Pediatric 5 Flashcard

At what age does autism spectrum disorder usually become evident? Select one answer only.

2-4 years

At what age would you expect the clinical features of spastic bilateral cerebral palsy to become evident? Select one answer only.

0-12 months

Evie is a 10-day-old infant and was born in London. Her health visitor reviews the family at home. She is feeding well and has a normal examination except that she has a squint. The health visitor tells her parents that she will keep this under review. At what age does Evie need to be referred for further review if the squint is still present? Select one answer only.

12 weeks

Mohammed, aged 8 months, presented with the clinical scenario described in question 6.7. He weighs 8 kg. He needs a bolus of normal saline 0.9% to treat his shock. What volume of fluid would you give initially? Select one answer only.

160 ml

Mohammed, aged 8 months, has presented with the clinical scenario described in Questions 6.6 and 6.7. He has received the fluid bolus of normal saline 0.9%, which has improved his condition. From his presentation you suspect he is 10% dehydrated. You receive his laboratory results, which reveal a plasma sodium of 138 mmol/L within the normal range.. His continuing fluid loss from vomiting is small and can be ignored. What is Mohammed's total fluid requirement for the initial 24 hours? He weighs 8 kg. Select one answer only.

1600 ml

Joanna is an active toddler. She is just being potty trained and has had several days where she has remained dry. She enjoys pulling her clothes off to use the potty but cannot dress herself again. She enjoys playing by pretending to make her mother a cup of tea but does not play well with her older siblings, as she has not yet learnt how to take turns. She is very bossy and demands things by saying 'give me' or 'me drink'. She can build a tower of six blocks and enjoys running and climbing on furniture. What developmental age is Joanna? Select one answer only.

24 months

You are called to see a 3-year-old boy with a high fever. The nurse is worried that he is very sleepy. As you walk into the resuscitation room he makes no spontaneous response. You try calling his name but he makes no response. On stimulation, his eyes open, he cries and he raises his hand and pushes your hand away. What is this child's Glasgow Coma Score GCS.? Select one answer only.

9

You perform a routine newborn examination on a baby who is 20 hours old. Which one of the following features requires further immediate assessment? Select one answer only.

A heart murmur

Hamim, a boy aged 3 years, fell 3 metres from a first-floor balcony on to a concrete path. He presents to the Emergency Department with his parents who are concerned that he has vomited several times since the episode. After the fall he immediately cried out in pain, but appeared to be all right. His mother reports that he did not lose consciousness. On examination he is found to be fully conscious but has a large bruise over the left parietal region. There are neither focal neurological signs nor any other injuries. His heart rate is 110 beats/min, his respiratory rate is 25 breaths/min and his blood pressure is 90/50 mmHg. Which of the following would be the most worrying additional clinical sign? Select one answer only.

A runny nose

Alan, a 4-month-old boy, sees his general practitioner for an ear infection. On listening to his chest a heart murmur is heard. Which one of the following features most suggests that it requires further investigation? Select one answer only.

A thrill

A 10-year-old girl is involved in a motor vehicle accident, sustaining multiple injuries to her head, arms, and abdomen. Her blood pressure is 90/60 mm Hg, and her pulse is 120/min. Her forearm is disfigured, and bone can be seen through the wound. She is breathing periodically and has cyanotic lips. Her abdomen is rigid, and there is flank discoloration. Which of the following is the most appropriate next step in management?

Administer crystalloid solution

A 12-year-old girl presents to the ED for left eye pain and swelling for 2 days. The patient has had cough, congestion, and rhinorrhea for the last week that is improving. On examination, her temperature is 100.8°F, HR 115 beats per minute, RR 12 breaths per minute, and BP 110/70 mm Hg. On eye examination, there is purple-red swelling of both upper and lower eyelids with injection of the conjunctiva. Pupils are equal and reactive to light. There is restricted lateral gaze. Visual acuity is 20/70 in the left eye and 20/25 in the right eye. The rest of the physical examination is normal. What is the most appropriate next step in management?

Administer vancomycin IV

John, a 3-year-old boy, is referred to paediatric outpatients because of concern about the development of pubic and axillary hair. His testes are 1.5 ml in size prepubertal.. His blood pressure is 100/75 mmHg. Gonadotrophin levels are normal for a prepubertal boy undetectable. but his bone age is 5 years. What is the most likely cause of his early pubertal development? Select one answer only.

Adrenal tumour

A 12-year-old girl with mild asthma comes to the office for a health maintenance visit. Her mother states that she is using her albuterol inhaler 2-3 times a week and that she has a cough that wakes her up at night about 3 times a month. On physical examination, she has diffuse inspiratory and expiratory wheezes. She has no accessory muscle use. Pulse oximetry shows 95% oxygen saturation on room air. Which of the following is the most appropriate treatment for her at this time?

Albuterol nebulized treatment

A 12-year-old boy presents to his pediatrician with frequent episodes of headache, nausea, blurry vision, and sweating. On physical examination, his temperature is 37.4 C 99.3 F., blood pressure is 148/94 mm Hg, pulse is 92/min, and respirations are 18/min. The rest of his examination is unremarkable. His 24-hour urinary vanillylmandelic acid VMA. and metanephrines are increased. An abdominal CT reveals an extrarenal mass above the left kidney. Which of the following is the most appropriate pharmacotherapy?

Alpha-adrenergic blocker

Poverty is associated with the greatest increased risk of which one of the following conditions during childhood in the UK? Select one answer only

Asthma

Jonathan is 4 years old and lives in a small village in southern England. He attends a paediatric outpatient clinic with his grandmother who is his legal guardian. She is concerned that he only seems to like to play with his toy train and insists on watching the same DVD every night before he goes to bed. He attends nursery where he plays with the toys but not with other children. His behaviour can be very difficult to manage at times. He does not say any words, whereas the grandmother's children were speaking in sentences at his age. On examination you notice he does not make eye contact with you and pushes his toy train back and forth on the floor. The rest of his examination is normal. What is the most likely diagnosis? Select one answer only.

Autism spectrum disorder

A 10-year-old girl comes to medical attention because of recurrent attacks of wheezing and dyspnea. The attacks occur mostly at home or, if outdoors, soon after exercise. Exacerbations are noted in springtime. The severity of symptoms is mild- Pulmonary function tests show that peak expiratory flow PEF. and forced respiratory volume per second FEVj. are reduced during an attack but are relatively normal during symptom-free intervals. Height and weight are in the 60th percentile. Complete blood count shows 8% eosinophils; all other parameters are normal. Cutaneous testing shows the patient to be allergic to a variety of allergens, including dust mites, animal dander, and several pollens. Which of the following is the most effective step in management?

Avoidance of respiratory irritants, such as cigarette smoke

A 12-year-old girl was hit in the face by a baseball 15 minutes earlier and has had her mandibular incisors knocked out. Which of the following represents the best plan of action?

Avulsed teeth can be transported in the mouth of the parent or a cooperative patient

A 1-year-old child with cerebral palsy secondary to perinatal asphyxia presents to her general pediatrician for a well-child visit. She was delivered at 37 weeks' gestation by emergency cesarean section for a tight nuchal chord. The patient has severe spastic quadriparesis that is limiting her movements. She also has mental retardation and is unable to speak. She has received physical and occupational therapy since early infancy; however, her parents are concerned by her lack of improvement. Which of the following is the best choice for treatment of spasticity in this child?

Baclofen

A 2-week postmature neonate exhibits severe respiratory distress immediately after birth. Previously, greentinged meconium was noted in the amniotic fluid. Which of the following is the most appropriate next step in management?

Suctioning of the mouth and nasopharynx

A 10-year-old girl is the unrestrained backseat passenger in a high-speed motor vehicle collision. She is intubated in the field for unresponsiveness and on presentation to the ER, her heart rate is 160 beats per minute, and her blood pressure is 60/35 mm Hg. She weighs 30 kg. Which of the following is the most appropriate recommendation for her fluid resuscitation?

Bolus 600 cc of normal saline initially followed by a repeat bolus. Transfuse if no response

A 12-year-old boy with cystic fibrosis presents to the emergency department with a 3-day history of severe coughing, which is productive of a yellow-greenish purulent sputum. He had fever and chills at home. He also complains of chest congestion and chest pain that is worse with coughing. On physical examination, his temperature is 39.6 C 103.2 F., blood pressure is 98/68 mm Hg, pulse is 102/min, and respirations are 24/min. He is noted to be lethargic. He has rales on the left lower lung field on auscultation, and chest radiography shows an infiltrate in the left lower lobe. Which of the following is the most appropriate initial antimicrobial therapy for this patient?

Ceftazidime and tobramycin

You are called to the resuscitation room where there is a 6-year-old child who has arrived by ambulance. The child has been having a generalized seizure for 15 minutes. The ambulance crew gave a dose of buccal midazolam 5 minutes ago. The emergency doctor has maintained the airway and has applied oxygen. His capillary refill time is less than 2 seconds and his heart rate 120 beats/min. What is the next most appropriate management step? Select one answer only.

Check blood glucose level

Rodney, a boisterous 2-year-old, has haddiarrhoea for the last 3 months. He produces upto four stools a day, which are loose, brown in colour and usually contain undigested food. The rest of the family are well. He has never been abroad. Examination is normal and his personal child health record shows that he is growing along the 50th centile. What is the most likely diagnosis?

Chronic non-specific diarrhoea

Emma is an 18-month-old girl who is seen in the outpatient department. She presents with loose stools two to three times each day, with no blood in them. She is generally difficult and it has become a battle to get her to feed. Examination of her abdomen, although difficult due to distress at being examined, is unremarkable apart from being distended. She is not on any medication. Her weight was on the 9th centile and is now below the 0.4th centile. What is the most likely cause for the weight loss? Select one answer only.

Coeliac disease

A mother has just found out she is pregnant with twins. Her antenatal scan reveals dichorionic, diamniotic twins. Which condition carries the biggest increased risk in her twin pregnancy? Select one answer only.

Congenital abnormalities

Ellie is a 4-year-old girl who has been complaining of pain in her tummy for a month. It is worse when she goes to the toilet; her stools are firm and she opens her bowels only every 2-3 days. She has not had any vomiting. For the last 2 weeks her stools have become loose. On examination she has a mass in the left iliac fossa. What is the most likely diagnosis? Select one answer only.

Constipation

Gloria is a 19-month-old girl who presents to you in primary care. Her health visitor is concerned because she is still only babbling and says no distinct words. She is able to walk, scribbles with crayons and feeds herself with a spoon. What is the most appropriate first action? Select one answer only.

Hearing test

A 2-year-old arrives in the emergency center after having swallowed a button battery from one of her toys. She is breathing comfortably, without stridor. Radiographs show the battery to be lodged in the esophagus. Which of the following is the correct next step?

Immediate removal of the battery via endoscopy

A 6-year-old Hispanic boy is brought to your office by his mother because of severe pain in his right hip and refusal to walk for the last 2 days. His blood pressure is 100/70 mm Hg, pulse is 90/min, respirations are 18/min, and temperature is 38.7C 102.7F.. His WBC count is 19,000/mm3 and ESR is 55 mm at one hour. On examination, he keeps his right hip externally rotated, and cries out in pain on any movement involving the right hip. Joint aspiration reveals a turbid fluid with total WBC: 90,000/mm3 and numerous bacteria. What is the most appropriate management in this patient?

Emergency surgical drainage

Jonathan, a newborn baby, is noted to have hepatosplenomegaly and a petechial rash. His red eye reflex is normal and there is no heart murmur. He fails his newborn screening hearing test. His mother is from the UK and her antenatal screening bloods were all normal. What is the most likely congenital infection that has caused these symptoms? Select one answer only.

Cytomegalovirus

A 3-month-old, previously well male infant presents to the emergency department in January with a 2-day history of clear rhinorrhea, low-grade fever, and poor appetite, but no cough. On physical examination, there are mild subcostal retractions, coarse breath sounds heard throughout the lung fields, and scattered expiratory wheezes. The child receives an intravenous fluid bolus in the emergency department and is admitted for observation. Which of the following is the most severe, life-threatening complication of this child's illness?

Dehydration

A 10-month-old girl is seen in clinic for a routine checkup. She weighs 11 kg 24.2 lb.. The infant's mother reports that she drinks whole cow's milk and takes solid food poorly. The infant's activity is decreased, but her muscle tone is good and her developmental milestones are up to date. The only significant abnormal physical finding is parlor. Which of the following is the most appropriate next step in management?

Dietary advice and oral iron treatment

In the UK all newborn babies have a heel-prick blood sample taken at 5-7 days of age for biochemical screening. Which of the following is not tested for in the UK? Select one answer only.

Duchenne muscular dystrophy

A 3-year-old girl is brought to the emergency department because of fever, chills, vomiting, and abdominal pain. Her temperature is 39.5°C 103.1°F., blood pressure is 70/40 mm Hg, pulse is 110/min, and respirations are 20/min. She is restless and diaphoretic. The abdominal examination shows right costovertebral tenderness. Laboratory studies show: Hemoglobin 15.0 g/L, Platelets 260,000/mm3, Leukocyte count 16,500/mm3, BUN 20 mg/dL, Serum creatinine 1.1 mg/dL. Urinalysis: Blood Negative, Glucose Negative, Ketones Negative, Leukocyte esterase Positive, Nitrites Positive, WBC 40-50/hpf, RBC 5-9/hpf. Blood and urine cultures are taken. Which of the following is the most appropriate next step in management?

Empiric therapy with intravenous antibiotics

A 12-year-old girl is seen by a pediatrician for a mild case of pneumonia. She is treated with an intramuscular injection of penicillin. About 15 minutes later, she develops extreme itchiness, accompanied by the development of wheals scatteredover her chest and extremities. She also begins to wheeze and complain of difficulty breathing. The color of her lips and face remains rosy. Which of the following is the most appropriate first step in management?

Epinephrine injection

Which of the following statements best describes the negative effects of poverty on child development? Select one answer only

Especially harmful from the ages of birth to 5 years

A 12-year-old boy is brought to the clinic because of a several-month history of strange behavior. According to his parents, the boy occasionally will start staring and not respond. He will also have tears in his eyes. These episodes last several seconds and he then returns to his baseline. He has not sustained any head trauma and is on no medications. Which of the following drugs is the most appropriate treatment?

Ethosuximide

A 20-month-old child is brought to the ED because of fever and irritability and refusal to move his right lower extremity. Physical examination reveals a swollen and tender right knee that resists passive motion. Which of the following is the most likely to yield the diagnosis in this patient?

Examination of joint fluid

A 12-year-old African American male with known sickle cell disease presents with a 2 hours history of right-sided arm weakness ans slurred speech. He has been hospitalized before for pain crises and pneumonia. He takes hydroxyurea, oxycodones as needed, and folic acid. His temperature is 36.6 C, BP is 153/83 mmHg and HR is 112/min with regular rhythm. On physical examination, he has right arm weakness and mild dysarthria. His laboratory values are the following: Hemoglobin 8.2 mg/dL, WBC count 14, 000.mm3, Platelet count 210, 000/mm3, Creatinine 0.9 mg/dL. CT of the head shows no evidence of intracranial bleeding. Which of the following is the best initial management for this patient?

Exchange transfusion

A 1-month-old female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and an ultrasound of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial management of this patient?

Exploratory laparotomy

A 12-year-old male is brought to the physician because of a two week history of right groin pain and limping. He is at the 60th percentile for height and the 90th percentile for weight. He is afebrile and his other vital signs are within normal limits. Examination shows the range of motion of the right knee joint is within normal limits, but hip movements are restricted and the right foot points medially. There is marked external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

External fixation of the hip joint with pins

Tom, a 7-year-old boy, is referred by his general practitioner with concerns about his growth. He is an adopted child and no details are available about his biological father although his biological mother was 'of average height'. Physical examination reveals a happy and playful boy with no dysmorphic features. His height is 110 cm which is just below the 0.4th centile. His weight is on the 0.4th centile. He has a normal physical examination. What is the most likely cause for his short stature? Select one answer only.

Familial short stature

Claire, a 7-year-old girl, has had abdominal pain for the last 6 months. On several occasions it has been sufficiently severe for her to be sent home early from school. The pain happens once or twice a week in the afternoon or early evening. It is periumbilical in nature. It does not wake her at night. She has not had vomiting or diarrhoea. She is growing well. Her examination is normal. Her urine is clear on dipstick testing. What is the most likely cause for her pain? Select one answer only.

Functional abdominal pain

Aiysha is a 2-month-old baby who is seen in the paediatric outpatient department. She was born at term, weighing 3.5 kg and is breastfed. Her mother is concerned as she has vomited some of the milk after most feeds since birth. She cries when she vomits. She is continuing to grow along the 50th centile. What is the most likely diagnosis? Select one answer only.

Gastro-oesophageal reflux

A mother has just found out she is pregnant and asks for advice about how to look after her health and nutrition during pregnancy. She smokes 15 cigarettes a day. You recommend she gives up smoking. If she continues to smoke despite your advice the baby is at increased risk of which of the following health problems? Select one answer only.

Growth restriction

Ritha, aged 2 months, is admitted to hospital with a 2-day history of mild coryza and tachypnoea without significant intercostal recession. She has been feeding poorly for the last 3 weeks. Which clinical feature most supports her having congenital heart disease rather than respiratory disease? Select one answer only.

Hepatomegaly

Matthew is a 3-day-old term infant who has not passed meconium since birth. On examination his abdomen is distended but the remainder of the examination is normal. An x-ray of the abdomen shows distended loops throughout the bowel, including the rectum. What is the most likely diagnosis? Select one answer only.

Hirschsprung disease

A 12-year-old girl with a history of asthma has been admitted to intensive care units two times in the past and has had three emergency department visits during the past 12 months. Her only medication is inhaled albuterol as needed, and she uses it two to three times a day. She has nocturnal symptoms about two times a week. She is free of symptoms now but reports that she gets short of breath easily. Which of the following pharmacologic interventions is most appropriate?

Inhaled corticosteroid

A mother is known to have pre-eclampsia and her fetus has shown signs of intrauterine growth restriction on antenatal scans. He is delivered at 37 weeks and weighs 2.2 kg. He is admitted to the Special Care Baby Unit because of his size. He appears well and has had a breast feed. What is he most at risk of? Select one answer only.

Hypoglycaemia

A 3-year-old girl is brought to the emergency department because she became partially unconscious, lethargic and febrile. Her mother claims that "she suddenly took a turn for the worse" 24 hours ago after an upper respiratory tract infection. She has no allergies, and was not taking oral antibiotics. Her blood pressure is 60/45mm Hg and pulse is 120/min. On examination, she appears emaciated and lethargic. Despite numerous attempts, it is impossible to start a peripheral intravenous line, and the child's condition continues to deteriorate. What is the best next step to obtain IV access in this patient?

Intraosseous

Jenny, a 3-year-old girl, was at a village fete. She suddenly developed swollen cheeks and lips and a widespread urticarial rash. She is rushed to the nearby general practice surgery, where it is noted that her breathing is very noisy. She is distressed and frightened. On auscultation she has widespread wheeze. Which medication would you give first?

Intramuscular adrenaline

A 2-year-old boy presents to the emergency department ED. with severe wheezing. His symptoms have not improved even after three treatments with nebulizers. This is his third trip to the ED in the past two weeks. In the ED, he is given a dose of intravenous steroids, but continues to wheeze. On auscultation, there is no air entry bilaterally. His chest x-ray result is normal. His oxygen saturation is 91% on 6 liters of oxygen. What is the next best step in the management of this patient?

Intravenous antibiotics

A 12-year-old boy comes to the emergency department with severe shortness of breath, cough, and fever. He was diagnosed with cystic fibrosis when he was five years old. He is currently not taking any medications. His temperature is 39.4 C 103F., blood pressure is 80/40 mmHg, pulse is 120/min, and respirations are 30/min. He is excessively using his accessory respiratory muscles. Lung auscultation reveals bilateral lower lobe crackles and expiratory wheezing. Pulse oximetry shows Sa02 of 85% that improves to 92% after oxygen supplementation. Which of the following antibiotics or combinations is the best choice for this patient?

Intravenous ceftazidime and gentamicin

Mohammed, aged 8 months, has been vomiting and off his feeds for 2 days. Initially, he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock. What is the most likely diagnosis? Select one answer only.

Intussusception

Sunil, a 3-month-old infant, presents with breathlessness and sweating on feeding. He has had several chest infections. You suspect heart failure. Which of the following is most likely to be correct regarding his heart failure? Select one answer only.

It is due to a left-to-right shunt

A 3-year-old boy is brought to the emergency room after spilling bleach onto his lower extremities. He is diagnosed with a chemical burn and all involved clothing are removed. In addition to resuscitation, which of the following is the most appropriate initial management of this patient?

Lavage of the burn wound with large volumes of water.

Fortuna is an 8-month-old black African girl who was born at term. She is seen in the paediatric outpatient department. She can roll over. She does not crawl. She can say 'dada', but says it to everyone not just her father. She reaches out and grasps objects with her left hand but not with her right, and puts objects in her mouth. She smiles, but is not able to wave bye-bye. Which aspect of her development is of most concern? Select one answer only.

Left-hand preference

Molly is 18 months old and needs to be admitted to the paediatric ward in the district hospital. There is one paediatric ward in the hospital. Her mother is concerned whether they will be geared to caring for such a young child. What is the most common age for children to be admitted to hospital? Select one answer only.

Less than 1 year

Cordelia is a 4-month-old baby girl who is assessed by her general practitioner because of constant crying and poor feeding. She is fed by bottle on infant formula. Her mother tearfully complains that she is finding it very difficult to cope. She also has a 20-month-old son who has recently been referred to the speech and language therapist because of language delay. Charlotte's development, growth and physical examination are normal. What is the likely cause of Cordelia's problems? Select one answer only.

Maternal postnatal depression/stress

Nazma, aged 4 years, presents with a 1-week history of episodic central abdominal pain. She is of Indian ethnicity, but the family live in Kenya and are visiting relatives in the UK. She is otherwise well. Her relative's general practitioner thinks she may be slightly pale and that her spleen is enlarged, as it is 3 cm below the costal margin. There are no other abnormalities on examination. Which of the following is the most likely cause for her enlarged spleen? Select one answer only.

Malaria

What is the most common cause of death in children aged 1 year to 14 years in the UK? Select one answer only.

Malignant disease

Sam, a two-day-old infant, weighs 3.6 kg at birth. He was born by vaginal delivery with Apgar scores of 7 at 1 minute and 10 at 5 minutes. On day 2 he is reported to be jittery, crying inconsolably and feeding poorly. He sneezes and yawns, and is thought to have some abnormal movements, possibly seizures. No dysmorphic features are present and he is not jaundiced. What is the most likely explanation for his problems? Select one answer only.

Maternal opiate use

A 12-year-old male is brought to the emergency department after direct blunt trauma to the upper abdomen. He has epigastric pain and repeated vomiting immediately after the trauma. He is afebrile and his other vital signs are stable. Barium examination shows duodenal obstruction. CT scan of the abdomen shows a duodenal hematoma and no other injuries are noted. Which of the following is the most appropriate next step in management?

Nasogastric suction with parenteral nutrition

A 12-year-old girl presents with a 2-month history of vaginal discharge. She describes it as clear and states that it stains her underwear. She says that she hates boys, and that "no way" has she ever had sex or even kissed a boy. She reports having had developing breasts for 2 years and thinks that her growth spurt was about a year ago. Genital findings include a pubic hair stage of Tanner III with no evidence of redness or irritation of the vulvovaginal area. A slight amount of odorless, clear mucus is seen. Microscopic examination of the mucus reveals epithelial cells and a few bacteria, but no white cells. The pH is between 3.5 and 4. Which of the following is the most appropriate next step in management?

No treatment, but the girl should be reassessed in a few months

Steven has just had his first birthday party. During his party he commando crawled with great speed, although he cannot walk. He managed to pick off all the Smarties round chocolate sweets. from his birthday cake. He can say two words with meaning. After his birthday party, he impressed his guests by waving goodbye. Which area of Steven's development is delayed? Select one answer only.

None - his development is within normal limits

Janine, a 9-month-old female infant, is seen by her family doctor because of concern that she is not growing fast enough. She is only on the 5th centile for height and 2nd centile for weight. What is the greatest influence on her growth rate at her age? Select one answer only.

Nutrition

A 10-year-old boy was the backseat belted passenger in a high-speed motor vehicle collision. On presentation to the ER, he is awake, alert, and hemodynamically stable. He is complaining of abdominal pain and has an ecchymosis on his anterior abdominal wall where the seatbelt was located. Which of the following is the best next step in his management?

Observe him regardless of negative test results.

Seb, a 2-year-old boy, was at his cousin's birthday party. His mother noticed that he has suddenly developed a widespread urticarial rash and has also become flushed in the face. His vital signs are normal and he has no respiratory compromise. Which medication would you give? Select one answer only.

Oral antihistamine

A 12-year-old boy presents with an intensely pruritic rash for 3 days. He just went on a camping trip, during which he wore only short-sleeve shirts and short pants. His temperature is 37.6 C 99.7 F., blood pressure is 96/62 mm Hg, pulse is 65/min, and respirations are 12/min. There are numerous erythematous papules and vesicles on both arms and legs. Most of them are in a linear array. Which of the following is the most appropriate pharmacotherapy?

Oral prednisone

A 10-year-old boy presents to the emergency room with pain in the left testicle. The pain was acute in onset and began 1 hour ago. On physical examination, he is noted to have a high-riding, firm, and markedly tender left testis. The right testicle is normal. Urinalysis is unremarkable. Which of the following is the most appropriate management of this patient?

Orchiopexy of bilateral testicles

A 12-year-old boy comes to the emergency department at midnight with a complaint of severe scrotal pain since 7 PM. There is no history of trauma. Which of the following is the most appropriate first step in management?

Order a surgical consult immediately

A 6-month-old boy presents to the Emergency Department with a three-day history of cough, congestion and low grade fever. The mother states that the baby has not been feeding well and has used only two diapers over the past 24 hours. Physical examination reveals a pale infant with a temperature of 37.8 C 100.1 F., pulse of 170/min, respirations of 60/min and oxygen saturation of 88% on room air. The patient exhibits nasal flaring, subcostal and intercostal retractions. Lung examination reveals diffuse wheezing. Cardiac examination reveals a regular but tachycardic rhythm with no murmur. Central capillary refill is four seconds. The remainder of the examination is normal. Which of the following is the most appropriate initial step in management?

Oxygen therapy

A 10-year-old girl with blue eyes and blonde hair is brought to the office by her mother for a routine check-up. All her immunizations are up to date. Her family history is significant for myocardial infarction in her father and schizophrenia in a maternal uncle. There is no family history of any skin malignancies. Her height is at the 60th percentile, and weight is at the 56th percentile. While you are examining her, the mother says with much concern that she saw a television program that claimed that the incidence of skin cancer is increasing dramatically. She wants to know the best way to prevent skin cancer in her daughter, especially since they live in California. What is the best advice to help prevent malignant melanoma in this child?

Protective clothing

A 7-year-old Caucasian boy with a history of cystic fibrosis presents to the emergency department with a two-day history of high-grade fever and cough productive of purulent, green-colored sputum. He also complains of chest pain, which is worsened by breathing. His temperature is 39.6°C 103.2°F., pulse is 112/min, respirations are 26/min, and blood pressure is 90/60 mm Hg. Chest examination shows dullness on percussion and increased tactile fremitus in the right lung base. Chest x-ray shows a right lower lobe infiltrate. Which of the following is the most appropriate pharmacotherapy for this patient?

Piperacillin and tobramycin

A mother has her routine 20-week antenatal scan. The sonographer finds the fetal abdominal and head circumference measurements are normal, but is concerned that there is an abnormally small amount of amniotic fluid oligohydramnios.. What is the most likely cause for this. Select one answer only.

Poorly functioning fetal kidneys

A 12-year-old boy is brought to the office by his mother due to a two-week history of generalized edema which is gradually progressing. His past medical history is insignificant. He is not taking any medications. His blood pressure is 110/80 mmHg, pulse is 85/min, respirations are 18/min, and temperature is 36.7C 98F.. The laboratory findings are as follows: Serum sodium 140 mEq/L, Serum potassium 3.7 mEq/L, Serum albumin 2.1 g/dl, Serum globulin 6.0 g/dl, Serum creatinine 1.0 mg/dl. Urinalysis reveals proteinuria 3+. What is the best next step in the management of this patient?

Prednisone

Sophia, an 18-month-old girl, is brought to outpatients by her mother, who is very worried as she has developed breasts. She is otherwise well and has been growing normally. On examination she has breast development stage 3 BIII. but no pubic or axillary hair. Her bone age is 20 months. What is the most likely cause of her early pubertal development? Select one answer only.

Premature thelarche

A 1-year-old presents for a well-child checkup, but the parents are concerned about giving the child his immunizations. Which of the following is a true contraindication to the administration of the fourth DTaP diphtheria and tetanus toxoid and acellular pertussis. vaccine?

Prolonged seizures 6 days after the last DTaP vaccine

A 10-year-old boy is brought to the ER by his mother because he has lost consciousness, while playing in the yard. He regained his consciousness quickly without following confusion. He never had such an episode before. His past medical history is significant for impaired hearing since birth and one episode of pneumonia three years ago, which required hospitalization. The family history is significant for a sudden cardiac death, in his cousin, at the age of 13. Physical examination is unremarkable. Blood pressure is 110/70 mmHg. Heart rate is 70/min, regular. Which of the following medication is most appropriate for this patient?

Propranolol

Sophie is a well 8-week-old baby who was born at term. She has come for a routine developmental check. Which of the following would you NOT expect her to be able to do? Select one answer only.

Reach out and grasp an object

Ben, aged 9 months, has had a 3 day history of diarrhoea and vomiting. On examination he is found to be quiet but alert, is tachypnoeic, has a tachycardia but normal pulses, dry mouth, no mottling of the skin but reduced skin turgor and a sunken fontanelle. Capillary refill time is 2 seconds. His blood pressure is normal for his age. He continues to vomit even with oral rehydration solution given via a nasogastric tube. Ben's plasma sodium is found to be 156 mmol/L normal range, 135-145 mmol/L.. He needs fluid as he has clinical dehydration. How would this fluid best be replaced? Select one answer only.

Rehydration over 48 hours with 0.9% or 0.45% saline

A black mother is found to have glycosuria at her midwife appointment at 32 weeks' gestation. Her glucose tolerance test and fasting glucose is abnormal. She is given dietary advice to control her blood glucose. What problem is her newborn baby at most increased risk of? Select one answer only.

Respiratory distress syndrome

A midwife is concerned that a mother who is at 32 weeks' gestation has a symphysis-fundal height smaller than expected. An ultrasound confirms intrauterine growth restriction. Which feature would be of most concern to the sonographer? Select one answer only.

Reverse end-diastolic flow in the umbilical artery

Benjamin is a 6-year-old boy who is seen in the paediatric emergency department. He has been vomiting and has had diarrhoea for 3 days. His stool is watery and foul smelling but has no blood in it. He has not been out of the UK since he was born. Examination reveals mild dehydration but is otherwise normal. What is the most likely organism that has caused his symptoms? Select one answer only.

Rotavirus

Rhys is a 4-year-old boy from Wales who is referred acutely to the paediatric team as he has developed pneumonia. He has also had increasing weakness in his legs. He has been admitted to the ward. Investigations reveal he has Duchenne muscular dystrophy. Who is the most appropriate person to inform the parents about his diagnosis? Select one answer only.

Senior doctor

A 10-year-old girl is brought to the physician because of throat pain, anorexia, and fever for 2 days. Her temperature is 38.9 C 102 F.. The patient's history is negative for allergic diseases. She has had two episodes of pharyngotonsillitis over the past several years. Examination reveals a purulent exudate in the posterior oropharynx and enlarged tonsils. There is bilateral tender enlargement of anterior cervical lymph nodes. Cardiac and chest auscultation is normal. A rapid strep test ispositive. Which of the following is the most appropriate next step in management?

Symptomatic treatment and oral penicillin V

Ryan, aged 10 months, is rushed to the children's emergency department after being found submerged in the bath. His mother runs screaming into the department saying 'Help my baby, please'. Which is the next most appropriate step? Select one answer only.

Stimulate the baby and shout for help

A 2 week post mature baby is born and immediately exhibits severe respiratory distress. Previously, green-tinged meconium was noted in the amniotic fluid. Which of the following is the most appropriate next step?

Suction the mouth and nasopharynx

There has been a dramatic decline in the incidence of sudden infant death syndrome in the UK. Which of the following is the single most important factor responsible for this decline?

Supine sleeping

A 12-year-old boy is brought to the physician because of right groin pain, knee pain, and limping. He has had these symptoms for the past 2 weeks. He is at the 90th percentile for weight and 60th percentile for height. He is afebrile, and his other vital signs are within normal limits. Examination shows that the range of motion of the right knee joint is within normal limits but hip movements are restricted and the right foot points outward. There is external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?

Surgical pinning of the fen1oral head

A 6-year-old child, attempting to pet a neighbor's domestic dog while the dog is eating, is bitten in the hand. The dog has been vaccinated regularly. Which of the following steps are needed for rabies prophylaxis in this case?

The dog should be observed for behavioral changes suggestive of rabies

A 10-year-old boy is brought to the psychiatrist by his mother. She states that for the past 2 months he has been increasingly irritable, withdrawn, and apathetic. He has been refusing to do his homework, and his grades have dropped. Which of the following is the best next step in management?

The child should receive an antidepressant medication

Mohammed is 24 hours old. His mother develops chicken pox varicella. 1 day after his delivery. From the following list of options what is the best advice you could give? Select one answer only.

There is a significant risk of serious neonatal infection

Gerald is a 16-month-old boy who has not yet said his first word and does not babble much. His mother believes he does not hear well because he does not startle when a door slams or show any response to his name. His development is otherwise normal. Which test would be best to assess Gerald's hearing? Select one answer only.

Visual reinforcement audiometry

Which of the following is the most common type of congenital heart disease in the UK? Select one answer only.

Ventricular septal defect

Daniel is a 15-year-old boy who went to see his general practitioner as he has been tired and not 'quite right' for the last 2 months. The general practitioner obtained a full blood count to see if he was anaemic. The haematology laboratory phone you, a newly qualified doctor, at 6 PM in the hospital saying they have received a full blood count on Daniel and his white cells are 200 × 109 /L and that there are blast cells. You ring Daniel's parents at home and tell them they need to come to the oncology ward at the hospital as the results of his blood tests are abnormal. They ask you what the abnormalities are and you tell them you will explain more when they come in. You ring the consultant who says he will come to the hospital to speak to the parents. When the parents arrive you ask them to wait 20 minutes until the consultant arrives and he will explain more. What is least ideal about the situation? Select one answer only.

You asked the family to come to an oncology ward rather than the paediatric assessment unit

A 6-year-old boy develops symptoms of cough, fever, and malaise followed by a generalized maculopapular rash that has spread from the head downwards. A clinical diagnosis of measles is made. A few days after the onset of the rash he is drowsy, lethargic, and complaining of headache. A lumbar puncture, electroencephalogram EEG., and computerized tomography CT. of the brain exclude other etiologies and confirm the diagnosis of encephalitis. Which of the following is the most likely delayed neurologic complication of measles virus encephalitis?

mental retardation or epilepsy

A 10-year-old boy presents with red discoloration of the urine since the morning. He is healthy and otherwise asymptomatic. He denies dysuria, frequency, urgency, flank, or abdominal pain. His BP is normal. His examination is within normal limits including abdomen and genitourinary system. There is no rash or edema. His urine is pink in color; urinalysis is negative for hemoglobin or protein. No white cells, red cells, or bacteria are noted. Which of the following is the most appropriate next step?

obtain a recent dietary and drug history