation because she has been scratching her bottom and experiencing painful urination for about 2 weeks. The girl has no history of fever, vomiting, abdominal pain, abnormal urinary frequency, or vaginal discharge. Her appetite is normal, and her urine and stool output are unchanged. She attends kindergarten and has remained playful. Her mother reports that the girl seems fidgety at night and has been tired during the day. The girl is well-developed and well-nourished. She has a few superficial abrasions on her buttocks near the gluteal cleft and anus, plus mild vulvar erythema. The remainder of the physical examination findings are normal. You ask the mother to collect specimens by touching the perianal skin with transparent adhesive tape and applying the tape to a glass slide. This collection should be performed for 3 consecutive mornings when the girl wakes up. At a follow-up appointment, you examine the specimen slide under a microscope (Item Q79 ). Of the following, the MOST accurate statement regarding the epidemiology of this condition is A.contact with contaminated toys, bedding, and toilet seats may lead to disease B.the incubation period from ingestion until perianal findings is 2 weeks C.it occurs more often in rural settings D.the prevalence is highest in children younger than 3 years E.transmission can occur to humans from infected cats or dogs
Correct Answer: E
A 6-year-old girl is brought to your office for evaluation of "swollen glands." For the past 2 days, she has had a low-grade fever, cough, and sore throat, and her activity level and appetite have decreased. The mother reports that, with several illnesses this year, the girl has had noticeable swelling of the glands in her neck. She was tested for strep throat several times, but the result was always negative. Each time, the swelling improved as the acute illness resolved. Her mother has a history of Hodgkin lymphoma, so she is worried that these recurring infections with lymphadenopathy may indicate something more serious. On physical examination, her vital signs are normal for age and her temperature is 37.5°C. Her tonsils are erythematous without exudate. Her bilateral jugulodigastric nodes are slightly tender to palpation and measure 1 cm in diameter. They are discrete and mobile, with no overlying erythema or warmth. The remainder of her examination is unremarkable, with no other significant lymphadenopathy or hepatosplenomegaly. You inform the mother that the girl's pattern of lymphadenopathy is not concerning and that lymphadenopathy in specific other locations would merit concern for malignancy. Of the following, the lymphadenopathy location you would find MOST concerning is A. posterior cervical B. preauricular C. submandibular D. submental E. supraclavicular
Correct Answer: C
A 6-year-old previously healthy, fully immunized boy is brought to your office by his mother. He has had a cough and runny nose for 1 week and developed fever yesterday. Today, the boy is complaining of neck pain, resists turning his head to the side, is refusing to eat, and will only take small sips of water. On physical examination, the boy is tired appearing with a temperature of 40.3°C, heart rate of 130 beats/min, respiratory rate of 45 breaths/min, and oxygen saturation of 98% by pulse oximetry. His lung fields are clear with good aeration. He has tender anterior cervical lymphadenopathy, torticollis, and his posterior oropharynx appears erythematous. The remainder of his physical examination is within normal limits. Of the following, the test MOST likely to confirm this boy's diagnosis is A. anteroposterior and lateral chest radiographs B. blood culture C. lateral neck radiograph D. lumbar puncture E. throat culture
Correct Answer: C
A 7-week-old infant was noted to have a short, soft 2/6 systolic murmur at the left upper sternal border at 2 weeks of age and comes today for a follow-up visit. His mother has noticed that he has been breathing rapidly for the last few days. The baby has been breastfeeding less than usual for the last 2 days, taking feedings every 3 hours, and only for 5 min. When you enter the examination room, you see an infant breathing at 90 breaths/min. The saturation is 68% in room air taken on the right hand. The baby becomes fussy when you do your examination, but the saturations are stable even with crying. The heart rate is 160 beats/min and the blood pressure is 80/60 mm Hg in the left leg. Physical examination shows the chest is clear, the respirations are shallow but there are no retractions, and there is a long 4/6 systolic murmur at the left upper sternal border that begins at S1 and is present for all of systole. You do not appreciate an ejection click or any split to S2. There is no hepatosplenomegaly and the femoral pulses are 2+ bilaterally. You start oxygen in the office and the saturation increases to 75%. You call emergency medical services and warn the emergency department that the baby is on the way. You speak to the cardiologist on call. Based on the clinical presentation and physical examination, the finding the echocardiogram is MOST likely to show is A.atrial septal defect B.coarctation of the aorta C.pulmonic stenosis D.tetralogy of Fallot E.ventricular septal defect
Correct Answer: E
A 7-year-old boy is seen for the first time in your office. He has just come from overseas to live with an aunt and uncle. On the flight, he became very dizzy and almost passed out. He has a history of a heart murmur as an infant and was thought to need surgery, but was not able to have that done. The murmur resolved by 4 years of age. He is not able to participate in gym class in his new school because he gets too short of breath. He is very drowsy in the morning. On physical examination, you note that he is cyanotic, but not in any acute distress. His weight is 19 kg (sixth percentile) and his height is 122 cm (50th percentile). His heart rate is 100 beats/min, his respiratory rate is 30 breaths/min, his blood pressure is 85/45 mm Hg, and his oxygen saturation is 78% on room air. His jugular veins are distended. His chest examination shows intercostal retractions. The breath sounds are clear. The cardiac examination is notable for a loud P2. There is a 3/6 systolic murmur at the right midclavicular line. The liver is 2 cm below the right costal margin. Screening laboratory test results are significant for a hemoglobin of 17 g/dL (170 g/L) and a hematocrit of 51%. Of the following, the MOST likely cause of the patient's symptoms and physical findings is A.aortic stenosis with a gradient of 60 mm Hg B.pulmonic stenosis with a gradient of 60 mm Hg C.tricuspid atresia with a large atrial septal defect D.ventricular septal defect with a gradient of 90 mm Hg and left to right shunt E.ventricular septal defect with no gradient across the defect
Correct Answer: E
A 7-year-old girl presents for evaluation of a 2-week history of worsening facial rash and skin ulcers. She has a purple, telangiectatic rash on her eyelids, with some extension to the cheeks and nasolabial folds bilaterally. There are flat-topped erythematous to violaceous papules on the extensor surfaces of the knuckles of both hands. There is a small ulceration of the superior portion of the right pinna, as well as lateral to the left eye and in the right axilla. Positive Gower's sign was present on exam. If her disease were left untreated, which of the following complications which you be most likely to see? A. Gastrointestinal vasculitis leading to ulceration and bleeding B. Antiphospholipid syndrome C. Respiratory failure D. Malignant transformation E. Calcinosis of the skin
Correct Answer: D
A 9-month-old male infant is brought to your office by his parents for a new patient health supervision visit. The infant was diagnosed with bilateral sensorineural hearing loss shortly after birth and now uses hearing aids. His parents have questions about cochlear implants and whether their son would be a good candidate. Of the following, the MOST accurate statement in response to the parents' questions about their son is that A. this device will preserve his natural hearing, if any B. even with good improvement in hearing and speech development with hearing aids, he would be a good candidate for this device C. hearing assessment in infants is accurate and reliable, making the decision regarding the use of this device a straightforward one in this case D. his social and educational outcomes would be optimized by implanting this device as early as possible E. sound quality heard via this device is similar to that heard by people with normal hearing
Correct Answer: E
A 9-year-old boy is brought to your office for "a pimple on his left eyelid." His mother reports that the lesion has been present for the past 4 weeks. The area has increased in size slightly over the past 4 weeks and is not tender. On physical examination, you find a 5 mm, painless, rubbery lesion located on the left lower eyelid. There is no erythema of the eyelid (Item Q61). Of the following, the BEST approach for initial management of this patient is A. incision and drainage B. referral to an ophthalmologist C. treatment with an oral cephalexin D. treatment with a topical erythromycin E. warm compresses 4 times a day
Correct Answer: D
A full term female newborn weighing 3,900 g is in the well-baby nursery and breastfed well on day 1 of life. You are performing the discharge physical on day 2 after birth, but the routine pulse oximetry screening has a saturation reading of 91%. The baby has a heart rate of 120 beats/min, respiratory rate of 40 breaths/min, and blood pressure is 65/45 mm Hg taken in the right leg. The baby is awake, alert, and fussy. The chest examination is unremarkable. The cardiac examination shows a single S2 and a 2/6 systolic murmur at the right upper sternal border. There is no hepatosplenomegaly. The femoral pulses are easily palpable but diminished. You are awaiting a call back from the neonatologist. Of the following, the MOST appropriate next step in management is to A.follow serial 4 extremity blood pressures and allow normal feedings B.give fluid bolus of 20 mL/kg of normal saline C.provide 100% O2 by facemask for 24 hours D.start low dose prostaglandin at 0.01 µg/kg per min E.stop feedings and start dopamine at 5 µg/kg per min
D
A full-term female neonate weighing 3,700 g is born to a 32-year-old woman with hepatitis C virus infection. The mother was diagnosed during this pregnancy and has not received antiviral therapy. Her human immunodeficiency virus test results are negative. Her husband's test results for hepatitis C virus infection are negative. She has never used intravenous drugs. As a child, she received a blood transfusion after sustaining an injury during a motor vehicle collision. She inquires about the long-term prognosis if the baby were to acquire hepatitis C virus infection from her. Of the following, you are MOST inclined to inform the mother that A.decompensated cirrhosis in adulthood is likely B.hepatocellular carcinoma without cirrhosis is likely C.rapidly progressive fibrosis in adulthood is likely D.slowly progressive fibrosis in childhood is likely E.spontaneous clearance of the virus in infancy is likely
Correct Answer: E
A previously healthy 4-year-old boy was brought to your office for evaluation of fever, irritability, and poor oral intake for 3 days. Today, he began drooling and his mother noticed sores in his mouth (Item Q195). In the office, his temperature is 40°C, heart rate is 112 beats/min, and respiratory rate is 24 breaths/min. He is ill appearing and irritable, but consolable. Physical examination reveals numerous vesicles with red halos on the buccal mucosa. The gingiva is intensely erythematous and edematous. He appears mildly dehydrated. The remainder of his examination is unremarkable. Of the following, the MOST likely diagnosis is A. acute necrotizing gingivitis B. aphthous ulcerations C. hand-foot-mouth disease D. herpangina E. primary herpetic gingivostomatitis
Correct Answer: A
A previously healthy 5-year-old boy is brought to your office for evaluation of fever and sore throat that began yesterday. In addition, he has mild cough and nasal congestion with minimal rhinorrhea. His oral intake is decreased, and he reports mild abdominal pain. He has a temperature of 39°C, heart rate of 100 beats/min, and respiratory rate of 24 breaths/min. He appears mildly ill. He has pharyngeal erythema, exudate on the tonsils, moderate palpebral conjunctivitis without discharge, and shotty, nontender, preauricular, and anterior cervical lymphadenopathy. The result of a rapid antigen detection test for group A Streptococcus is negative. Of the following, the MOST likely etiology is A. adenovirus B. coxsackievirus C. echovirus D. Epstein-Barr virus E. parainfluenza virus
Correct Answer: A
A previously healthy 8-year-old girl presents to the emergency department with an unprovoked generalized tonic-clonic seizure lasting 20 minutes. She has never had a seizure or head injury before and there is no family history of seizures. Her physical examination shows a mildly sleepy girl, with no other neurological abnormalities. Electrolytes, glucose, and a complete blood cell count are normal. Magnetic resonance imaging of the head is also normal. She is admitted for observation and the next day has an electroencephalogram that is normal. You are planning to discharge her home. Of the following, the BEST statement about her seizure recurrence risk is it A. is 25% to 45% B. is greater than 45% because she had a prolonged seizure C. is greater than 45% because she is prepubertal D. will stay the same over the next 2 years, then decrease E. will stay the same over the next 14 years, then decrease
Correct Answer: A
A term neonate is born to a previously healthy mother. The child is noted to have an annular facial rash with central clearing. A tissue infarction of the right pinna of the ear is noted on exam. The child has a platelet count of 100, AST of 300, a LT of 300, and decreased C4. An ANA is positive. The patient's serial CBC and PERRL calcitonin are reassuring, and blood and urine cultures are pending. What additional study should to water? A. nEKG B. aEEG C. Echocardiogram D. Head ultrasound E. MRI of the brain
Correct Answer: B
An 11-month-old male infant presents to the emergency department in March with a 2-day history of high fevers and worsening rhinorrhea, cough, vomiting, and diarrhea. He has no significant past medical history and his birth history is unremarkable. Physical examination shows an ill-appearing infant with a temperature of 39°C, respiratory rate of 45 breaths/min, heart rate of 120 beats/min, blood pressure of 90/45 mm Hg, and O2 saturation of 93% on room air. Physical examination is notable for a bulging, erythematous, nonmobile, left tympanic membrane, mild respiratory distress, clear rhinorrhea, and frequent dry cough. Auscultation of the lungs reveals diffuse wheezing with rhonchi and retractions. Laboratory data are shown: The infant's chest radiographs are shown in Item Q5A and Item Q5B. Of the following, the MOST likely cause of his illness is A. Bordetella pertussis B. human metapneumovirus C. Mycoplasma pneumoniae D. parainfluenza virus E. Streptococcus pneumoniae
Correct Answer: B
An 11-year-old girl faints as she walks off the soccer field at sleep away camp. The temperature at camp has been 95°F (35°C) all day and she has been outside and active. Emergency medical services (EMS) was called and she was taken to the small emergency department near the camp. By history, she was unresponsive on arrival with a heart rate of 190 beats/min, blood pressure of 65/45 mm Hg, and respiratory rate was 15 breaths/min. While she was being evaluated, she regained consciousness, her heart rate dropped to 90 beats/min, and her blood pressure normalized to 105/70 mm Hg. She was observed for several hours and discharged home. She comes to see you in the office next week. The family has requested a copy of the EMS rhythm strip, but does not have it with them. She is feeling well today and has an unremarkable physical examination. She is anxious to get back to playing competitive soccer. The patient faints again in your office and you call 911. You obtain an electrocardiogram in the office (Item Q152). Of the following, the BEST next step is A.adenosine, 200 µg/kg intravenously B.cardioversion with 0.5 to 1.0 J/kg with increase to 2 J/kg if unsuccessful. C.digoxin, 5 µg/kg slow intravenously D.normal saline, 20 mL/kg intravenously E.propranolol, 40 mg orally
Correct Answer: E
An 11-year-old girl presents 2 weeks after an office visit for a presumed viral illness characterized by fever, malaise, and flushing of the cheeks. Today, her mother notes that she no longer has a fever, but she complains of pain in her knees and elbows. On physical examination, the left knee is slightly swollen and warm but not erythematous. The girl reports pain on movement of both elbows, but there are no physical findings on examination of the elbows or other joints. The remainder of the physical examination findings are normal, except for an oral temperature of 100.6°F (38.1°C). Results of laboratory studies include a white blood cell count of 8.9x103/mcL (8.9x109/L) with 40% polymorphonuclear leukocytes, 45% lymphocytes, and 15% monocytes; hemoglobin of 11.0 g/dL (110.0 g/L); platelet count of 472.0x103/mcL (472.0x109/L); and erythrocyte sedimentation rate of 20 mm/hr. Of the following, the MOST likely pathogen to cause this child's joint complaints is A. Borrelia burgdorferi B. Coxsackievirus C. group A beta-hemolytic streptococci D. influenza A virus E. parvovirus B19
Correct Answer: A
An 18-year-old pregnant girl presents to your clinic with complaints of discomfort in her knees and hands. She denies any swelling or erythema of these areas or recent trauma. She takes no regular medications, and she has been healthy until 6 days ago, when she developed these complaints. She did receive a rubella vaccination about 1 month ago because on her first visit to an obstetrician she was found to have a negative serum titer to rubella. Her physical examination findings are normal. Of the following, the MOST likely diagnosis is A. adverse effect of the rubella vaccine B. anicteric hepatitis B infection C. poststreptococcal arthritis D. reactive arthritis due to Salmonella sp E. recent infection with parvovirus
Correct answer: B
An 18-year-old young woman presents to your office with a 4-day history of left ear pain and swelling. She reports no recent trauma or insect bites to the ear, but did have a new piercing along the upper pinna about 1 week ago. Her past medical history is significant only for seasonal allergies. Physical examination shows an uncomfortable young woman complaining of 8 out of 10 pain in her left ear and left lateral neck. Vital signs show a temperature of 37°C, respiratory rate of 18 breaths/min, heart rate of 95 beats/min, and blood pressure of 125/65 mm Hg. Her left ear is impressively swollen, hot, erythematous, and tender along the helix; there is fluctuance with an earring embedded in the swelling. Left postauricular swelling is also seen. There is no lymphadenopathy and she has full range of motion in her neck. The left tympanic membrane and external auditory canal appeared normal. Laboratory data are shown: When the earring is removed, about 3 mL of pus is expressed. The pus is sent for culture and Gram stain (Item Q25). Of the following, the BEST choice for initial therapy is A. ceftriaxone B. ciprofloxacin C. mupirocin D. trimethoprim-sulfamethoxazole E. vancomycin
Correct Answer: C
An 8-year-old boy with a known history of myopia was recently diagnosed with upward dislocation of the lens. He has a tall stature, long arms, pectus excavatum, arachnodactyly, flat feet, and reduced elbow extension. His face is long and narrow with deep-set eyes and a receding chin (Item Q40 ). His mother has a similar appearance and body habitus, as well as a history of mitral valve prolapse and myopia. The maternal grandfather died in his 50s of a sudden cardiac death. Of the following, the boy's MOST likely diagnosis is A. Ehlers Danlos syndrome B. Loeys Dietz syndrome C. Marfan syndrome D. Sotos syndrome
Correct Answer: D
An 8-year-old male with no significant past medical history is being seen in urgent care for pain in the right hip with any range of motion that started 2 days ago that is worsening in nature. Mother mentions he recently had some common cold symptoms. Denies any recent trauma to the leg or injury. Child describes pain intensity to be 7 out of 10. Vital signs are temperature 99.9 F, heart rate 98 bpm, respiratory rate 25. What is the most likely diagnosis? A. Septic arthritis B. Osteomyelitis of the hip joint C. Juvenile idiopathic arthritis D. Toxic synovitis E. Myositis
Correct Answer: B
The mother of a previously healthy 2-year-old boy has brought him T every for a well-child check. She points out that she has recently noticed something wrong with his left leg. Upon examination, there is a region of moderate subcutaneous atrial feed of the lateral side of the left thigh. It appears as if the underlying adipose tissue had been "scooped out", so much so that it is easy to see the muscle fibers under the skin in the "scooped out" region. The overlying skin is without erythema or swelling. A slight amount of hyperpigmentation is present at the site of the lesion. He is developmentally appropriate for age. What is the diagnosis? A. Lichen sclerosis et atrophicus B. Localized scleroderma C. Morphea-like lesions of phenylketoneuria D. Lipohypertrophy E. Lupus panniculitis
Correct Answer: C
You work as a voluntary attending pediatrician in the resident continuity clinic at your local hospital. You are precepting a resident, who tells you that she has just evaluated a 16-yearold varsity volleyball player. The girl's height is 71 inches, weight is 125 lb, and blood pressure is 115/74 mm Hg. The resident is concerned about scoliosis and a 3/6 holosystolic murmur heard at the cardiac apex with radiation to the left axilla (Item Q229). Of the following, the MOST likely diagnosis for this patient is A. Ehlers—Danlos syndrome B. infective endocarditis C. Marfan syndrome D. rheumatic heart disease E. Williams syndrome
Correct Answer: D
You are called to the nursery to see a male neonate born at 38 weeks of gestation to a 24- year-old gravida 1 para 0 woman who received routine prenatal care. Ultrasonography performed at 30 weeks of gestation because of poor fetal growth revealed hyperechogenic bowel and periventricular intracranial calcifications. At delivery, the small-for-gestational age neonate was noted to have a diffuse petechial rash and hepatosplenomegaly. Of the following, the condition MOST commonly associated with this neonate's condition is A. cerebral palsy B. learning disability C. seizures D. sensorineural hearing loss E. vision impairment
Correct Answer: C
You are caring for a 2-day-old male neonate in the newborn nursery who was born at term after an uncomplicated pregnancy. His delivery and neonatal course have been similarly uncomplicated. He recently underwent an auditory brainstem response hearing screening as part of the nursery's standard protocol, and he did not pass the screening test of his left ear. Of the following, the MOST appropriate plan for this neonate is to A. follow up with his primary care provider and retest his hearing only if he develops signs of hearing loss B. refer for formal audiologic evaluation only if he has a family history of hearing loss C. refer for formal audiologic evaluation to be completed before 3 months of age D. refer for formal audiologic evaluation to be completed between 24 and 36 months of age E. refer to audiology to be fitted for an age-appropriate hearing aid or assistive device
E
You are discussing the human papillomavirus (HPV) vaccine with a resident who is rotating in your office. Of the following, the statement that you are MOST likely to include in your discussion is A.for children 9 to 14 years of age, a 3-dose schedule is recommended B.girls who receive the vaccine are more likely than those who do not to be sexually active and to have an increased number of sexual partners C.more than 75% of girls and 50% of boys receive 3 or more doses of the HPV vaccine D.the vaccine is associated with an increased risk of developing central nervous system demyelinating disease E.the vaccine provides protection against noncervical HPV-associated cancers
A
You are evaluating a 10-day-old term newborn who is in the emergency department because of decreased activity, poor feeding, and respiratory distress. The baby was born by normal spontaneous vaginal delivery with no pregnancy or delivery complications. Maternal history is negative for premature or prolonged rupture of membranes, group B Streptococcus colonization, genital herpes, hepatitis B surface antigen, human immunodeficiency virus, and rapid plasma reagin. The newborn is critically ill and has a temperature of 35.3°C. He is in respiratory failure and shock. Skin examination findings are normal. Laboratory data are significant for leukopenia, thrombocytopenia, disseminated intravascular coagulation, and severe hepatitis. A chest radiograph shows bilateral pulmonary infiltrates. Blood and urine cultures were obtained, but the newborn is not stable enough for lumbar puncture. Of the following, the BEST initial antimicrobial treatment is ampicillin, cefotaxime, and A.acyclovir B.amphotericin B C.oseltamivir D.trimethoprim-sulfamethoxazole E.vancomycin
Correct Answer: C
You are evaluating a 10-year old African-American child with chronic joint pain, skin nodules, bilateral eye pain with redness, and chronic intermittent cough. The child's parents deny any recent travel, recent illnesses or exposure to any family or friends with illnesses. Physical exam is significant for lymph-node enlargement and skin rash which appears to be erythema nodosum. Chest x-ray shows bilateral hilar lymphadenopathy. What is the most likely diagnosis for this patient? A. Histoplasmosis B. Tuberculosis C. Sarcoidosis D. Pneumoconiosis E. Drug induced hypersensitivity syndrome
Correct Answer: A
You are reviewing the list of infants to be screened by the pediatric ophthalmologist for retinopathy of prematurity (ROP). It includes an infant born at 34 weeks of gestation that is now 4 weeks of age. He was born to a 32-year-old woman with a history of substance abuse who presented with placental abruption. He weighed 1.6 kg at birth, required surfactant administration for respiratory distress syndrome, and remained intubated for the first 3 weeks of life. He received antibiotics until blood cultures were negative for 72 hours and a red blood cell transfusion. A nurse in your neonatal intensive care unit questions his inclusion for screening. Of the following, the clinical factor that MOST qualifies this infant for ROP screening is A. duration of intubation B. gestational age C. maternal history of substance abuse D. placental abruption E. red blood cell transfusion
Correct Answer: E
You are reviewing the medical records of a patient who is entering your practice. This 2-week-old male newborn was born at term to a 20-year-old, gravida 1 para 1 mother who did not receive prenatal care. At delivery, the baby was found to have micrognathia, glossoptosis, and a cleft palate consistent with Pierre Robin sequence. He was cared for in the neonatal intensive care unit, and at the time of discharge he was being fed breast milk through a nasogastric tube. Notes report that he is able to breathe comfortably and maintain adequate oxygen saturation when he is positioned prone or on his side. Genetics consultation and testing during his hospital stay confirm Stickler syndrome. Of the following, the condition MOST commonly associated with this syndrome, other than those conditions already noted, is A. autism spectrum disorder B. cardiac anomaly C. intestinal malrotation D. renal anomaly E. vision impairment
Correct Answer: B
You are seeing a 16-year-old adolescent boy with obstructive sleep apnea and a history of recurrent sinusitis in your office. On physical examination, you note that he has a bifid uvula. You refer him to an otolaryngologist for adenoidectomy and counsel the parents about his risk of postoperative complications. Of the following, based on physical examination findings, this patient postoperatively is at INCREASED risk of A. bleeding B. hypernasal voice C. nasopharyngeal stenosis D. surgical site infection E. torticollis
Correct Answer: D
You are seeing a 4-year-old boy for recurrent purulent otorrhea. He had frequent episodes of acute otitis media as an infant and had myringotomy tubes placed at age 2 years, after which he had only occasional ear infections. Since an episode of acute otitis media 3 months ago, he has had frequent recurrences of purulent ear drainage from his left ear, which improved when treated with topical fluoroquinolone/glucocorticoid drops. The boy has been otherwise well. His left ear currently has purulent drainage obscuring the tympanic membrane. The remainder of his physical examination findings are normal. Screening shows a mild decrease in hearing in the left ear, with normal hearing in the right ear. Of the following, the MOST appropriate next step in management for this boy is A. avoidance of water in the ears and reevaluation in 2 weeks B. treatment with oral amoxicillin and topical bacitracin-polymyxinhydrocortisone drops C. referral to an allergy/immunology specialist for evaluation D. referral to an otolaryngology specialist for evaluation E. repeat administration of topical fluoroquinolone/glucocorticoid drop
Correct Answer: D
You are seeing a 7-year-old girl in your office who is brought in for "pink eye." She has had a fever for 2 days, with temperatures of up to 38.8°C, cloudy rhinorrhea, mild cough, and headache. Today she developed left eye redness with watery drainage. She denies any trauma to her eye. On physical examination, you find a mildly ill appearing, febrile child. She has pharyngeal redness with scant exudates, a palpable left preauricular lymph node, and edematous nasal mucosa. Her left eye conjunctiva is hyperemic and there is profuse tearing. On close inspection, tiny follicles are present on the inner lower lid. No foreign body is seen. The remainder of the examination findings are within normal parameters. Of the following, the MOST appropriate treatment for this child is A. ciprofloxacin drops to the eye B. intravenous immunoglobulin C. oral prednisone D. symptomatic treatment E. trifluridine drops to the eye
Correct Answer: D
You are seeing an 11-year-old girl in your office for a health supervision visit. She reports daily headaches that started 2 months ago. The headaches are described as pounding, with nausea and vomiting, but no phonophobia or photophobia. The pain worsens when she leans over to put on her shoes and socks. Occasionally, her vision will turn gray for a few seconds. When her headache is severe, the girl develops double vision. She does not take any medications or supplements. She reports that her weight has increased by more than 20 lbs since her visit 1 year ago. On physical examination, the girl's blood pressure is 102/78 mm Hg and her heart rate is 92 beats/min. Her body mass index is at the 96th percentile. Her neurologic examination shows an inability to abduct her right eye. Of the following, the MOST likely additional finding on this girl's physical examination would be A. cataracts B. nystagmus C. orbital bruit D. papilledema E. ptosis and pupillary miosis
