Boards

A. Only anaerobe

A 12-year-old girl is being evaluated for tooth pain that started a few days ago, but worsened yesterday. She has left upper molar pain with localized gingival swelling; the pain is making it difficult to eat. Her vital signs include a temperature of 38.3°C, a heart rate of 105 beats/min, and a respiratory rate of 17 breaths/min. Her mouth has an area of redness, swelling, and fluctuance along the maxillary left molar, which is tender to the touch. Of the following, the MOST likely cause of this infection is A.Actinomyces israeliiB.Pseudomonas aeruginosaC.Staphylococcus aureusD.Streptococcus pyogenes

D. hypopit b/c has low glucose, but underdeveloped sex stuff as well

A 1-day-old neonate is admitted to the neonatal intensive care unit for persistent hypoglycemia. He was born at 40 weeks' gestation by cesarean delivery because of failure of labor progression. The pregnancy was otherwise uncomplicated. His birth weight was 3400 g. Jitteriness noted at 8 hours after birth prompted measurement of a plasma glucose level, which was 28 mg/dL (1.6 mmol/L). Despite treatment with oral feedings of standard infant formula, the neonate was unable to maintain a plasma glucose level above 50 mg/dL (2.8 mmol/L). He is requiring a glucose infusion rate of 8 mg/kg/min to maintain normal glucose levels. He is afebrile and has normal vital signs for age. Physical examination findings are normal except for the genital examination. His right testicle is not palpable, and his left testicle is palpable high in the scrotum. The stretched phallic length is 1.6 cm. Of the following, the MOST likely etiology of this neonate's hypoglycemia is A.a fatty acid oxidation disorderB.a glycogen storage diseaseC.hyperinsulinismD.hypopituitarism

D. This patient has chronic bronchitis

A 10-year-old girl has had a chronic wet cough, present day and night, for 6 months. She has no identified triggers. It is not exacerbated by exercise and does not limit her in any way. There is no seasonal pattern and no tobacco smoke or other irritant exposure. There is a pet dog in the home. Review of systems finds nasal congestion without rhinorrhea. The family history is negative for asthma, allergies, and immunodeficiency. Physical examination shows mildly edematous nasal mucosa without discharge. The oropharynx and chest wall anatomy are normal. Breath sounds are somewhat coarse with a few scattered rhonchi and no fine rales or wheezes. Spirometry findings are normal. Chest radiography demonstrates a mild increase in central peribronchial markings with no other abnormalities. Of the following, the BEST next management step for this patient is A.computed tomography of the chestB.measurement of quantitative immunoglobulin levelsC.removal of the dog from the homeD.3-week course of amoxicillin/clavulanic acid

Ampicillin (gram + rods=Listeria)

A 12-day-old infant is seen in the emergency department for evaluation of fever. Yesterday she was noted to be fussy and today, she has a temperature of 39°C and is difficult to console. She has no other symptoms. She was born at term via vaginal delivery to a 34-year-old woman who had an uncomplicated pregnancy. Her vital signs include a temperature of 38.6°C, heart rate of 180 beats/min, respiratory rate of 50 breaths/min, and blood pressure of 82/45 mm Hg. On physical examination, she is irritable and her anterior fontanelle is full. Blood, urine, and cerebrospinal fluid specimens are collected for microbiologic evaluation. Gram stain of her cerebrospinal fluid is shown in Item Q89. Of the following, the BEST treatment for this infection is A.ampicillinB.azithromycinC.ceftazidimeD.vancomycin

C. Referral to PT. He does not meet Ottawa rules for x-ray (he's tender, but can ambulate) and he does not indicate a massive ligament injury that would warrant an MRI

A 14-year-old basketball player is being evaluated for a recurrent left ankle injury. Several days ago he sustained his third inversion injury to this ankle over the past several months. These injuries result in mild swelling over the lateral ankle for several days, which he treats with a compression wrap, ice, and several doses of ibuprofen. He was able to return to full basketball participation within 7 to 10 days after each injury. However, with the current injury, the ankle feels unstable and he tapes it before practice. The patient is otherwise healthy. On physical examination, the adolescent's left ankle is slightly swollen and minimally tender inferior to the lateral malleolus. He has full and pain-free strength and range of motion in both ankles. There is increased laxity with anterior drawer testing on the left compared with the right. His gait is normal and he moves comfortably throughout the evaluation. The adolescent has some difficulty with single leg hop and balance testing on the left leg compared with the right. Of the following, the BEST next step in management for this patient is A.anteroposterior and lateral ankle radiographyB.magnetic resonance imaging of the left ankleC.referral to a physical therapistD.use of an ankle-stabilizing brace

biopsy- need to see non-caseating granulomas on the biopsy

A 15-year-old adolescent girl is evaluated in the office for a 2-month history of chronic nonproductive cough associated with fatigue, 5- to 10-lb weight loss, low-grade fever, and mildly painful nodules on her arms and legs. She has not traveled out of the state or had any known sick exposures. On pulse oximetry, her oxygen saturation is 98% on room air. On physical examination, the girl has no respiratory distress, and no crackles or wheezes are heard. She has several 1- to 3-cm diameter, tender, nonerythematous, nonexcoriated nodules on the extensor surfaces of both arms and legs. Chest radiography suggests hilar adenopathy. Computed tomography additionally demonstrates interstitial changes in the pulmonary parenchyma. Pulmonary function testing shows a mild restrictive pattern with a decrease in forced vital capacity and total lung capacity. Carbon monoxide diffusion is slightly decreased for age and hemoglobin concentration. A tuberculin skin test has a negative result 60 hours after placement. Of the following, the BEST next step in the evaluation of this adolescent is A.biopsy of a skin nodule B.bronchoscopy and bronchoalveolar lavageC.repeat spirometry after administration of albuterolD.6-minute walk test

Linear Scleroderma (LS lesions have a red border and a white "waxy" center.)

A 15-year-old adolescent girl is seen for evaluation of hair loss. She first noted hair loss several months ago. At that time, the area was slightly itchy, tender, and pink. She has no significant past medical or family history and has no other signs or symptoms. She is afebrile with age-appropriate vital signs. Her scalp is shown (Item Q40). The remainder of her physical examination findings are normal, including full range of motion of all of her joints with no evidence of effusion and no other skin lesions. Of the following, the MOST likely diagnosis is

A. CT scan with IV contrast is the best. US is of limited use in stable patients bc if is how's fluid you need to investigate it further with CT

A 15-year-old, previously healthy adolescent is brought to the emergency department directly from football practice; he complained of left upper quadrant abdominal pain after being tackled. There was no loss of consciousness; he does not have a headache and has not vomited. He has left shoulder pain that is worse with inspiration. Vital signs include a temperature of 37.2°C, heart rate of 100 beats/min, respiratory rate of 20 breaths/min, blood pressure of 106/65 mm Hg, and room air oxygen saturation on pulse oximetry of 100%. He appears to be in pain but is alert and oriented. His examination findings are significant for left upper quadrant tenderness and slight abdominal distention. His skin is warm and well-perfused; he has good range of motion of all extremities. Two large-bore intravenous lines are placed, and a chest radiograph has normal findings. Of the following, the BEST abdominal imaging modality to confirm the diagnosis is A.computed tomographyB.magnetic resonance imagingC.radiography D.ultrasonography

A. Aspergillus ( would be sicker with PJP, would have ground glass opacities)

A 16-year-old adolescent boy diagnosed with acute myeloid leukemia 8 weeks ago has remained hospitalized for fever and neutropenia since his last chemotherapy course. He has had persistent fever and neutropenia for the last 5 days despite treatment with broad-spectrum antibiotics, including vancomycin and ceftazidime. He is febrile and has a heart rate of 110 beats/min, a respiratory rate of 24 breaths/min, a blood pressure of 110/86 mm Hg, and an oxygen saturation of 92% on room air. He has decreased breath sounds and dullness to percussion at the right lower lung field and in the right axillary area. Laboratory findings are notable for an absolute neutrophil count of 200/µL (0.2 × 109/L), anemia, and thrombocytopenia. Blood culture results have remained negative. Chest radiography and computed tomography with contrast (Item Q55) show diffuse nodular densities of various sizes in both lung fields. Of the following, the organism MOST likely responsible for the patient's findings is A.AspergillusB.mycoplasmaC.Pneumocystis jiroveciiD.Staphylococcus aureus

C. A. including nausea, vomiting, diaphoresis, and lethargy. Liver function abnormalities peak between 72 and 96 hours after ingestion and may be accompanied by hepatic encephalopathy B. ncluding agitation, tachycardia, hypertension, elevated temperature, dry and flushed skin, and decreased pupillary responsiveness D. N/V

A 16-year-old adolescent is brought to the emergency department by ambulance after he was found wandering outside at 2 am. He is accompanied by a friend who reports that the patient ingested an over-the-counter cough and cold medication that night in order to get high. The patient is uncooperative and agitated. He is not oriented to place or situation. He has a heart rate of 140 beats/min, blood pressure of 125/90 mm Hg, respiratory rate of 12 breaths/min, and oxygen saturation of 100% in room air. He is diaphoretic, and his pupils are dilated. Of the following, the ingredient that is MOST likely responsible for the adolescent's signs and symptoms is A.acetaminophenB.chlorpheniramineC.dextromethorphanD.guaifenesin

D. Mode of delivery, the idea being that the baby takes on some water weight from Mom getting IV fluids during c-section. In this case the baby has lost weight, but not more than 10% so no need to supplement

A 24-hour-old term neonate is being evaluated. He was born at 38 weeks' gestation by cesarean delivery after failed induction for maternal preeclampsia; his birthweight was 3.6 kg. Since birth, he has breastfed 8 times. His nurse reports a good latch. He has had 1 meconium stool and 2 wet diapers. His weight is 3.2 kg and his physical examination findings are unremarkable. Of the following, the clinical information that SUPPORTS the decision not to supplement with formula is A.the neonate's sexB.gestational ageC.history of maternal preeclampsiaD.mode of delivery

C. Sudden onset syncopal episodes always need further evaluation (unlikely that dehydration and hypoglycemia will lead to a sudden syncopal episode)

A 16-year-old adolescent is having a sports preparticipation physical examination 1 week before the start of the cross country running season. Based on her responses on the required history and physical examination form (Item Q69), additional information is obtained about a syncopal event that occurred while she was running in the first meet of her cross country season last year. She recovered immediately, and finished the remainder of her season without incident. The girl and her mother attribute this episode to dehydration and low blood sugar, though no medical evaluation was performed. Her medical history is significant for anxiety; the mother reports that her daughter gets very nervous before her track meets. On physical examination, the girl's lungs are clear to auscultation, cardiac findings are normal, and pulses are symmetrically present in all extremities. The remainder of her physical examination findings are within normal limits. Of the following, the BEST next management step for this girl is to A.provide clearance for full participation and counseling on pre-exercise nutrition and hydrationB.provide provisional clearance with the girl's commitment to pursue cognitive behavioral therapy C.withhold clearance for all sports participation pending cardiac evaluationD.withhold clearance pending results of fasting blood glucose level, electrolyte levels, and complete blood cell count

D. The reasoning being is she received cranial radiation which hits the thyroid

A 17-year-old adolescent girl is seen for a health supervision visit. Her medical history is significant for a diagnosis of acute T-lymphoblastic leukemia at 12 years of age. She was treated with chemotherapy and 1,800-cGy cranial irradiation. She completed all treatment 2 years ago and remains in complete remission. The importance of healthy eating, particularly given the treatment she received, is discussed. Of the following, the BEST description of how she compares with her peers is that she has A.a higher basal metabolic rateB.a higher protein intake requirementC.an increased risk of experiencing anorexia nervosaD.an increased risk of experiencing metabolic syndrome

A. provides the most support and therapy (Mom), B. doesn't help, C. She might not follow through, and D. its too far out

A 17-year-old patient is seen for a health supervision visit. The patient seems withdrawn during the visit and does not contribute much to the conversation. During the confidential psychosocial interview, the patient discloses that 6 weeks ago she went to a party during a freshman orientation program and was given some punch that she thinks was altered. She knows that she was sexually assaulted but cannot recall what happened or who harmed her. She has not disclosed this information to anyone and fears having to go back to campus. She declines to contact the school and let them know what has occurred. She reports no abdominal pain, vaginal discharge, or dysuria. Her last menstrual period was 1 week ago. The pediatrician explains that the patient will be screened for sexually transmitted infections and that as a mandated reporter, the physician is required to file a report. The pediatrician also shares concerns about the patient's mental health after this traumatic event. Of the following, the BEST next step in management is to A.encourage the patient to discuss the incident with her mother and recommend therapy to address the traumatic eventB.encourage the patient to report the incident to officials at the college and recommend that she not attend the college where the traumatic event occurredC.provide the patient with resources if she decides she wants to go to therapy before she starts college in the fallD.recommend that the patient undergo a sexual assault medical examination to collect evidence in case she decides she wants to report the incident to law enforcement in the future

C. Has laryngomalacia --> resolves when supine, usually better by 18-24 months

A 2-month-old male infant is seen for a health supervision visit. His mother reports that he has noisy breathing, particularly when he is sleeping at night. He is breastfed and nurses well; he has only occasional regurgitations after feeding. On physical examination, his room air oxygen saturation is 100%, weight is at the 60th percentile, and length is at the 80th percentile. The infant breathes quietly at rest, but has inspiratory stridor when he is agitated or crying, which resolves when he calms. When placed supine on the examination table, he has intermittent stridor associated with intercostal retractions. When placed prone, the stridor resolves. Of the following, the BEST next management step for this infant is A.change from breast milk to an elemental formulaB.immediate referral to an otolaryngologist for evaluationC.reassurance that symptoms will resolve by age 18 to 24 monthsD.use of a home apnea monitor for 6 months

D. As her current formula provides excess nutrients she needs A- zinc deficiency, but normal formula has enough B- Just no C- Not enough vitamin A to cause this

A 2-week-old female infant is seen during rounds in the neonatal intensive care unit. The infant was delivered at 32 weeks' gestation because of maternal preeclampsia; she was small for gestational age with a birthweight of 1,200 g. Her neonatal course was complicated by mild respiratory distress requiring nasal continuous positive airway pressure for the first 4 days after birth and unconjugated hyperbilirubinemia for which she received 3 days of phototherapy in the first week after birth. She tolerated enteral feeding well, and was receiving fortified breast milk. However, her mother's milk supply has decreased and the infant was recently switched to a cow milk-based premature formula. She is growing well and takes a combination of oral and nasogastric feedings without difficulty. Her parents ask about using a cow milk-based formula designed for term infants. Of the following, the condition this neonate would be MOST at risk for, with the use of this suggested formula, is A.acrodermatitis enteropathicaB.cow milk protein allergyC.hypervitaminosis AD.osteopenia of prematurity

B. Kidney stones, other risks include Gi upset vs. constipation She is at risk for carnitine and zinc, but long term Acutely at risk of osteopenia, but treated in this case with Vitamin D

A 2-year-old girl with mild global developmental delay and refractory epilepsy is placed on a ketogenic diet for management of her seizures. She experiences improved seizure control and is followed closely by a pediatric epileptologist and dietician. Her mother brings her for her health supervision visit and states that overall the girl is tolerating the diet well with mild constipation and is taking her multivitamin with calcium and vitamin D supplements daily. Her mother states that she understands that the diet can have other side effects and asks if the girl should be monitored for additional complications. Of the following, the girl is MOST at risk for A.carnitine deficiencyB.kidney stonesC.osteopeniaD.zinc deficiency

Autonomy

Disclosure, or communication of a medical error from the physician to the patient, is grounded in the ethical principle of

testes Breast

First sign of puberty in a boy? First sign in a girl?

Hirschsprung disease

A 25-hour-old neonate with abdominal distention is being evaluated. His 34-year-old mother has gestational diabetes controlled by diet; her hemoglobin A1c level is 6.6%. Echogenic bowel was noted on prenatal ultrasonography. He was delivered vaginally with an Apgar score of 9 at 1 and 5 minutes. He has breastfed 6 times with a good latch. He has not yet had a bowel movement. On physical examination, the neonate appears comfortable. He has a prominent white forelock, barrel-shaped chest, moderate abdominal distention, and decreased bowel sounds (Item Q114A). Abdominal radiography is performed (Item Q114B). Of the following, the MOST likely diagnosis for this neonate is A.Hirschsprung diseaseB.inadequate oral intakeC.necrotizing enterocolitisD.small left colon syndrome

respiratory papillomatosis

A 3-year-old boy is seen by the otolaryngologist for progressive hoarseness over the last few months. When crying, his voice is weak and he has respiratory distress. He has an intermittent cough without fever, rhinorrhea, congestion, emesis, or abdominal pain. He was born at term via vaginal delivery and does not have any chronic medical conditions. Vital signs include a temperature of 37°C, heart rate of 115 beats/min, respiratory rate of 30 breaths/min, and blood pressure of 95/52 mm Hg. On physical examination there is moderate stridor. Nasopharyngoscopy is performed (Item Q47 ). (image shows a center nodule between the vocal cords) Of the following, the MOST likely cause of this boy's symptoms is

C Radiant heat loss refers to heat loss to the surrounding air. Because the neonate is covered with a blanket, there is likely minimal radiant heat loss. Conductive heat loss describes thermal energy transferred to an adjacent object. Because the neonate is being held by her mother, conductive heat loss should be minimal. Convective heat loss is loss of heat because of moving air around the neonate. If this neonate were exposed to air conditioning or air drafts, the convective heat loss could be more significant.

A 35-week-gestation female neonate is delivered at home precipitously. Her mother had routine prenatal care. The father drives the mother and neonate to the nearest hospital, with the mother holding the neonate in a wet receiving blanket. On arrival at the emergency department, the neonate has a temperature of 35.6°C, heart rate of 92 beats/min, respiratory rate of 15 breaths/min, blood pressure of 55/37 mm Hg, and oxygen saturation on pulse oximetry of 87% in room air. Her extremities are cool. Of the following, the MOST likely mechanism for the neonate's heat loss is A.conductiveB.convectiveC.evaporativeD.radiant

They have tuberous sclerosis --> cardiac rhabdomyomas are common so echo

A 4-month-old infant is seen in the office as a new patient. She has a seizure disorder that is controlled by medication. She is doing well, and her mother has no concerns regarding her eating, growth, or development. Her physical examination findings are unremarkable, except for multiple hypopigmented macules (Item Q108). Her father has similar hypopigmented lesions on the skin, a benign brain tumor, and renal cysts. Of the following, the MOST appropriate study for this infant is and what disease do they have? A.echocardiography to evaluate for rhabdomyomasB.echocardiography to evaluate for ventricular septal defect(s)C.electrocardiography to evaluate for atrioventricular blockD.electrocardiography to evaluate for prolonged QT interval

CGG repeats in FMR1C (Fragile x-syndrome)

A 4-year-old boy (Item Q76) is seen for a health supervision visit. He was born at full term to a 35-year-old mother. The mother reports that at age 30 years she underwent fertility treatments because of premature ovarian failure. The boy has delayed speech and can say only 10 words. He is very active and runs around the room during the entire visit. The mother expresses concern about his behavior, frequent temper tantrums, hand flapping, and biting his 2-year-old sister. The family history is significant for bipolar disorder in the maternal grandmother and Parkinson disease in the maternal grandfather. The family history on the paternal side is unknown. Of the following, the MOST likely underlying etiology of this boy's clinical disorder is A.CAG repeats in HTTB.CGG repeats in FMR1C.CTG repeats in DMPKD.GAA repeats in FXN

A. AD complete penetrance, they have achondroplasia

A 4-year-old boy is seen for a health supervision visit. He has eczema and has had recurrent ear infections that required the placement of myringotomy tubes. He attends preschool, knows his letters, and can draw a triangle and a square. He is interactive during the physical examination. His height is at the 30th percentile, his weight is at the 50th percentile, and his head circumference is at the 70th percentile. He can hop on one foot for 2 seconds and sing his favorite nursery rhyme. His mother reports that his father, paternal uncle, and grandmother have short stature, a large head, small fingers, and shortening of both arms and thighs. His father has been relatively healthy except for obstructive sleep apnea. His grandmother had stenosis of the lumbar spine and hearing loss. His uncle recently had a newborn son with a large head and short limbs who underwent ventriculoperitoneal shunt insertion because of obstructive hydrocephalus. Of the following, the inheritance pattern of the disorder MOST likely seen in this family is A.autosomal dominant with complete penetranceB.autosomal dominant with incomplete penetranceC.X-linked dominantD.X-linked recessive

A. B. severe systemic neurologic symptoms; however, typically, significant erythema and edema are seen at the site of the bite which may progress to ecchymosis and hemorrhagic blebs C. Pain but all localized without many systemic signs D. only systemic is anaphylaxis

A 4-year-old boy is seen in the emergency department for 6 hours of progressive restlessness, abnormal movements of the extremities, blurred vision, and drooling. His parents report that the boy was in good health until he felt something sharp touch his right great toe as he put on his shoes. His parents examined his toe at the time but were unable to see any marks. Over the course of the next hour he complained of a "funny feeling" in his right leg. Shortly thereafter, the other symptoms commenced. On physical examination, the boy's temperature is 38.2°C, heart rate is 140 beats/min, respiratory rate is 22 breaths/min, blood pressure is 110/60 mm Hg, and his room air oxygen saturation is 100%. He is alert and oriented and able to answer questions appropriately. The boy appears uncomfortable and is intermittently writhing on the stretcher. His pupils are equal, round, and reactive to light; however, he has abnormal extraocular movements. His mucous membranes are moist and he has minimal drooling. On auscultation, his heart has a normal rhythm with no murmurs, scattered expiratory wheezes can be heard; and his abdominal examination findings are normal. On skin examination, no marks are found and there is no bruising. Palpation of his right great toe produces intense pain. Of the following, the creature MOST likely to have caused this child's symptoms is A.Centruroides sculpturatus (Arizona bark scorpion)B.Crotalus atrox (Western diamondback snake)C.Latrodectus mactans (brown recluse spider)D.Vespula squamosa (southern yellowjacket wasp)

Adrenal glands Not central because FSH/LH low, not exogenous because DHEA level high too

A 5-year-old boy is seen in the office for concerns of pubic hair growth and penile enlargement. During a recent bath, his mother noticed pubic hair and thought his penis looked too large. He has no significant medical history. His newborn screen was normal, including a 17-hydroxyprogesterone level. There is no family history of precocious puberty. His vital signs are normal for age. His height and weight are at the 95th and 75th percentile, respectively. He has mild acne over his forehead and a small amount of axillary hair. He has a pubertal-sized penis, and his sexual maturity rating is 3 for pubic hair. His testes are 2 mL in volume bilaterally. The remainder of his physical examination findings are unremarkable. Laboratory data are shown: Laboratory Test Resulta Luteinizing hormone < 0.1 mIU/mL (reference range, 0.02-0.3 mIU/mL) Follicle-stimulating hormone 0.6 mIU/mL (reference range, 0.26-3 mIU/mL) Testosterone 210 ng/dL (7.3 nmol/L) (reference range, < 2.5-10 ng/dL [0.1-0.4 nmol/L]) Dehydroepiandrosterone sulfate 1,600 μg/dL (43.2 µmol/L) (reference range, 13-83 μg/dL [0.4-2.2 µmol/L]) aReference ranges are for individuals younger than 10 years. The result of bone age radiography is 8 years. Of the following, the MOST likely source of this boy's precocious puberty is A.exogenous steroidsB.his adrenal glandC.his central nervous systemD.his gonads

classic for acute flaccid myelitis

A 5-year-old girl is seen in the emergency department for acute onset of left arm weakness. Two weeks earlier she had a nonspecific viral illness that self-resolved. She awoke on the day of admission with inability to move her left arm. She denies pain, numbness, headache, bowel or bladder involvement, or prior trauma. In the emergency department, the girl is alert, pleasant, and interactive with no evidence of encephalopathy. Her vital signs and general physical examination findings are normal. On neurologic examination, cranial nerve findings, fundoscopy, sensation, and gait are normal. Motor examination is notable for flaccid paralysis of the left upper extremity with areflexia; strength, reflexes, and coordination are preserved in her other extremities. Brain magnetic resonance imaging (MRI) is normal. Spine MRI scans are shown (Item Q52A and Q52B). Lumbar puncture reveals clear cerebrospinal fluid with a lymphocytic pleocytosis. Cerebrospinal fluid is sent for viral testing and bacterial culture. Of the following, the MOST likely diagnosis for this girl is A.acute flaccid myelitisB.acute disseminated encephalomyelitisC.Guillain-Barré syndromeD.idiopathic transverse myelitis

D. Permethrin due to this being scabies Remember treated once then again 7 days later

A 6-month-old male infant developed a pruritic rash 2 weeks ago. He has been otherwise well and is taking no medications. There are numerous erythematous papules located on his trunk and extremities, including the hands (Item Q101A) and feet (Item Q101B). Of the following, the MOST appropriate treatment is cephalexin administered orallyB.hydrocortisone administered topicallyC.hydroxyzine administered orallyD.permethrin administered topically

C. A. no indication as no findings B. Non-diagnostic D. Shes not immunized

A 6-week-old infant girl is seen in the office for evaluation of a 4-day history of cough, posttussive emesis, and fussiness. The mother reports that the infant became apneic and limp for a brief period after a coughing episode at home. Her grandmother has had a chronic cough for more than 1 month. The infant has a temperature of 37.2°C, a heart rate of 148 beats/min, a respiratory rate of 37 breaths/min, a blood pressure of 82/44 mm Hg, and an oxygen saturation of 96% on room air. Findings of a respiratory examination are notable for bilateral coarse breath sounds. Several episodes of transient apnea are observed. Findings from the rest of the physical examination are unremarkable. Rapid viral antigen testing via direct fluorescent antibody is negative for respiratory syncytial virus. Of the following, the BEST next diagnostic step in the evaluation of this infant's illness is A.chest radiographyB.complete blood cell countC.nasopharyngeal swab for polymerase chain reactionD.serology

A. allergic contact dermatitis (notice how it is linear due to brushing up against the poison ivy or oak)

A 7-year-old girl is being evaluated for a 3-day history of an itchy rash. She is otherwise well, is receiving no medications, and has no history of a similar eruption. Her vital signs are normal, and her physical examination findings are unremarkable aside from a rash in a patchy distribution on the face and upper extremities (Item Q67). Of the following, the MOST likely diagnosis is A.allergic contact dermatitisB.atopic dermatitisC.irritant contact dermatitisD.seborrheic dermatitis

B. She has Turner's recurrent infections and struggles with math Declining growth velocity can be consistent with an endocrine disorder such as growth hormone deficiency or hypothyroidism. Bone age, however, would be delayed in these endocrine disorders.

A 7-year-old girl is seen for a health supervision visit. Her mother is concerned that she is the smallest child in her class. The girl's medical history is significant for placement of ear tubes at age 2 years because of multiple episodes of acute otitis media. She takes no medication. She is generally doing well in the second grade but requires extra help in math. A comprehensive review of systems is otherwise unremarkable. Her adjusted midparental height is 164 cm (50th percentile for an adult female), and pubertal timing for both parents was normal. Vital signs are normal for age. Her growth chart is shown in Item Q147. Her body mass index is 15.4 kg/m2 (50th percentile). The physical examination findings are unremarkable. A bone age radiograph is read as concordant with her chronological age. Of the following, the test MOST likely to lead to this girl's diagnosis is A.insulin-like growth factor-1B.a karyotypeC.thyroid-stimulating hormoneD.tissue transglutaminase IgA antibody

Parent's clothing (organophosphate poisoning) Bradycardia Miosis Lacrimation Salivation Bronchospasm and bronchorrhea Urination Emesis and diarrhea

A 9-month-old infant is seen in the clinic for urgent evaluation. Her parents report that she is sleepy, weak, and listless. She developed a runny nose and increased drooling yesterday. Today, she has had 5 loose stools and decreased oral intake. She has had a normal number of wet diapers. She lives with her parents on a farm. She has no known sick contacts and does not attend daycare. She has a temperature of 37.5°C, heart rate of 80 beats/min, respiratory rate of 50 breaths/min, and blood pressure of 90/50 mm Hg. She has decreased tone and is sleepy, but responds appropriately to painful stimuli. Her pupils are constricted (1-2 mm diameter), and she is tearing and drooling. Her lungs are clear to auscultation. Intermittent intercostal retractions are noted. The heart has a regular rate and rhythm, and her abdomen is soft and nontender without distention or hepatosplenomegaly. Her skin is dry, and she has a capillary refill time of 3 seconds. Of the following, the MOST likely source of the toxin causing her symptoms is A.chicken droppingsB.goat milkC.parents' clothingD.unpasteurized honey

B- Glucocorticoids (too much from inhalation leading to growth delay)

A 9-year-old boy is seen for a routine follow-up for asthma that was diagnosed at age 3 years. He has been treated with inhaled corticosteroids since the time of diagnosis. His current medications include mometasone furoate 100 μg with formoterol fumarate 5 μg two inhalations twice daily, fluticasone propionate one spray in each nostril daily, and albuterol two puffs inhaled every 4 hours as needed for cough, shortness of breath, or wheeze. His asthma has been well controlled since his inhaled corticosteroid therapy was intensified 3 years ago. His last asthma exacerbation and last course of oral corticosteroids was more than 1 year ago. His vital signs are normal for his age. His growth chart is shown in Item Q66. His body mass index is 15.9 kg/m2 (40th percentile). Examination of his respiratory system yields normal findings. The remainder of his physical examination findings are unremarkable. Of the following, the MOST likely cause of this boy's physical findings is A.constitutional delay of growthB.exogenous glucocorticoidC.growth hormone deficiencyD.pituitary adenoma Figures shows symmetric growth delay, with a delay in height then weight

C. usually making friends, but without a single one, and play sports B. simple directions, counting to 100, demonstrating basic writing skills, and demonstrating emerging reading skills such as recognizing words on sight or reading simple book. relationships with adults and peers D. Increasing importance of peer relationships, usually of the same sex, and sharing ideas with their peers become more apparent. Participation in after-school activities such as sports, music, or other organizations increases.

A girl comes to the clinic with her mother for a health supervision visit. She sits quietly reading a book, which she can do with just a little help from her mother. The girl's participation in age-appropriate activities and her development are reviewed. She has joined a soccer team this year and really enjoys playing competitive sports. Math is her favorite class; they are learning fractions. She names several friends and says she enjoys playing with both sexes but does not have one single best friend. Of the following, the girl's age is MOST likely A.4 yearsB.6 yearsC.8 yearsD.10 years

Vitamin B12 deficiency

High doses of vitamin B9 (folic acid) may mask what?

A national trafficking organization. NOT CPS or law enforcement

If there is concern for sex trafficking who do you contact first?

Ultrasound of the umbilicus

In a healthy infant with persistent umbilical drainage, at 2 months of age, after multiple cauterization attempts, the next best step is what?

Decreased glycogen stores

A male neonate is delivered at 37 weeks' gestation because of maternal preeclampsia. His mother's history is significant for obesity and chronic hypertension. He weighs 2.2 kg at birth. At 18 hours after birth, shortly after breastfeeding and supplementing with formula, his bedside glucose level is 35 mg/dL (1.9 mmol/L). He is breathing comfortably in room air and has good perfusion. Of the following, the MOST likely explanation for this neonate's glucose level is

C. RPR- you want to know if the baby has it, not antibodies, b/c they will have antibodies from Mom regardless. PCR is not used clinically in the USA so D is wrong

A neonate born at term is being evaluated in the newborn nursery. She was born overnight via vaginal delivery to a 27-year-old gravida 1, para 0 woman with a history of asthma. The mother's prenatal records report group B Streptococcus-negative status and a positive VDRL test (1:2) result with positive treponemal test. The neonate has unremarkable physical examination findings. She is breastfeeding well. Of the following, the BEST next diagnostic test for this neonate is A.direct fluorescent antibody B.Treponema pallidum enzyme immunoassayC.rapid plasma reagin D.treponemal polymerase chain reaction

B. A. The hearing loss, plus cardiac disease say no C. snuffles, mucocutaneous lesions, osteochondritis, pseudoparalysis, hepatosplenomegaly, and lymphadenopathy. D. Hydrocephalus, chorioentitis, calcifications

A neonate is born at term via precipitous vaginal delivery to a 22-year-old woman who recently emigrated from El Salvador and did not receive any prenatal care. A rapid human immunodeficiency virus test and rapid plasma reagin test performed on the mother soon after delivery have negative results. The neonate weighs 2.2 kg and has microcephaly. He is alert and has a good cry, normal tone, and normal activity. Red reflex is decreased in the right eye and absent in the left eye. He has mild hepatosplenomegaly, petechiae, and a grade 2/6 systolic ejection murmur on auscultation of the left upper chest. The remainder of his physical examination findings are unremarkable. Laboratory data are notable for thrombocytopenia. A computed tomographic scan of the head reveals calcifications. Audiologic evaluation reveals absent auditory brainstem responses in both ears. Skeletal survey shows the presence of transverse lucent bands in both proximal humeral metaphyses. Evaluation by an ophthalmologist reveals bilateral cataracts. Of the following, the MOST likely etiology for the findings in this neonate is A.cytomegalovirusB.rubellaC.syphilisD.toxoplasma

B. B/c she has core antibodies and surface antibodys, but no antigen so she had an infection, but not currently

A newborn is being evaluated in the nursery. He was born this morning via vaginal delivery to a 32-year-old mother who did not receive prenatal care until 28 weeks of gestation. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. He did well at birth and has been rooming in with his mother. Physical examination reveals a newborn whose growth parameters are appropriate for gestational age and has otherwise unremarkable examination findings. His mother's medical records are reviewed. Maternal laboratory data are as follows: Laboratory Test Patient Result Group B Streptococcus culture Negative HIV enzyme-linked immunosorbent assay Negative Rapid plasma reagin Nonreactive Hepatitis B surface antigen Negative Hepatitis B core antibody Positive Hepatitis B surface antibody Positive Rubella Nonimmune Of the following, the mother's hepatitis B status is MOST likely A.actively infectedB.immune due to infectionC.immune due to vaccinationD.susceptible to infection

human leukocyte antigen (HLA)-B27.

Juvenile ankylosing spondylitis is a type of enthesitis-related arthritis most closely linked to what lab test?

Mother NAIT have normal platelets, mother's platelets in ITP are low

Main difference between ITP in a neonate and NAIT?

C. A is too broad (symptoms can't be quantified) B and D have no comparison to measure

A pediatrician notes that the number of patients with asthma seen in the clinic appears to be increasing. The pediatrician wants to evaluate the relationship between asthma symptoms and medication use in children with asthma. Of the following, the question that BEST frames an evidence-based-medicine approach to this clinical situation is A.Among children aged 12 to 36 months with asthma, does the use of a controller medication decrease asthma symptoms when compared with no controller use?B.Among children aged 12 to 36 months with asthma, does the use of inhaled corticosteroids decrease growth velocity?C.Among children aged 12 to 36 months with asthma, does the use of inhaled corticosteroids plus bronchodilators compared with the use of bronchodilators alone reduce the frequency of emergency department visits?D.Among children aged 12 to 36 months with moderate persistent asthma, does montelukast result in fewer asthma exacerbations?

C. Making the recommendation

An 11-year-old who was assigned female at birth is seen for a health supervision visit. He has been diagnosed with gender dysphoria by a psychologist who has followed him for several years. He asks to be called "Michael" and uses the pronouns "he" and "him." His mother states that he displays typical male play behaviors; prefers typical male clothing, including underwear; and has insisted that he is a boy since about age 3 years. He became very distressed when he recently began showing signs of typical female puberty. An interdisciplinary gender team has recommended that he start receiving a gonadotropin-releasing hormone agonist to suppress puberty. His parents have consented, and he has provided assent for this therapy. They understand the potential adverse effects, including that on bone health. He is wearing typical male clothing and has a typical male hair style. His sexual maturity rating is 2 for breast and pubic hair development. The remainder of his physical examination findings are normal. Of the following, the team's action that BEST represents the ethical principle of beneficence is A.ensuring that the parents have consented to therapyB.ensuring that the child and family understand potential adverse effects of therapyC.making the recommendation to initiate therapyD.obtaining assent of the child before the initiation of therapy

C. Hyperpronation- she has a nurse maids Not D because its supination with hyperflexion

An 18-month-old girl is brought to the emergency department for evaluation of a left arm injury. Twenty minutes before arrival, she was walking down the street holding her father's hand when she slipped. She never fell to the ground because her father tightened his grip on her wrist; however, since then she has been crying and not moving her left arm. On physical examination, she cries when approached and is holding her left arm to her side with the elbow slightly flexed. The parents are informed that their daughter's condition can be resolved with a quick maneuver. Of the following, the intervention MOST likely to be successful is A.hyperflexionB.hyperextensionC.hyperpronationD.hypersupination

Prader-Willi syndrome is characterized by neonatal hypotonia with failure to thrive. This is replaced by hyperphagia and obesity in early childhood.

An 8-year-old boy is seen for a health supervision visit. He is in the third grade in a special education classroom. His parents report that he walked at 2 years, started putting 2 words together at 3 years, and has been receiving physical, occupational, and speech therapy for his entire life. His birth and postnatal history are significant for hypotonia and failure to thrive, and he required a gastrointestinal tube for feeding. His parents are currently concerned about his excessive eating behavior. His weight and height are at the 98th and 2nd percentile, respectively. He has almond-shaped eyes, a thin upper lip, small hands and feet, and a small penis with a hypoplastic scrotum. The remainder of his physical examination findings are normal. Of the following, the MOST appropriate therapy for this condition is A.glucocorticoid therapy in the first year after birth with nutrition management B.growth hormone therapy in the first year after birth with nutrition management C.growth hormone therapy in the first year after birth with supplementation of carnitine D.levothyroxine therapy in the first year after birth with nutrition management

6.4%

An A1C of greater than _________ signifies diabetes

18-24 months

At what age do infants normally grow out of trachoemalacia?

>10mm

Criteria for a positive TB skin test in a patient from an endemic country?

adrenal gland

Dehydroepiandrosterone sulfate is made by the adrenal gland and is a marker of androgen production.

Coloboma, heart defects, choanalatresia, growth retardation, GU anomalies, ear deformity and deafness. Chr8. Vertebral anomalies, anogenital anomalies, cardiac defects, tracheoesophageal fistula, limb abnormalities

Difference between CHARGE and VACTERL

Prevalence is the number of affected cases in a specific population at a given point in time. Incidence is the number of new cases that develop over a specific period

Difference between incidence and prevalence?

RTA Diarrhea

RTA Diarrhea The urine AG is + in ________ and - in __________

patient problem or population, intervention, comparison group, and outcome measure. Of the choices listed, only response C incorporates all of the elements of a PICO question:

The four elements of a PICO question are what?

Distal renal tubular acidosis

The infant in the vignette has failure to thrive and normal anion gap metabolic acidosis. The higher-than-expected urinary pH and positive urine anion gap favors a diagnosis of

sleep deprivation, alcohol consumption, stress, and flashing lights.

The most common triggers for seizures in JME are what?

C. Because she struggle to pick up the routine for class, which is concerning for potential learning disability

The mother of a girl who is 6 years and 10 months old expresses concerns about her daughter's poor school performance. The girl started kindergarten in the fall. She was hesitant to engage in class activities and was teased by her classmates for her small size. In comparison with her classmates, she required additional guidance and support from her teachers to understand class routines and class lessons. After a few weeks, she was moved to a transitional kindergarten class, where the girl adjusted well and made several friends. Her teacher recently informed the girl's mother that she is performing at a level appropriate for the class. Her mother is concerned about why her daughter was not successful in kindergarten and would like additional guidance. The girl has no significant medical history. She walked at age 12 months, spoke single words at age 11 months, and spoke in 2-word phrases/sentences at age 2 years. Her height and weight are at the 10th percentile. During the visit, the girl initially stays close to her mother and is quiet, but eventually engages in a brief conversation about the toy unicorn she has brought. Physical examination findings are within normal limits; vision and hearing screening results are normal. Of the following, the MOST appropriate next step is to recommend A.cognitive behavioral therapyB.genetic testingC.psychoeducational evaluationD.reassessment in the fal

8 and 9

The traditional definition of precocious puberty is signs of puberty before the age of _______ years in girls and ______ years in boys.

polyp, adenomyosis, leiomyoma, malignancy and hyperplasia coagulopathy, ovulatory dysfunction, endometriosis, iatrogenic, not yet classified

The universally accepted classification system for causes of AUB in women of reproductive age is PALM-COEIN, which stands for

C. Radiation (vomiting, belly pain, diarrhea) --> shows up 2-3 days later or month depending on dose A. cutaneous, gastrointestinal, or inhalational syndrome (localized skin ulcers) Phosgene gas is a chemical classified as a pulmonary agent (as is chlorine gas); it primarily affects the upper and lower respiratory tracts. VX gas is a highly toxic nerve agent that causes anticholinergic symptoms immediately on exposure.

Three adolescents are brought to the emergency department 2 days after attending a political rally at which a small explosion occurred near them. None of the girls sustained any physical injuries, so they did not seek immediate medical care. Later that evening, all three began to have nonbloody nonbilious vomiting, diarrhea, mild headache, and fatigue, which has persisted. In the emergency department, all three adolescents appear well and have normal vital signs. On physical examination, each patient has mild diffuse abdominal tenderness and one appears to be mildly dehydrated. The remainder of their physical examination findings are normal. Intravenous lines are placed and a bolus of normal saline is administered to each adolescent. All three have a decreased absolute lymphocyte count, but laboratory findings are otherwise normal. Of the following, the MOST likely cause of the adolescents' symptoms is exposure to A.anthraxB.phosgene gasC.radiationD.VX gas

False- no such correlation exists, correlation does exist with parents increasing activity and children increasing physical activity

True or false, increased screen time correlates to increased physical activity

CF and constipation (if neither get colonoscopy)

Two most common causes of rectal prolapse?

High serum chloride levels and metabolic acidosis

What electrolyte abnormalities do you see in RTA and diarrhea?

Low serum chloride levels and metabolic alkalosis

What electrolyte abnormalities do you see in pyloric stenosis?

< 5 feet

What height of a fall precludes imaging? (I.e. don't order it?)

Central: LH high (>0.3) and testes greater than 4 mL

When considering precocious puberty how do you differentiate central vs. non-central causes

From high to low the brain will blow (cerebral edema) From low to high the pons will die

When correcting sodium what mnemonic should you remember?

Full vaccine series and most recent within 5 years (i.e. booster or last vaccine)

When do you not need to do tetanus pox?

immunocompromised individuals, pregnant women, and eligible newborns (former premies, those whose mother develop it within the first 5 days of life)

Who is provided post exposure prophylaxisf or a varicella zoster exposure?

Frothy

Women who are symptomatic may have a yellowish-green vaginal discharge characteristically described as being what?

Tuberous sclerosis

an autosomal-dominant, neurocutaneous, multisystem disorder that results in localized cellular overgrowth that, in turn, leads to benign tumors (hamartomas) in multiple organs, most commonly the brain, skin, kidney, and eye.

Diarrhea and Renal tubular acidosis

are the most common causes of normal anion gap acidosis in children.

Rumination syndrome

characterized by effortless and painless nonbilious, nonbloody regurgitation of food within minutes to hours of eating, after which partially digested food is then rechewed, re-swallowed or expulsed

Beneficence

is the ethical principle concerned with benefiting others

Girls 13, boys 14 (give 2 years before you investigate)

mean age of puberty in girls? Boys?