Pediatric Flashcard

A child can walk well holding on to furniture but is slightly wobbly when walking alone. She uses a neat pincer grasp to pick up a pellet, and she can release a cube into a cup after it has been demonstrated to her. She tries to build a tower of two cubes with variable success. She is most likely at which of the following age?

1 year

A 10-year-old boy, the star pitcher for the Salt Lake City Little League baseball team, had a sore throat about 2 weeks ago but did not tell anyone because he was afraid he would miss the playoffs. Since several children have been diagnosed with rheumatic fever in the area, his mother is wor- ried that he may be at risk as well. You tell her that several criteria must be met to make the diagnosis but the most common finding is which of the following?

Arthralgia

A 7-year-old boy has cramping abdominal pain and a rash mainly on the back of his legs and buttocks as well as on the extensor surfaces of his forearms. Laboratory analysis reveals proteinuria and microhematuria. You diagnose Henoch-Schönlein, or anaphylactoid, purpura. In addition to his rash and abdominal pain, what other finding is he likely to have?

Arthritis or arthralgia

During a regular checkup of an 8-year-old child, you note a loud first heart sound with a fixed and widely split second heart sound at the upper left sternal border that does not change with respirations. The patient is otherwise active and healthy. Which of the following heart lesions most likely explains these findings?

Atrial septal defect ASD.

A 4-month-old infant is brought to your clinic by his mother . The mother said that when she took the babyfor a 2-month examination at a health center, the nurse said the baby had a "cold" and could not receive his immunizations. The baby has gotten only his 1stOral Polio and hepatitis B immunization in the hospital.The baby has had ARI for the past week, but according to the mother he is happy, interactive, afebrile, and feeding well. On physical examination, the baby is appropriate weight and length for age, smiles and interacts, and the rest of the exam is completely normal with the exception of minimal clear nasaldischarge. Which immunization should be given to this childnow, according to the national EPIrecommendations?

BCG, hepatitis B, diphtheria-tetanus-pertussis DTaP., poliomyelitis vaccine OPV.

A 6-year-old child is hospitalized for observation because of a short period of unconsciousness after a fall from a playground swing. He has developed unilateral pupillary dilatation, focal seizures, recurrence of depressed consciousness, and hemiplegia. Which of the following is the most appro- priate management at this time?

CT scan

A 6-week-old child arrives with a complaint of "breathing fast" and a cough. On examination you note the child to have no temperature eleva- tion, a respiratory rate of 65 breaths per minute, and her oxygen saturation to be 94%. Physical examination also is significant for rales and rhonchi. The past medical history for the child is positive for an eye discharge at 3 weeks of age, which was treated with a topical antibiotic drug. Which of the following organisms is the most likely cause of this child's condition?

Chlamydia trachomatis

A 6-week-old infant is admitted to the hospital with jaundice. Her out- patient blood work demonstrated a total bilirubin of 12 mg/dL with a direct portion of 3.5 mg/dL. Which of the following disorders is most likely to be responsible?

Choledochal cyst

The parents of a 3-year-old patient followed in your clinic recently took their child on quickly planned 5-day trip to Africa to visit an ill grand-parent. Everyone did well on the trip, but since their return about 10 days ago the boy has been having intermittent, spiking fevers associated with headache, sweating, and nausea. The parents had not been too concerned since he was relatively well, except for being tired, between the fevers. Today, however, they feel that he looks a bit pale and his eyes appear "yellow." Which of the following is likely to reveal the source of his problem?

Complete blood count CBC. with smear

The mother of a 2-week-old infant reports that since birth, her infant sleeps most of the day; she has to awaken her every 4 hours to feed, and she will take only an ounce of formula at a time. She also is concerned that the infant has persistently hard, pellet-like stools. On your examination you find an infant with normal weight and length, but with an enlarged head. The heart rate is 75 beats per minute and the temperature is 35°C 95°F.. The child is still jaundiced. You note large anterior and posterior fontanelles, a distended abdomen, and anumbilical hernia. This clinical presentation is likely a result of which of the following

Congenital hypothyroidism

A 5-year-old boy is brought into the ER immediately after an unfortunate altercation with a neighbor's immunized Chihuahua that occurred while the child was attempting to dress the dog as a superhero. The fully immu- nized child has a small, irregular, superficial laceration on his right forearm that has stopped bleeding. His neuromuscular examination is completely normal, and his perfusion is intact. Management should include which of the following? A. Irrigation and antimicrobial prophylaxis B. Tetanus booster immunization and tetanus toxoid in the wound C. D. Primary rabies vaccination for the child E. Destruction of the dog and examination of brain tissue for rabies

Copious irrigation

A 14-year-old girl has a 9-month history of diarrhea, abdominal pain usually periumbilical and postprandial., fever, and weight loss. She has had several episodes of blood in her stools. Which of the following is the most likely diagnosis?

Crohn disease

A previously healthy 8-year-old boy has a 3-week history of low-grade fever of unknown source, fatigue, weight loss, myalgia, and headaches. On repeated examinations during this time, he is found to have developed a heart murmur, petechiae, and mild splenomegaly. Which of the following is the most likely diagnosis?

Endocarditis

The 3-year-old sister of a newborn baby develops a cough diagnosed as pertussis by nasopharyngeal culture. The mother gives a history of having been immunized as a child. Which of the following is a correct statement regarding this clinical situation?

Erythromycin should be administered to the infant.

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 2950-g baby boy is born at home at term. On arrival at the hospital, he appears pale, but the physical examination is otherwise normal. Laboratory studies reveal the following: mother's blood type A, Rh-positive; baby's blood type O, Rh-positive; hematocrit 38%; and reticulocyte count 5%. Which of the following is the most likely cause of the anemia?

Fetomaternal transfusion

A previously healthy 18-month-old has been in a separate room from his family. The family notices the sudden onset of coughing, which resolves in a few minutes. Subsequently, the patient appears to be normal except for increased amounts of drooling and refusal to take foods orally. Which of the following is the most likely explanation for this toddler's condition?

Foreign body in the esophagus

A mentally retarded 14-year-old boy has a long face, large ears, micropenis, and large testes. Chromosome analysis is likely to demonstrate which of the following?

Fragile X syndrome

A 12-month-old girl has been spitting up her meals since 1 month of age. Her growth is at the 95th percentile, and she is otherwise asymptomatic and without findings on physical examination. Which of the following is the most likely diagnosis?

Gastroesophageal reflux

A 14-year-old child has headache, hypertension, edema, and a change in urine output and color.Match above clinical condition with the most likely cause

Glomerulonephritis

A 17-year-old boy is brought to the emergency department by his parents with the complaint of coughing up blood. He is stabilized, and his hemoglobin and hematocrit levels are 11 mg/dL and 33%, respectively. During his ospitalization, he is noted to have systolic blood pressure persistently greater than 130 mm Hg and diastolic blood pressure greater than 90 mm Hg. His urinalysis is remarkable for hematuria and proteinuria. You are suspicious the patient has which of the following?

Goodpasture syndrome

A mother wishes to breast-feed her newborn infant, but is worried about medical conditions that would prohibit her from doing so. You coun- sel her that of her listed conditions, which of the following is a contraindication to breast-feeding?

HIV infection

A 4-year-old boy, whose past medical history is positive for three urinary tract infections, presents with a blood pressure of 135/90 mm Hg. He is likely to exhibit which of the following symptoms or signs?

Headache

A 3-day-old infant was born to a mother with active systemic lupus erythematosus SLE.. Match above clinical condition with the most likely cause

Heart block

A healthy 1-year-old child comes to your office for a routine checkup and for immunizations. His parents have no complaints or concerns. The next day, the CBC you performed as customary screening for anemia returns with the percentage of eosinophils on the differential to be 30%. Which of the following is the most likely explanation?

Helminth infestation

A 4-year-old boy and his family have recently visited a local amusement park. Several of the family members developed "gastroenteritis" with fever and diarrhea, but the 4-year-old's stool was slightly different, as it contained blood. His mother reports that in the past 24 hours he developed pallor and lethargy; she relates that his face looks swollen and that he has been urinating very little. Laboratory evaluation reveals a hematocrit of 28% and a platelet count of 2,000/μL. He has blood and protein in the urine. Which of the following diagnoses is most likely to explain these symptoms?

Hemolytic-uremic syndrome

Blood samples of a 3-day-old full-term infant are sent for screening to iden- tify diseases that would have serious, permanent consequences without prompt and appropriate treatment. Select the most appropriate treatment for Hypothyroidism

Hormone therapy

Two weeks after a viral syndrome, a 2-year-old child develops bruising and generalized petechiae, more prominent over the legs. No hepatospleno- megaly or lymph node enlargement is noted. The examination is otherwise unremarkable. Laboratory testing shows the patient to have a normal hemo- globin, hematocrit, and white blood cell WBC. count and differential. The platelet count is 15,000/μL. Which of the following is the most likely diagnosis?

Idiopathic immune. thrombocytopenic purpura ITP.

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.

You are awakened in the night by your 2-year-old son, who has deve- loped noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils, and a barking cough. He has had a mild upper respiratory infection URI. for 2 days. Which of the following therapies is indicated?

Inhaled epinephrine and a dose of steroids

A 15-year-old is participating in high school football practice in August in Texas. He had complained of headache and nausea earlier in practice, but kept playing after a cup of water. He is now confused and combative. He is dizzy and sweating profusely. His temperature is 41°C 105.8°F.. Therapy should consist of which of the following?

Initiate whole body cold water immersion

At 43 weeks' gestation, a long, thin infant is delivered. The infant is apneic, limp, pale, and covered with "pea soup" amniotic fluid. Which of the following is the best first step in the resuscitation of this infant at delivery?

Intubation and suction of the trachea; provision of oxygen

After being delivered following a benign gestation, a newborn infant is noted to have a platelet count of 35,000/μL, decreased fibrinogen, and ele- vated fibrin spilt products. On examination you note a large cutaneous heman- gioma on the abdomen that is purple and firm. Which of the following anomalies might also be expected in this infant?

Kaposiform hemangioendothelioma

The mother of a 6-month-old infant is concerned that her baby may be teething. You explain to her that the first teeth to erupt in most children are which of the following?

Mandibular central incisors

A 10-year-old girl has had a "cold" for 14 days. In the 2 days prior to the visit to your office, she has developed a fever of 39°C 102.2°F., purulent nasal discharge, facial pain, and a daytime cough. Examination of the nose after topical decongestants shows pus in the middle meatus. Which of the following is the most likely diagnosis?

Maxillary sinusitis

One of your asthmatic patients arrives for a checkup. The mother reports that the child seems to need albuterol daily, especially when exercising, and she has coughing fits that awaken her from sleep about twice a week. Her grandmother had recommended a Chihuahua as a "cure" for her asthma, but her mother has seen no difference since the arrival of the pet. Appropriate treatment measures would include which of the following?

Medium-dose, inhaled corticosteroids with short-acting β-agonists

A newborn's mother complains that her infant seems to have very small white dots all over his nose. The dots do not wipe off with bathing, but they are also not erythematous. Many rashes and skin lesions can be found first in the newborn period. For the descriptions listed above, select the most likely diagnosis.

Milia

Your 6-year-old son awakens at 1:00 AM screaming. You note that he is hyperventilating, is tachycardic, and has dilated pupils. He cannot be consoled, does not respond, and is unaware of his environment. After a few minutes, he returns to normal sleep. He recalls nothing the following morning. Which of the following is the most likely diagnosis?

Night terrors

An 8-month-old infant arrives to the emergency department ED. with a 2-day history of diarrhea and poor fluid intake. Your quick examination reveals a lethargic child; his heart rate is 180 beats per minute, his respiratory rate is 30 breaths per minute, and his blood pressure is low for age. He has poor skin turgor, 5-second capillary refill, and cool extremities. Which of the following fluids is most appropriate management for his condition?

Normal saline

A 9-month-old is brought to the emergency center by ambulance. The child had been having emesis and diarrhea with decreased urine out- put for several days, and the parents noted that she was hard to wake up this morning. Her weight is 9 kg, down from 11 kg the week prior at her 9-month checkup. You note her heart rate and blood pressure to be normal. She is lethargic, and her skin is noted to be "doughy." After confirming that her respiratory status is stable, you send electrolytes, which you expect to be abnormal. You start an IV. Which of the following is the best solution for an initial IV bolus?

Normal saline 154 mEq sodium/L.

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.

The parents of a 2-year-old bring her to the emergency center after she had a seizure. Although the parents report she was in a good state of health, the vital signs in the emergency center reveal a temperature of 39°C 102.2°F.. She is now running around the room. Which part of the story would suggest the best outcome in this condition?

Otitis media on examination.

Aunt Mary is helping her family move to a new apartment. During the confusion, 3-year-old Jimmy is noted to become lethargic. The contents of Aunt Mary's purse are strewn about on the floor. In the ER, the lethargic Jimmy is found to have miosis, bradycardia, and hypotension. He develops apnea, respiratory depression, and has to be intubated. His condition would most likely benefit from which of the following therapies?

Pediatric intensive care unit PICU. support and trial of naloxone

A 10-year-old boy has been having "bellyaches" for about 2 years. They occur at night as well as during the day. Occasionally, he vomits after the onset of pain. Occult blood has been found in his stool. His father also gets frequent, nonspecific stomachaches. Which of the following is the most likely diagnosis?

Peptic ulcer

A 14-month-old infant suddenly develops a fever of 40.2°C 104.4°F.. Physical examination shows an alert, active infant who drinks milk eagerly. No physical abnormalities are noted. The WBC count is 22,000/μL with 78% polymorphonuclear leukocytes, 18% of which are band forms. Which of the following is the most likely diagnosis?

Pneumococcal bacteremia

A 5-year-old girl without past history of UTI is in the hospital on antibio- tics for Escherichia coli pyelonephritis. She is still febrile after 4 days of appro- priate antibiotics. A renal ultrasound revealed no abscess, but a focal enlargement of one of the lobes of the right kidney. CT of the abdomen reveals a wedge- shaped area in the right kidney distinct from the normal tissue with minimal contrast enhancement. Appropriate management of this patient includes which of the following interventions?

Prolonged antibiotic therapy

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 2-month-old child of an HIV-positive mother is followed in your pediatric practice. Which of the following therapies should be considered for this child?

Prophylaxis against Pneumocystis jiroveci pneumonia Pneumocystis carinii.

A nurse calls you to evaluate an African American newborn whom she thinks has a bacterial skin infection. The areas in question have many scat- tered pustules full of a milky fluid. Upon examining pustules, they easily wipe away, revealing a small hyperpigmented macule. Many rashes and skin lesions can be found first in the newborn period. For the descriptions listed above, select the most likely diagnosis.

Pustular melanosis

A 2-year-old presents to the emergency center with several days of rectal bleeding. The mother first noticed reddish-colored stools 2 days prior to arrival and has since changed several diapers with just blood. The child is afebrile, alert, and playful, and is eating well without emesis. He is slightly tachycardic, and his abdominal examination is normal. Which of the follow- ing is the best diagnostic study to order to confirm the diagnosis?

Radionucleotide scan

You are called to a delivery of a woman with no prenatal care; she is in active labor but has no history of amniotic rupture. The biophysical pro- file done in the emergency center revealed severe oligohydramnios. When you get this infant to the nursery, you should carefully evaluate him for which of the following?

Renal agenesis

A 14-year-old girl awakens with a mild sore throat, low-grade fever, and a diffuse maculopapular rash. During the next 24 hours, she develops tender swelling of her wrists and redness of her eyes. In addition, her physician notes mild tenderness and marked swelling of her posterior cervical and occipital lymph nodes. Four days after the onset of her illness, the rash has vanished. Which of the following is the most likely diagnosis?

Rubella

The obstetrical resident on call asks you to evaluate an area of a newborn's scalp that seems to have no hair and is scaly and yellowish. Many rashes and skin lesions can be found first in the newborn period. For the descriptions listed above, select the most likely diagnosis.

Sebaceous nevus

A newborn's father complains that his son has dandruff, with many waxy flakes of skin on the scalp. When he scrapes the lesions, hair often comes off with the flakes of skin. In addition, the baby has flaking of the eyebrows. Many rashes and skin lesions can be found first in the newborn period. For the descriptions listed above, select the most likely diagnosis.

Seborrheic dermatitis

You are admitting to the hospital a 3-month-old infant who has been having poor feeding, emesis, and diarrhea for 3 days. In the emergency center, her electrolytes were found to be: sodium 157 mEq/L, potassium 2.6 mEq/L, chloride 120 mEq/L, bicarbonate 14 mEq/L, creatinine 1.8 mEq/L, blood urea nitrogen BUN. 68 mEq/L, and glucose 195 mEq/L. She was given a fluid bolus in the emergency center and has subsequently produced urine. Which of the following is the most appropriate next step in her management?

Slow rehydration over 48 hours

As part of your anticipatory guidance to new parents of a healthy new- born, you suggest putting the child in which of the following positions for sleep?

Supine position

A 14-year-old high school student arrives to your clinic for well-child care. In reviewing his records you determine that his most recent immunization for tetanus was at 4 years of age. Which of the following should you recommend?

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed Tdap.

A routine prenatal ultrasound reveals a male fetus with meningomyelocele. The 24-year-old primigravid mother is told the infant will require surgery shortly after birth. You counsel her about the etiology of this defect and the risk of further pregnancies being similarly affected, and state which of the following?

The hereditary pattern for this condition is autosomal recessive.

A 28-year-old primigravida develops an erythematous skin discoloration in the upper outer quadrant of the left breast. She has achy, flu-like symptoms and fever to 38.3C. You suspect bacterial mastitis. At this time, what would you do?

continue breastfeeding and treat the mother with hot compresses and antibiotics

After two more visits, the mother decides to bottle-feed. She returns when the child is 3 months old, complaining that the infant is constipated. After a careful history, you find that the infant has one hard stool a day but otherwise has no symptoms. On examination, the infant is well hydrated and has had adequate weight gain. The physical exam, including the anal sphincter tone, is normal. You advise which of the following?

explain to the mother that formula-fed babies generally have fewer stools than breast-fed babies. If the infant is having a stool every 1 to 3 days and has no symptoms, no treatment is needed

A 4-month-old infant is brought to your clinic by his mother . The mother said that when she took the babyfor a 2-month examination at a health center, the nurse said the baby had a "cold" and could not receive his immunizations. The baby has gotten only his 1stOral Polio and hepatitis B immunization in the hospital.The baby has had ARI for the past week, but according to the mother he is happy, interactive, afebrile, and feeding well. On physical examination, the baby is appropriate weight and length for age, smiles and interacts, and the rest of the exam is completely normal with the exception of minimal clear nasaldischarge. Which of the following statements regarding future immunizations for the child is true?

give an immunization even if the child has a low-grade fever or a runny nose

A 4-month-old infant is brought to your clinic by his mother . The mother said that when she took the babyfor a 2-month examination at a health center, the nurse said the baby had a "cold" and could not receive his immunizations. The baby has gotten only his 1stOral Polio and hepatitis B immunization in the hospital.The baby has had ARI for the past week, but according to the mother he is happy, interactive, afebrile, and feeding well. On physical examination, the baby is appropriate weight and length for age, smiles and interacts, and the rest of the exam is completely normal with the exception of minimal clear nasaldischarge. Which of the following statements is true regarding hepatitis B vaccine in children?

it is recommended as a routine immunization, and the first dose should be given prior to discharge from the hospital after birth

A 3-year-old refuses to walk, is afebrile, had an upper respiratory tract infection a week ago, has right hip pain with movement, and has a normal WBC count. For case above, select the most likely diagnosis.

Transient synovitis

Examination of the cerebrospinal fluid CSF. of an 8-year-old, mildly febrile child with nuchal rigidity and intermittent stupor shows the following: WBCs 85/μL all lymphocytes., negative Gram stain, protein 150 mg/dL, and glucose 15 mg/dL. A computed tomographic CT. scan with contrast shows enhancement of the basal cisterns by the contrast material. Which of the fol- lowing is the most likely diagnosis?

Tuberculous meningitis

A 17-year-old adolescent female is 6 weeks postpartum. She presents to the emergency room with the complaints of increased jaundice, abdomi- nal pain, nausea, vomiting, and fever. Her examination is remarkable for jaundice, pain of the right upper quadrant with guarding, and a clear chest. Chest radiographs appear normal. Which of the following tests is most likely to reveal the cause of this pain?

Ultrasound of the right upper quadrant

A 2-month-old infant comes to the emergency center with fever for 2 days, emesis, a petechial rash, and increasing lethargy. In the ambulance he had a 3-minute generalized tonic/clonic seizure that was aborted with lorazepam. He does not respond when blood is drawn or when an IV is placed, but he continues to ooze blood from the skin puncture sites. On examination, his anterior fontanelle is open and bulging. His CBC shows a WBC of 30,000 cells/μL with 20% band forms. Which of the infant's problems listed below is a contraindication to lumbar puncture?

Uncorrected bleeding diathesis

A 3-day-old infant born at home is brought to the emergency center with bloody stools,hematemesis, and purpura. His circumcision is oozing blood. For presented child above, choose the one most appropriate vitamin or trace element replacement therapy to treat the described condition.

Vitamin K

A mother comes to your office with her 8-week-old infant girl. The mother is tearful and depressed. She has been trying to breastfeed, but she tells you, "I'm obviously inadequate. I'm not producingenough milk, and the baby is fussy all of the time." On examination, the infant looks thin. Since her lastcheckup 3 weeks ago, she has gained only 90 g. The rest of the physical examination is normal. At this time, what should you not do?

advise immediate and complete cessation of breast milk with switch to formula

A 4-month-old infant is brought to your clinic by his mother . The mother said that when she took the babyfor a 2-month examination at a health center, the nurse said the baby had a "cold" and could not receive his immunizations. The baby has gotten only his 1stOral Polio and hepatitis B immunization in the hospital.The baby has had ARI for the past week, but according to the mother he is happy, interactive, afebrile, and feeding well. On physical examination, the baby is appropriate weight and length for age, smiles and interacts, and the rest of the exam is completely normal with the exception of minimal clear nasaldischarge. Which of the following statements regarding immunization against measlesis true?

measles vaccine should be given at age 9 months

A 3.3 kg infant delivered at 396 weeks arrives in the OPD of a pediatric hospital with normal vital signs and a respiratory rate of 80 breaths/ minute. The labor and subsequent delivery were precipitous according to the labor and delivery midwife.Which of the following statements is true?

normal respiratory rate in a newborn is less than 60 breaths/minute

A 15-month-old is seen in your office for the 4th time this month with unexplained intermittent episodes of fever of 39°C. The mother has used children's ibuprofen to treat the fever and has been able to bring the temperature down to 38°C. However, the mother is now frustrated because thisis her 4th visit to the office and nobody knows why her child is continuing to have these fevers. The child is not in day care and has no history of any serious illnesses, travel, or sick contacts. The child has had no symptoms of an upper respiratory infection. On examination, the child is actively playing with his toys. He does not look ill. His rectal temperature is 39°C. The head, neck, lungs, cardiovascular, abdominal, neurologic, and musculoskeletal examination are all normal.Your clinical judgment is that the child looks well and has no serious illness. What is your diagnosis at this time?

recurrent viral infection

A 3.3 kg infant delivered at 396 weeks arrives in the OPD of a pediatric hospital with normal vital signs and a respiratory rate of 80 breaths/ minute. The labor and subsequent delivery were precipitous according to the labor and delivery midwife. Which of the following is manifest during the first hours after delivery?

transient tachypnea of the newborn

Amother of a 2-month-old wants more information about immunizations. Which of the following statements regarding immunization against Haemophilus influenzae type b Hib. is correct?

Hib vaccine can be administered effectively as early as 2 months of age.

All of the following are included in the revised Jones Major criteria EXCEPT:

Maculopapular rash

The earliest sign of congestive heart failure on a chest X-ray is:

Increased heart size.

Ellie, a 7-year-old girl, is newly diagnosed with diabetes mellitus. She has been drinking lots of fluid and has had to pass urine frequently. She has a markedly raised blood glucose 20 mmol/L. and heavy glycosuria. Which of the following is most likely to be true about her diabetes? Select one answer only.

There is autoimmune pancreatic β-cell damage

A 3-year-old boy presents with acute right leg pain and a limp. There is no history of trauma. He holds his right hip in external rotation and flexion and he has mild restriction of range of motion. He appears otherwise well and is afebrile. His WBC is normal and ESR is 25 mm/h. What is the best treatment option at this time?

anti-inflammatory drugs and bed rest

Infants typically double their birth weight by what age?

4 months

A 4-year-old girl had bloody diarrhea for several days. One week later she develops periorbital edema and fatique. What is the most likely laboratory finding?

anemia and thrombocytopenia

Apreviously healthy 3-month-old infant develops generalized weakness with difficulty in sucking, swallowing, and crying, and labored breathing. No fever is present. Which study will most likely provide the diagnosis?

stool culture

An infant is born to a mother who acquired primary CMV infection during pregnancy. What will be the most likely finding in this infant?

subclinical infection

Which of the following best describes patients with constitutional growth delay?

they will achieve normal adult height

A concerned young parents asking about frequent lying behavior experienced by their 3-year-old girl. The following advices are true EXCEPT

it indicates a potential for future lying behavior

Which of the following best describes atopic​ dermatitis in children?

it is characterized by pruritus and lichenification

Which of the following best describes idiopathic scoliosis?

it is most commonly noted during preadolescence or adolescence

James, aged 11 years, has type 1 diabetes mellitus. While playing football during the mid-morning break at a holiday camp, he suddenly feels faint. His classmates call the supervisor who finds him lying unresponsive in the playground. What should be his immediate management? Select one answer only.

Give buccal glucose gel

An infant is born to a mother who is HBsAg positive. What should be the next step?

Give infant hepatitis B immune globulin and hepatitis B vaccine.

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

0-12 months

A 7 year old girl presents with a tender and swollen right knee as well as a more recently appearing swollen left wrist. She also has a fever. This patient fulfills which of the following modified Jones criteria?

1 Major 2 minors

A 3-year-boy with severe hypotonia and mild mental retardation is severely obese. He is obsessed with eating and does not have a sense of satiation. What abnormality will you most likely find

micropenis and cryptorchidism

Anewborn has delayed passage of meconium stools and barium enema radiograph shows dilated proximal colon and small obstructed distal colon. What should be the next diagnostic test?

rectal suction biopsies

A16-month-old girl presents with acute onset of truncal ataxia with vomiting, nystagmus, and dysarthria. She is afebrile and has no nuchal rigidity. Which of the following historical items would help you to identify a cause for these symptoms?

sore throat with blisters on palate 3 weeks ago

Which of the following represents the occurrence of significant bilateral hearing loss in infants in well newborn nurseries in the United States?

1/1000

Which of the following is the normal, or average, hemoglobin concentration in a 12-monthold infant?

12 g/dL

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

Which of the following represents the ethnic group with the highest neonatal and infant mortality rates in the United States?

African-American

A 5-year old boy comes with overnight petechial spots 2 weeks back he had history of abdominal pain and no hepato-splenomegaly. Diagnosis is:

Aplastic anemia

A 1-month-old infant is seen in a well-baby clinic. The mother states that the baby is constipated and feeds poorly. On examination, he is jaundiced, has a large posterior fontanel and an umbilical hernia, and exhibits poor muscle tone. He has gained only 300 g since discharge from the normal newborn nursery. Which of the following is the most likely diagnosis?

Congenital hypothyroidism

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 previously healthy, active, 18-month-old African American child presents with unilateral nasal obstruction and foul-smelling discharge. The child's examination is otherwise unremarkable. Which of the following is the most likely diagnosis?

Foreign body

A12-month-old child has had poor weight gain. The child started to have loose stools at the age of 8 months and has a very poor appetite. On examination, you see a clingy, irritable child with very little subcutaneous fat and a protuberant abdomen. What is the next best test?

IgA-endomysial antibody

The species of malaria associated with adherence to endothelial walls, cerebral malaria, and a high mortality rate is:

P. falciparum

Failure to initiate and maintain spontaneous respiration following birth is clinically known as

Respiratory failure

Which viral infection involving the CNS is likely to present with focal neurological findings?

St. Louis virus

The mother of a 2-year-old male child states that she has noticed white, cheeselike materialarising from his foreskin and also that he cannot fully retract the foreskin behind the glans penis. Which of the following is the correct advice for this parent?

The child is normal.

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

Ventricular septal defect

Encephalitis is usually the result of which of the following:

Viral

A mother comes to your office with her 5-year-old boy who has developed severe crampy diarrhea and mild fever. The family has just returned from a trip inMondulkiri province; the child became sick on the third day. He was apparently drinking water from a local stream. Which of the following pediatric infections often presents with diarrhea as the initial symptoms?

all of the above (acute appendicitis, otitis media, urinary tract infections, pneumonia)

A medical student asked you during the morning round about his observation of infants cry in response to the cry of another infant. Of the following, the MOST appropriate answer is that it represent

an early sign of empathy development

An 8-year-old male with sickle cell disease presents with 2-3 days of runny nose and mildto-moderate anterior chest pain. On chest x-ray a new infiltrate is noted in the right middle lobe. Which of the following diagnoses, is most likely?

acute chest syndrome

Which of the following would be expected in a 6-month-old child with a large ventricular septal defect?

an enlarged heart

Wilms tumor nephroblastoma. is the most frequent malignant tumor of the genitourinary tract in childhood. The most common presenting sign of this neoplasm is which of the following?

abdominal mass

A 4-week-old male infant has vomiting and a hypochloremic metabolic alkalosis. What is the next best study?

abdominal ultrasound

A3-year-old girlpresent s with a 6 weeks of runny nose, congestion, sneezing, andcough. The child seems to havelong colds especially during spring, early summer,and, occasionally, late summer. The child also hadan episode of difficulty breathing a few days ago forwhich they visited a local emergency room and weregiven an inhaler. What is the most effective pharmacologic treatmentfor the condition described here?

antihistamines

A 2-year-old child drinks kerosene that had been left in a glass. After the first swallow, she cries and drops the glass. She is most likely to develop which of the following?

chemical pneumonitis

A12-month-old infant is unable to sit by herself and parents have noticed an exaggerated startle response. What are you most likely to find on physical examination?

cherry red macular spot

An 8-month-old female presents with failure to thrive, constipation, fevers, and polydipsia. On evaluation, you find hypokalemia and hyperchloremic metabolic acidosis and suspect Fanconi syndrome. Which of the following would be the most likely inherited cause?

cystinosis

A 10-year-old boy comes to the office with fever and chills for 5 days and myalgia. He has recently returned from a 2-week vacation to NewEngland with his family. On physical examination he has mild splenomegaly. Which of the following is the most likely cause of his symptoms?

babesiosis

You evaluate an 8-year-old girl with hyperactivity and inattentiveness. Which of the following manifestations is required to make a diagnosis of attention-deficit hyperactivity disorder?

impulsivity

The usual presentation of an annular pancreas in childhood is which of the following?

vomiting

You are resident in Pediatrics, called at midnight to attend delivery of expected baby with multiple malformations and oligohydromnias as had been reported in antenatal scan, mother in stage I labor so far. Of the following, your BEST plan of action is to

call your consultant or senior resident

In comparison to cow milk, human milk contains more of what substance?

calories

An infant has been diagnosed with congenital hypoparathyroidism. What are you most likely to find on evaluation?

candidiasis

A16-year-old male presents for a sports physical. Examination reveals hypermobile joints, pes planus, and a high-arched palate. Which of the following would be most appropriate at this time?

cardiac ultrasound

A38-week infant is born to a mother with gestational diabetes. Birth weight is 4255 g. What would you expect to see most commonly in this infant?

cardiomegaly

Chronic upper airway obstruction from enlarged tonsils and adenoids in a child may cause which of the following?

cor pulmonale

A12-year-old boy has migratory arthritis with red, warm, and swollen joints. He has serologic evidence of recent group Astreptococcal infection. Arthritis in this condition is characterized by which of the following?

heals without deformity

A 9-year-old has hematuria and an increased serologic titer to antistreptolysin O ASO.. What will be the most likely finding?

decreased serum C3

The parents of an 8-year-old boy are concerned about their son's short stature. What should be the most important next step?

determination of height velocity

Which of the following is most common presentation of hypoparathyroidism beyond the neonatal period?

seizure

A 2-year-old male presents for a checkup. His parents tell you that he has been doing well, but he has had episodes of wheezing four times during the past year. He is the product of an uncomplicated pregnancy and delivery, but he was hospitalized at age 6 months for bronchiolitis. Both parents have a history of allergies, and his father has asthma. His mother smoked during pregnancy but quit smoking last year. The child was never breast-fed. Which of the following statements is false concerning asthma in children?

wheezing and cough are usually worse in the midday, after lunch, related to increased reflux

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

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

2-4 years

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

Of those babies who have prolonged crying episodes in the first 2 mo of life, the percentage that will remain having similar episodes is about

5%

A 3-year-old child presents to your office for an evaluation of consti- pation. The mother notes that since birth, and despite frequent use of stool softeners, the child has only about one stool per week. He does not have fecal soiling or diarrhea. He was born at term and without pregnancy com- plications. The child stayed an extra day in the hospital at birth because he did not pass stool for 48 hours, but has not been in the hospital since. Initial evaluation of this child should include which of the following?

A barium enema and rectal manometry

A 3-year-old child presents to your office for an evaluation of constipation. The mother notes that since birth, and despite frequent use of stool softeners, the child has only about one stool per week. He does not have fecal soiling or diarrhea. He was born at term and without pregnancy complications. The child stayed an extra day in the hospital at birth because he did not pass stool for 48 hours, but has not been in the hospital since. Initial evaluation of this child should include which of the following?

A barium enema and rectal manometry

A 13-year-old comes to your office expressing concern about his height. He had first seen you a year prior for his routine checkup and a preparticipation sports physical for soccer see growth curve.. Now in the eighth grade, all of his friends are taller than he is, and he is at a disadvantage on the soccer field playing against much larger boys. After obtaining height information from his parents shown here, you order a skeletal bone age radiograph. Which of the following results would allow you to assure him of an excellent prognosis for normal adult height?

A bone age of 9 years

A 30-hour-old infant has not passed meconium since birth. He was full term with a birth weight of 3856 g 8 lb 8 oz.. The pregnancy was uncomplicated. The baby appears well with no respiratory distress. Slight abdominal distention is noted. Rectal examination reveals a slightly tight rectum and results in a greenish gush of stool. Which of the following tests will probably confirm the likely diagnosis?

A rectal biopsy

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

Respiratory Problems in premature infants may be secondary to choose one:

A, B & C (Surfactant deficiency, Increased chest wall compliance, Incomplete alveolar development)

The fever of malaria:

A, B& C (Can be tertian occurring every 48 hours, Can be quartan occurring every 72 hours, Occur with no pattern at all)

The pathogenesis of malaria can affect which of the following organ systems:

A, B& C (Liver and brain, Lungs and kidneys, Spleen and GI tract)

A 12-year-old girl comes to the physician because of a 2-day history of periorbital edema and abdominal distention. She has no other complaints. She has never been diagnosed with hypertension. Her father died at the age of 40, with renal failure. Her temperature is 37.1°C 98.9°F., blood pressure is 125/75 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows facial puffiness, shifting dullness, and 1+ bilateral pitting pedal edema. Urinalysis shows 3+ proteinuria and lipid laden casts. 24-hour urinary protein excretion is 5 g/day, total serum protein is 4.5 g/dl and serum albumin is 2.3 g/dl. Which of the following is this patient at increased risk of developing?

Accelerated atherogenesis

The 7-year-old boy now in your office was last seen 2 weeks ago with a mild viral upper respiratory tract infection. Today, however, he presents with fever, ataxia, weakness, headache, and emesis. In the office he has a 3 minute left-sided tonic-clonic seizure. You send him to the hospital and order a magnetic resonance imaging MRI. of the brain, the results of which show disseminated multifocal white matter lesions that enhance with contrast. This boy's likely diagnosis is which of the following?

Acute disseminated encephalomyelitis

An 8-moth old infant was admitted with history of excessive crying and pain abdomen. The child is pale and having recurrent pain. An hour before hospitalization, the child was passing blood and mucous likely diagnosis is:

Acute intussusception

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

A female infant is normal at birth but develops a severe hemolytic anemia after age 6 months. Peripheral blood smear shows a microcytic, hypochromic anemia with numerous target cells and increased reticulocytes. Hemoglobin electrophoresis at 9 months of age demonstrates hemoglobin F of 90%, increased hemoglobin A2, and decreased hemoglobin. Which of the following is the most likely diagnosis?

Alpha-thalassemiatrait

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 3.3 kg infant delivered at 396 weeks arrives in the OPD of a pediatric hospital with normal vital signs and a respiratory rate of 80 breaths/ minute. The labor and subsequent delivery were precipitous according to the labor and delivery midwife. Which of the follow is not a common pathogen found in neonatal sepsis?

Bacteroidesfragilis

A 4-day-old boy is brought to the physician for an outpatient follow-up visit. His mother's pregnancy and delivery were uncomplicated. The patient weighed 3.4 kg 7.5 lb. and was 48.2 cm 1'7". long at birth. He did well in the newborn nursery and was discharged from the hospital on day 2 of life. His mother reports that he is now exclusively breastfed and nurses for 10 minutes on each breast every 3 hours. He has two wet diapers/day and has not had a bowel movement for 2 days. He weighs 2.95 kg 6.5 lb. and is 48.2 cm 1'7''. long. He appears jaundiced on the face and chest. The remainder of the physical examination shows no abnormalities. Laboratory studies reveal: Total bilirubin 15 mg/dl, direct bilirubin 1 mg/dl, Infant's blood type 0 positive, Mother's blood type A positive. Which of the following is the most likely cause of this infant's hyperbilirubinemia?

Breastfeeding failure jaundice

A 2-year-old boy with cough and difficulty breathing is brought to the emergency department by his mother. She says that he was well and playing with his toys until 2 hours prior to presentation. He is healthy, but his 6-year old brother has a peanut allergy. The patient's temperature is 36.7 C 98 F., blood pressure is 92/48 mmHg, pulse is 114/min, and respirations are 48/min. The patient's pulse oximetry shows 91 % on room air. Physical examination shows nasal flaring and grunting with both subcostal and intercostal retractions. Wheezing is heard in the right lung field; the left field is clear to auscultation. No rales or rhonchi are noted. The remainder of the physical examination is within normal limits. Supplementary oxygen is applied. Chest x-ray reveals mild hyperinflation of the right lung. Which of the following is the most appropriate next step in management of this child?

Bronchoscopy

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

A 5-month-old child regularly regurgitates a large portion of her feeds. A pH probe study showed significant periods of low esophageal pH. The child has normal growth and no other significant past medical history. Which of the following is the best management at this point?

Close observation only

A 3-month-old male infant is brought to the emergency department by his mother because of difficulty in breathing. His mother was admitted in the hospital ten days ago due to a urinary tract infection, and he was cared for by his grandmother during that period. His mother had just been discharged from the hospital yesterday, and noticed that he was constipated and having difficulty with breastfeeding. On examination, he is afebrile. His pulse rate is 110/min, respirations are 36/min with shallow breathing efforts, and blood pressure is 90/50mm Hg. His weight is at the 35th percentile. Examination shows ptosis, dilated pupils with sluggish reaction to light, diminished deep tendon reflexes and decreased muscle tone. What is the most likely mechanism of his illness?

Clostridium botulinum in the intestinal tract

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

A 1-year-old boy is brought to the clinic by his 28-year-old mother for the evaluation of his eyes. For the past several months, he has been bumping into objects. His perinatal history is unremarkable. Physical examination of the eyes reveals a bilateral white reflex. The retina cannot be visualized properly. Fundal reflection is absent, and the pupil is white. What is the most likely diagnosis?

Congenital cataract

Becky is a 7-year-old girl. She is seen by her general practitioner with a 2-day history of fever and abdominal pain. Her mother has noted that she is going to the toilet to pass urine more often than usual. On examination she is now afebrile and has no abdominal tenderness. What is the most likely diagnosis? Select one answer only.

Cystitis

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 2-year-old boy is rushed to the emergency department by his 21 -year-old white mother because he had a sudden-onset nosebleed which has now subsided. He never had any previous episodes. He is "sickly" and suffers from a productive cough and diarrhea that "refuses to go." His stools are greasy and foul-smelling. His appetite is normal, although his diet consists mainly of milk. His mother's boyfriend lives with them and is a chronic alcoholic. He was delivered vaginally without any complications. His weight is at the 25th percentile for his age. Physical examination reveals dry skin and dried blood at the nasal turbinates. What is the most likely cause of this child's failure to thrive?

Deficiency of pancreatic enzymes

A 1-year-old child presents with failure to thrive, frequent large voids of dilute urine, excessive thirst, and three episodes of dehydration not associated with vomiting or diarrhea. Over the years, other family members reportedly have had similar histories. Which of the following is the most likely diagnosis?

Diabetes insipidus

A 10- year-old boy is admitted to the hospital because of bleeding. Pertinent laboratory findings include a platelet count of 50,000/µL, prothrombin time PT. of 15 seconds control 11.5 seconds., activated partial thromboplastin time aPTT. of 51 seconds control 36 seconds., thrombin time TT. of 13.7 seconds control 10.5 seconds., and factor VIII level of 14% normal 38%-178%.. Which of the following is the most likely cause of his bleeding?

Disseminated intravascular coagulation DIC.

A 6-year-old boy had been in his normal state of good health until a few hours prior to presentation to the ER room. His mother reports that he began to have difficulty walking, and she noticed that he was falling and unable to maintain his balance. Which of the following is the most likely cause for his condition?

Drug intoxication

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 12-year-old male child comes to the office after being referred for a medical evaluation. His schoolteacher says that he has a problem concentrating during class. He stares in space for a few seconds several times a day, and appears totally absorbed in his thoughts. He is not disruptive in class, but appears forgetful. There is no history of trauma, infection or problem at birth. On examination, the child is alert with stable vital signs. There is no loss of motor or sensory perceptioin. Which of the following can confirm the patient's diagnosis?

EEG studies

A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child's disorder?

Echocardiography

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

A 1-week-old child's mother complains that the child has a transient rash that has splotchy areas of erythema with a central clear pustule. Your microscopic examination of the liquid in the pustule reveals eosinophils. Many rashes and skin lesions can be found first in the newborn period. For the descriptions listed above, select the most likely diagnosis.

Erythema toxicum

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 3-month-old infant without significant past history was brought to the emergency center by her mother with a generalized tonic-clonic seizure. She is found to have glucose of 5 mg/dL. After correction of her hypoglycemia, she is admitted to your service for further evaluation. Several hours later, her nurse calls to tell you that her bedside glucose check was now 10 mg/dL. You order laboratory work suggested by the pediatric endocrinology team and again correct the infant's hypoglycemia. The results of the laboratory tests you drew include an elevated serum insulin level of 50 µU/mL, and a low IGFBP-1 plasma insulin-like growth factor binding protein-1.. C-peptide levels are not detectable. Which of the following is the likely cause of this child's recurrent hypoglycemia?

Factitious hypoglycemia

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

A 2-year-old child is brought to the emergency department because of generalized convulsions that last 15 minutes. He has had a fever for 24 hours, and his current temperature is 39.5 C 103 F.. He also has a sore throat, but otherwise looks healthy. His father also had several episodes of febrile seizures in his childhood. Which of the following is the most important factor that will increase the risk of recurrence of febrile seizures?

Family history of febrile seizures

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

A 3-month-old Jewish infant is brought to the emergency department because of a generalized seizure 1 hour ago. He is lethargic, weighs 2.7kg 61b., and has a doll-like face with fat cheeks, relatively thin extremities, and a protuberant abdomen. His liver is felt 5cm 2in. below the right costal margin. His kidneys are enlarged. His blood sugar level is 40mg/dl. His serum uric acid, total cholesterol, triglycerides and lactic acid levels areelevated. The levels of his liver transaminases are normal. What is the most likely cause of this infant's symptoms?

Glucose-6-phosphatase deficiency

Episodes of cerebellar ataxia may be seen in which of the following?

Hartnup disease

A 10-year-old boy is brought to the office for the evaluation of worsening fatigue for the past few weeks. He has sickle cell anemia, and has had several hospitalizations for painful crises. His vital signs are stable. He appears pale. He has a hemoglobin level of 7. 7 g/dl and hematocrit of 22.5%. Which is the most likely type of anemia of this patient?

Hemolytic anemia

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 1-day-old male infant has bilious vomiting after every feeding. He hasn't passed any stools yet. He had no prenatal care, and was delivered vaginally at term. He weighs 3kg 6.61b., and his APGAR scores were 6 and 7 at 1 min and 5 min, respectively. On examination, the neonate is hypotonic, he has a flat facial profile, short ears with downfolding ear lobes, a single palmar crease, and a depressed fontanel. There is abdominal distention which is most prominent in the upper abdomen. His abdominal x-rays show gastric and duodenal gas distension with no air distally. What other anomaly can also be expected in this infant?

Hirschsprung's disease

A 14-year-old male is brought into the office by his mother. For the past 2 weeks, he has been very tired and has felt short of breath. The mother tells you that she thinks he has been losing weight. On physical examination, the child is alert and in nodistress; vital signs are normal, but he has lost 3.5 kg since his last visit 6 months ago. The lungs are clear bilaterally, and the heart examination is normal. You palpate an enlarged supraclavicular node. Chest radiography reveals a large mediastinalmass. The presence of Reed-Sternberg cells in tissue is diagnostic of which disease?

Hodgkin's disease

A 14-year-old male is brought into the office by his mother. For the past 2 weeks, he has been very tired and has felt short of breath. The mother tells you that she thinks he has been losing weight. On physical examination, the child is alert and in nodistress; vital signs are normal, but he has lost 3.5 kg since his last visit 6 months ago. The lungs are clear bilaterally, and the heart examination is normal. You palpate an enlarged supraclavicular node. Chest radiography reveals a large mediastinalmass. What is the most likely diagnosis?

Hodgkin's disease

A 3-month-old infant is taken to the emergency department with constipation and behavioral changes. Physical examination demonstrates ptosis and an absence of facial expression. The child appears conscious but has trouble following a toy with her gaze. The crying is very weak, and saliva is pooling in her mouth. She is also developing a generalized hypotonia, and breathing is becoming more shallow. This child's condition is most likely related to ingestion of which of the following food products?

Honey

A 1-month-old, previously healthy infant develops forceful projectile vomiting. No bile is seen in the vomitus. After the infant feeds, gastric peristaltic waves are visible crossing the epigastrium from left to right. Several minutes later, the projectile vomiting occurs. Which of the following is the most likely diagnosis?

Hypertrophic pyloric stenosis

Which of the following best describes chylous ascites in infancy?

Hypoalbuminemia and lymphopenia are common.

A 3-week-old boy presents to the physician's office with a 1-week history of forceful, projectile vomiting. He has been vomiting after almost every feeding. The vomitus contains mostly undigested formula and is non-bilious. On examination, his oral mucosa is dry, his anterior fontanel appears to be depressed, and his capillary refill is 3-4 seconds. An abdominal examination reveals an olive-sized mass in the epigastrium. Which of the following electrolyte findings will most likely be seen?

Hypochloremic metabolic alkalosis

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 3.8 kg baby of a diabetic mother developed seizures at 16 hours of birth. Most probable cause is:

Hypoglycemia

A 2 -year-old child is evaluated by a neurologist because of difficulty walking. Neurological examination documents ataxia and mental retardation. The neurologist notes the presence of multiple telangiectasias involving the conjunctiva, ears, and antecubital fossae. The child also has a history of multiple respiratory tract infections. Immunoglobulin studies on the child would most likely demonstrate an absence of which of the following?

IgA and IgE

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 10-year-old boy from the Connecticut coast is seen because of discomfort in his right knee. He had a large, annular, erythematous lesion on his back that disappeared 4 weeks prior to the present visit. His mother recalls pulling a small tick off his back. Which of the following is a correct statement about this child's likely illness?

In addition to skin and joint involvement, CNS and cardiac abnormalities may be present

A 10-year-old patient with sickle cell disease comes to the physician for a routine visit. The patient has a history of multiple pain crises and pneumonias. He was started on hydroxyurea one year ago and has not had any further pain crises since then. He has had no recent illnesses or hospitalizations. His physical examination is unremarkable. The patient's laboratory results are shown below. Complete blood count: Hemoglobin 9.0 g/L, Erythrocyte count 2.2 mln/mm3, MCHC 32%, MCV 105 fl, Reticulocytes 2.0%, Platelets 212,000/mm3, Leukocyte count 9500/mm3, Neutrophils 56%, Eosinophils 3%, Lymphocytes 36%, Monocytes 5%. Which of the following best describes the role of hydroxyurea in the treatment of patients with sickle cell disease?

Increases fetal hemoglobin

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 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

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 16-month-old toddler has painless rectal bleeding. His stools have currant jelly consistency. Physical examination of the patient, including rectal examination, is completely normal. A routine barium study is normal. Which of the following is true for this condition?

It is the most common congenital gastrointestinal anomaly.

A mother with mild mental retardation has a 10-year-old son with severe mental retardation. The boy is tall, has a long face with prominent jaw and large ears. Which statement about his condition is true?

It is the most common form of inherited mental retardation.

An 18-year-old friend of the family returns from spring break from a coastal town in Central America. He has an intensely pruritic lesion on his foot. The lesion is raised, red, serpiginous, and has a few associated bullae. Match the common skin condition with the most appropriate therapy

Ivermectin

What is most the endemic form of encephalitis in Cambodia?

Japanese encephalitis virus.

An alert, 6 month old male has a history of vomiting and diarrhea. He appears pale and has an RR of 45 breaths per minute, HR of 180 beats per minute, and a systolic blood pressure of 85 mm Hg. His extremities are cool and mottled with a capillary refill time of 4 seconds. What would best describe his circulatory status?

Late decompensated. shock caused by supraventricular tachycardia

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

A 1-day-old infant who was born by a difficult forceps delivery is alert and active. She does not move her left arm spontaneously or during a Moro reflex. Rather, she prefers to maintain it internally rotated by her side with the forearm extended and pronated. The rest of her physical examination is normal. This clinical scenario most likely indicates which of the following?

Left-sided Erb-Duchenne paralysis

A 2-year-old refuses to walk, has fever, has significant pain with external rotation of the right leg, and has an elevated WBC count. For case above, select the most likely diagnosis.

Legg-Calvé-Perthes disease

A 6-year-old boy has developed a limp and has limited mobility of the hip, but denies pain and fever. For case above, select the most likely diagnosis.

Legg-Calvé-Perthes disease

A 2-week-old boy in the neonatal intensive care unit had a birth weight of 1200 g. Ultrasound of the head reveals grade II intraventricular hemorrhage and periventricular leukomalacia. An ophthalmologic examination reveals retinopathy of prematurity of both eyes. In addition, a hearing screen demonstrates bilateral hearing deficits. Which of the following is the most important determinant of this child's neurodevelopmental outcome?

Length of gestation

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

A 16-day-old infant presents with fever, irritability, poor feeding, and a bulging fontanelle. Spinal fluid demonstrates gram-positive cocci. Which of the following is the most likely diagnosis?

Listeria monocytogenes

A 2-year-old child is brought to the physician for a routine visit. He is growing and developing appropriately. He drinks 3-4 glasses of whole milk each day. He is starting to put words together into short sentences. His mother has no concerns. Physical examination shows mild pallor. Laboratory studies show the following: Hemoglobin 9.5 g/dL, RDW 21%, MCV 70 fl, Platelet count 284,000/mm3, Leukocyte count 6,500/mm3. Which of the following additional findings is most likely in this patient?

Low reticulocyte count

A 15-year-old female presents to your office with secondary amenor- rhea. As part of your evaluation, you find that she is pregnant. After inform- ing her of the pregnancy, you continue to explain that young mothers have a higher risk of several pregnancy-related complications, including which of the following?

Low-birthweight infants

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

A 1-day-old boy is evaluated in the nursery for minimal right arm movement. He was born at 41 weeks gestation to a woman with poorly controlled type 1 diabetes mellitus. Attempted vaginal delivery was complicated by shoulder dystocia and became a cesarean section delivery. Family history is positive for obesity in the boy's father and osteoporosis in both grandmothers. Birth weight was 4.5 kg. Examination shows crepitus and irregularity over the right clavicle. Moro reflex is absent on the right. Bilateral biceps and grasp reflexes are intact and symmetric. The infant is plethoric and has excessive fat accumulation in the abdominal and scapular regions. The remainder of the examination is normal. Which of the following is the most significant risk factor for this patient's condition?

Maternal history of diabetes

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

An 18-month-old child is brought to the emergency department by his mother due to a one-day history of lethargy and anorexia. He had a fever the whole day yesterday, which responded to Tylenol Acetaminophen.. He then developed a petechial rash over his entire body, which worsened in the last few hours. He is up-to-date with his immunizations, and is an otherwise healthy baby. On examination, he is drowsy and lethargic. He has neck stiffness and appears septic. He flexes his hips when his neck is flexed. What is the most likely organism responsible for the patient's symptoms?

Meningococcus

A 6-year-old African-American child is brought in by his father for complaints of easy fatigability and pallor. These symptoms occurred after the son was treated with "some medication" for a recent diarrhea. Physical examination is normal except for pallor and multiple petechiae. Laboratory values are as follows: Hb 8.0 g/dL, WBC 12,000/cmm, Platelets 50,000/cmm, Blood glucose 118 mg/dL, Serum Na 135 mEq/L, Serum K 5.3 mEq/L, Chloride 110 mEq/L, Bicarbonate 18 mEq/L, BUN 38 mg/dL, Serum creatinine 2.5 mg/dL, Total bilirubin 3 mg/dL, Direct bilirubin 0.5 mg/dL, PT 12 seconds, APTT 30 seconds, LDH 900 IU/L, Reticulocyte count 6%. A peripheral blood smear reveals giant platelets and multiple schistocytes. What is the most likely underlying pathophysiology for this boy's pallor?

Microangiopathic hemolytic anemia

A 3-year-old boy is brought to the office by his 27-year-old white mother for the evaluation of recurrent bone fractures. His first fracture was that of the femur, and occured when he was 6 months old. He had a fracture of the wrist 4 months ago. His mother also has a history of multiple fractures since childhood. She lost all her teeth at a very early age and is complaining of deafness. Her husband has a history of severe alcohol abuse. On examination, both mother and son have blue sclerae. What is the most likely involved disease process?

Mutations in type 1 collagen

A 3-year-old girl presents to a health center with a fever for the past 36 hours. Maximum temperature was 40°C at 2 am, which decreased to38.7°F with children's ibuprofen. Her appetite andfluid intake have decreased during the past 24 hours. Physical examination shows an ill-appearing child.Her temperature is 37.2°C. The skin has a macular-papular petechial rash on the chest and back. Theremainder of the physical examination is normal. Which of the following is the most likely organism that you need to consider in this situation?

N. meningitidis

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 2-year-old girl is brought to the clinic due to fever, irritability and lethargy for the past two weeks. Over the past two months, she has complained of intermittent abdominal discomfort and has lost weight. Abdominal palpation reveals a firm nodular mass in the right flank. No bruits are heard. Abdominal x-ray reveals multiple calcifications in the renal area. Urine examination reveals increased levels of homovanillic acid and vanillylmandelic acid. Which embryonic structure has this mass most likely arisen from?

Neural crest cells

A 1-year-old girl is brought to the emergency department by her mother because the child's "eyes and feet are dancing." On physical examination, the girl is well developed and in no acute distress. Her temperature 37.0 C 98.6 F., blood pressure is 100/55 mm Hg, pulse is 100/min, and respirations are 20/min. The patient has opsoclonus, myoclonus, and ptosis of the right eye. On history, the mother notes the child was born "looking like a blueberry muffin" and has had a persistent cough since the age of 2 months. Which of the following is the most likely diagnosis?

Neuroblastoma

A 1-year-old female infant is brought to the clinic by his 30-year-old mother due to feeding problems since birth. She still cannot walk nor speak. She began to sit when she was 8 months old. Her weight is in the 15th percentile, height is in the 20th percentile, and head circumference is in the 100th percentile for her age. She has multiple freckles in her armpit and groin area. She has cafe-au-lait spots on her skin, and the diameter of at least 20 of these spots is greater than 1.5mm. What is the most likely diagnosis?

Neurofibromatosis type 1

Abdominal manifestations of Henochschonlein purpura include all EXCEPT:

Non-migratory arthralgia.

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 2-year-old child is brought to the emergency department with sudden onset of unresponsiveness, miosis, bradycardia, and muscle fasciculations. These findings are most suggestive of poisoning with which of the following?

Organophosphates

A 3-month-old girl is brought to the pediatrician for a scheduled visit. She has been meeting all development milestones but has been vomiting after each feeding. The infant weighed 3 kg 6 lb 10 oz. at birth and now weighs 6 kg 13 lb 3 oz.. She does not have diarrhea and is afebrile. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of this patient's vomiting?

Overfeeding

A 3-month old infant is brought to a pediatrician's office because of increased lethargy and irritability. The parents state that the child rolled off the couch and fell on the floor one day prior to presentation. His parents report that the child has been previously healthy and is up to date on his vaccinations. He has been meeting his development milestones. His fontanelles are full. While in office the patient develops a tonic-clonic seizure. Which of the following is the next appropriate step?

Perform a retinoscopic examination

A 12-year-old boy is brought to the clinic by his parents because "he cannot walk anymore." Yesterday, he became irritable, uneasy, and complained of tingling and weakness in both his legs. This morning, he couldn't stand up or move his legs, and complained of pain in his leg and thigh muscles. He denies any headaches, nausea or vomiting. He had an episode of febrile diarrhea 10 days ago. His family history is unremarkable. Physical examination reveals symmetric flaccid paralysis of both legs, absent deep tendon reflexes, and decreased superficial touch and vibratory sense. There is no nuchal rigidity. What structure is most likely affected in this patient's condition?

Peripheral nerves

Which of the following is a definite indication to start antiretroviral treatment in HIV infected children?

Pneumocystis carinii pneumonia.

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

You have just given a 10-year-old boy an injection of pollen extract as prescribed by his allergist. You are about to move on to the next patient when the boy starts to complain about nausea and a funny feeling in his chest. You note that his face is flushed and his voice sounds muffled and strained. Which of the following is the first priority in managing this episode of anaphylaxis?

Preparation for endotracheal intubation

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

A 2-year-old presents to the emergency center with several days of rectal bleeding. The mother first noticed reddish-colored stools 2 days prior to arrival and has since changed several diapers with just blood. The child is afebrile, alert, and playful, and is eating well without emesis. He is slightly tachycardic, and his abdominal examination is normal. Which of the following is the best diagnostic study to order to confirm the diagnosis?

Radionucleotide scan

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

A 1-month-old infant is brought to the office for a routine neonatal visit. His prenatal and birth histories are unremarkable. His vital signs are normal. Examination reveals a harsh, loud holosystolic murmur over the left, lower sternal border. Palpation reveals a thrill over the precordial region. There is no cyanosis, and pulmonary auscultation reveals no rales. Chest radiograph reveals a heart of normal size and a slight increase in pulmonary vascularity. EKG is normal. Which of the following is the most appropriate course of action?

Reassurance

A 12-month-old girl has been diagnosed with transient erythroblastopenia of childhood TEC.. Which statement about this disorder is correct?

Red blood cell transfusions may be necessary.

A 2-year-old boy is brought to the pediatrician for a routine well-child visit. He has been growing and developing normally. He is starting to put words together into 2-word phrases. The boy eats a variety of foods including meats, vegetables, and fruits, and drinks 24-28 ounces 700ml. of whole milk each day. Past medical history is unremarkable. His mother has no concerns at today's visit. His physical examination is within normal limits. Laboratory results are as follows: Complete blood count: Hemoglobin 9.4 g/dl, Hematocrit 28%, Mean corpuscular volume 64 fl, Red cell distribution width 14% normal 11.5%-16.0%., Reticulocytes 3.0%, Platelets 240,000/µL, Leukocytes 7,500/µL, Blood, plasma, and serum, Ferritin 100 ng/ml 7-140 ng/ml., Iron-binding capacity 300 µg/dl 240-450 µg/dl.. Which of the following is the most likely cause for this child's anemia?

Reduced production of globin chains

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

A 12-year-old boy is brought to the emergency department because of severe pain near his left knee. He has sickle cell disease and has been hospitalized previously for sickle cell crisis. Vital signs are notable for persistent fever. Examination of the left lower extremity reveals a normal knee joint with marked tenderness and swelling over the proximal tibia. Laboratory studies show leukocytosis and elevated ESR. Imaging studies confirm the diagnosis of osteomyelitis. Which of the following organisms is the most likely cause of his condition?

Salmonella species

A 10-year-old boy is brought by his parents to the emergency department for the evaluation of headaches, fever, chills, and a rash over his neck, chest, and axillae. The rash appeared today, and for the past two days the child was complaining of a sore throat. He has no history of allergies, and his immunizations are up-to-date. His blood pressure is 112/70 mmHg, pulse is 1 08/min, respirations are 20/min, and temperature is 38.3C 101 F.. Examination reveals an erythematous rash with a sandpaper-like texture, and which blanches with pressure. There is submandibular tender lymphadenopathy, and the throat is erythematous with gray-white exudates. What is the most likely diagnosis?

Scarlet fever

An 8-year-old is accidentally hit in the abdomen by a baseball bat. After several minutes of discomfort, he seems to be fine. Over the ensuing 24 hours, however, he develops a fever, abdominal pain radiating to the back, and persis- tent vomiting. On examination, the child appears quite uncomfortable. The abdomen is tender, with decreased bowel sounds throughout, but especially painful in the midepigastric region with guarding. Which of the following tests is most likely to confirm the diagnosis?

Serum amylase levels

A 1-day-old normal-appearing infant develops tetany and convulsions. He was born at 34 weeks' gestation with Apgar scores of 2 and 4 at 1 and 5 minutes, respectively. to a woman whose pregnancy was complicated by diabetes mellitus and pregnancy-induced hypertension. Which of the following serum chemistry values is likely to be the explanation for his condition?

Serum calcium of 6.2 mg/dL

A 12-year-old girl has a solitary thyroid nodule found on routine examination; she has no symptoms. Which of the following is the most appropriate next step for this patient?

Serum thyroid function tests

A 10-month-old boy develops an upper respiratory tract infection 2 days before presentation. On the day of presentation, he has a generalized tonic-clonic seizure lasting 30 seconds. His temperature is 40.0 C 104 F., blood pressure is 90/60 mm Hg, and respirations are 22/min. He is alert and smiling. He has rhinorrhea, and his neck is supple. He has bruises below his knees. Which of the following is the most likely diagnosis

Simple febrile seizure

An afebrile, obese 14-year-old boy has developed pain at the right knee and a limp. For case above, select the most likely diagnosis.

Slipped capital femoral epiphysis

A 4-year-old girl is brought to the physician because of a crusted honey-colored erythema resulting from rupture of tiny vesicles and pustules. Her temperature is 37.7 C 102 F.. Skin lesions are distributed over the face and extremities. Physical examination reveals enlargement of lymph nodes in the cervical and axillary regions. Which of the following is the most frequent pathogen of this skin infection?

Staphylococcus aureus

The bacterial pathogens most commonly encountered in the lungs of patients with cystic fibrosis are which of the following?

Staphylococcus aureus and P aeruginosa

A 4-year-old boy, who has a ventriculoperitoneal shunt for congenital hydrocephalus, develops fever, headache, irritability, lethargy, photophobia, and vomiting. His temperature is 39.6 C 103.2 F.. He is noted to have nuchal rigidity, with the presence of both Kernig's and Brudzinski's signs. The shunt tract is erythematous on the surface. A lumbar puncture is performed and shows a WBC of 40,000/mm3 with 85% neutrophils, a glucose concentration of 48 mg/dL, and a protein concentration of 169 mg/dL. Which of the following is the most likely pathogen?

Staphylococcus epidermidis

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 10-year-old male fell while riding his scooter down a steep hill. In the Emergency Department, his injuries included a fractured wrist and a lacerated spleen, which required surgical removal. Two years later he is diagnosed with bacterial pneumonia. Which of the following bacterial agents is the most likely pathogen for this patient's pneumonia?

Streptococcus pneumoniae

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

A 1-year-old child is brought in for a regular "well baby" check-up. The child appears to have strabismus. The reflection of a bright light from the ceiling of the examination room comes from a different place in each eye. The family explains that the child has always looked that way, and there has been no recent change in the appearance of his eyes. Which of the following is the most effective management?

Surgical correction as soon as it is practical to do it

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 10-month-old infant has poor weight gain, a persistent cough, and a history of several bouts of pneumonitis. The mother describes the child as having very large, foul-smelling stools for months. Which of the following diagnostic maneuvers is likely to result in the correct diagnosis of this child?

Sweat chloride test

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

A 2-week-old infant presents with hepatosplenomegaly and a thick, purulent, bloody nasal discharge. Coppery, oval, maculopapular skin lesions are present in an acral distribution. The neurologic examination is normal, including head circumference. Which of the following is the most likely cause of this congenital infection?

T. pallidum

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

A 3-day-old infant, born at 32 weeks' gestation and weighing 1700 g 3 lb, 12 oz., has three episodes of apnea, each lasting 20 to 25 seconds and occurring after a feeding. During these episodes, the heart rate drops from 140 to 100 beats per minute, and the child remains motionless; between episodes, however, the child displays normal activity. Blood sugar is 50 mg/dL and serum calcium is normal. Which of the following is most likely true regarding the child's apneic periods?

They are due to an immature respiratory center

A 1 and half -year-old girl is sent to a children's hospital for evaluation following a nosebleed which was so severe as to require nasal packing and transfusion of platelet concentrates. When a blood sample had been drawn in the emergency room for serum chemistry studies, the local hospital laboratory had noted that the clot that formed was unusual in that it failed to retract. Peripheral blood smear obtained by finger puncture showed an appropriate number of normal-sized platelets, all of which were individual, without clumping. At the children's hospital, it was noted that the child's parents were cousins. Special platelet studies showed that the child's platelet's failed to aggregate with any physiologic aggregating agent, including a high concentration of exogenous ADP. Which of the following is the most likely diagnosis?

Thrombasthenia

A 10-year-old boy is brought to the office by his mother after having a seizure this morning. All he can recall before the episode is "seeing funny little lights." According to his mother, his body went stiff; he lost consciousness, and then had jerky movements of the entire body. He bit his tongue, and started to drool. The seizure lasted for about one minute. After the seizure, he appeared confused for several minutes, and passed urine. He has been complaining of a headache for the past two hours. The neurological examination is normal. What type of seizure did this patient experience?

Tonic clonic seizure

A 4- week-old male infant is brought to the office due to several episodes of projectile vomiting for the last few days. The vomitus contains milk and doesn't contain bile or blood. The child's appetite has increased for the last few days. He has been fed with goat's milk since birth, but doesn't seem to tolerate it anymore for the last few days. He vomits a few minutes after feedings. He appears dehydrated, and abdominal examination reveals no mass. Blood tests reveal macrocytosis. What is the most appropriate next step in the management of this patient?

Ultrasound of the abdomen

You counsel the new parents of a baby boy with hypospadias about circumcision. Which information will you most likely share with the parents?

Urinary tract infections are 10-15 times more common in uncircumcised infants.

John, who is 6 years old, presents to the Emergency Department feeling sick and dizzy. He was brought to hospital by a paramedic crew who were called after he became unwell at school. His heart rate was noted to be very quick, at 260 beats/min and supraventricular tachycardia is diagnosed. He says he can feel his heart beating quickly and looks pale. He is crying, saying he wants his mother. Which of the following should be undertaken by the attending team? Select one answer only.

Vagal stimulation manoeuvre

A 1-year-old child with ALL in remission for 3 months is in the office for a health maintenance visit. He is due for multiple vaccinations including hepatitis B vaccine, inactivated polio vaccine IPV., varicella vaccine H. influenzae B vaccine Hib., and pneumococcal vaccine PCV.. You remember that some of these vaccines are live attenuated viruses and are contraindicated in immunocompromised patients. Which vaccine will you not give to this patient?

Varicella vaccine

A 15-year-old female has a 1 year history of secondary amenorrhea. She is an avid gymnast and has an intese fear of becoming fat. Her weight is at 80% of ideal body weight. For what long-term irreversible complication is this patient at greatest risk?

osteoporosis

The primary lesion in acne is which of the following?

plugging of the sebaceous gland

A previously well 12-year-old girl presents to clinic because of painful swellings on the front of the legs of about 3 days' duration. Examination reveals tender erythematous nodules, 1-2 cm in diameter, on the extensor surfaces of the lower legs. The remainder of the physical examination is unremarkable. Which of the following is most likely to confirm the cause of this condition?

throat culture

What hematologic abnormality should you suspect in a newborn with bilateral absence of radii?

thrombocytopenia

Which of the following is frequently seen in sickle cell patients with splenic sequestration?

thrombocytopenia

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days but worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 3kg and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 38°C, pulse of 120 beats/minute, blood pressure within normal limits, and a respiratory rate of 60 breaths/minute. The infant is well hydrated but ill appearing. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical exam. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. In which of the following patients is palivizumabnot indicated?

1-month-old female born at 33 weeks of gestation with no current health issues

Postoperative nausea and vomiting PONV. occurs in the immediate postoperative period, within the 1st 1-2 hr, or several hours after surgery and anesthesia. All the following may decrease the incidence of PONV EXCEP

preoperative fasting

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

A 1-week-old infant is brought to the emergency department due to vomiting and poor feeding. The prenatal and birth histories are unremarkable. The infant's pulse is 140/min, temperature is 37 C 98.7 F., and capillary refill is 2 sec. He has sunken eyes, depressed anterior fontanel, and dry mucus membranes; skin elasticity is reduced. Heart and lungs are clear. There is no abdominal mass. Genital examination shows enlarged clitoris, and fusion of the labioscrotal folds. The initial laboratory work-up reveals the following: Sodium 128 mEq/L, Potassium 5.8 mEq/L, BUN 25 mg/dl. If this patient's karyotype is 46 XX, which of the following is most likely to be increased in this patient's serum?

17 -alpha-hydroxyprogesterone

A 3-year-old female presents for her routine visit. The physician notes pallor and bruising. On physical examination, the vital signs are normal but there is a generalized lymphadenopathy and hepato-splenomegaly. A complete blood count CBC. reveals a white blood cell WBC. count of 33,000/mm3 and a platelet count of 81,000/mm3. The peripheral blood smear shows blasts, and the lactate dehydrogenase activity is elevated. CBC shows blasts as well as hypochromic red blood cells. Most cases of acute lymphoblastic leukemia ALL. are diagnosed between the ages of which of the following ranges?

2 and 3 years

Which of the following in an 8-year-old child is most likely to indicate an underlying psychologic or behavioral problem?

encopresis

A term infant requires intubation in the delivery room after aspiration of thick meconium and is brought to the neonatal intensive care unit. Which of the following is the most likely risk factor for meconium aspiration syndrome in this infant?

fetal distress

A 5-month-old female presents in the winter with a 2-day history of vomiting, diarrhea, and fever. The diarrhea is without blood or mucus. On examination, she is moderately dehydrated and has a serum sodium of 152 meq/L. What is the most likely etiologic agent?

rotavirus

A highly careful mother of a 10-month-old baby boy complaining that her baby has inadequate weight gain. She explained to you how she is so strict and so careful to feed her baby by spoon, but he was always refusing. Of the following, the LEAST helpful advice is to

offer softer diet

Postoperative nausea and vomiting PONV. may be related to the stress, trauma of surgery, and pain. Of the following, the MOST likely drug that cause PONV is

opioid analgesics

Patient culture can change the doctor treatment options and even the way of behavior with the patient. All the following culture values are expected if he is dealing with Muslim patients EXCEPT

routine postmortem exam

Anormal 6-month-old infant has a continuous cardiac murmur and bounding peripheral pulses. What step should be taken next?

surgical or catheter correction of the defect

Postanesthetic apnea is most common within the 1st 12 hr after surgery and has been reported in premature infants up to 48 hr later. General anesthesia should be avoided except for emergency surgery. in full-term infants younger than postconceptual age of

44 wk

An infant with failure to thrive has rectal prolapse. What test will most likely provide the diagnosis?

sweat chloride test

During the first year of life, birth length increases by what percent?

50%

Which of the following is NOT TRUE about breast feeding?

50% of energy from proteins

Fentanyl anesthesia used as analgesia to provide pain relief during operative procedures in neonates. reduces the incidence of all the following postoperative conditions EXCEPT

tachycardia

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

A 15-month child is brought to you fordiarrhea, with an average 7 loose stools per day for the past 4 days. The stool is watery without any mucus or blood. He also vomited several times during the first 2 days but now it appears to be subsiding. He has been drinking fluids but has not had much appetite for food. For the past 2 days, he has been running a "low-grade fever" and appears to have some abdominal discomfort. He attends a local day care, where some of the children have had similar symptoms.On physical examination, the child is active without any fever. He has dry, cracked lips with moist oral mucosa. The ears, throat, lungs, and abdomen are normal. There are no abdominal masses and no palpable tenderness. Which of the following represents the composition of an ideal rehydrating solution for moderate dehydration?

90 mM Na+, 20 mM K+, 80 mMCl-, 10 mMcitrate, and 111 mM glucose

The most common congenital infection is infection with cytomegalovirus, affecting 3/1000-4/1000 livebirths. Of those babies infected, approximately what percent are normal at birth and develop normally?

90%

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

Acellular pertussis vaccine is recommended for infants, children, adolescents, and adults. Compared to the previously available whole cell vaccine, which of the following best describes these products?

they are associated with fewer side effects

A 12-year-old male is found to have a murmur during a routine sports physical. He has a family history of sudden death at a young age. It is a harsh crescendo-decrescendo murmur that begins after S1 and is best heard at the left lower sternal border. Valsalva maneuver intensifies the murmur. Which of the following is the most likely mitral valve abnormality in this patient?

Abnormal mitral leaflet motion

Which of the following best describes juvenile gastrointestinal polyps?

they usually present as blood-streaked stools

A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?

Absence of ganglion cells on full-thickness rectal biopsy 2 cm above the dentate line

A 4-week-old infant is brought to the office due to several episodes of vomiting over the past week. The episodes have progressively become more frequent and forceful, but the vomitus never contains any blood or bile. The infant has been breastfed since birth. His vital signs are stable, and he is afebrile. An olive-shaped mass is palpated just to the right of the umbilicus, and peristaltic waves are seen in theupper abdomen. Lab studies reveal a sodium level of 135 mEq/L, potassium level of 3.3 mEq/L, chloride level of 92 mEq/L and bicarbonate level of 30 mEq/L. Which of the following is the most appropriate diagnostic test for this patient?

Abdominal ultrasound

Which circulatory finding is the hallmark of the diagnosis of late decompensated. shock?

Absent distal pulses

A 10-year-old boy presents to the emergency room with chief complaints of fever and increasing fatigue. He was well until 2 weeks ago when he had an upper respiratory illness URI.. He has a decreased appetite and has lost 2 lbs over the last 2 weeks. He has some shortness of breath when he climbs the stairs. His past medical history is unremarkable. On examination his vital signs are normal, and his height and weight are at the 80th percentile. His conjunctiva are pale, and he has bilateral, mobile about 1-2cm. and non-tender nodes in the cervical, axillary, and inguinal regions. Hepatosplenomegaly is present, and skin shows no lesions. Labs are Hemoglobin 7.3g/dl, platelet count 20,000/mm3, WBC count 42,100/mm3, with 24% lymphoblasts, 70% lymphocytes, and 6% atypical lymphocytes. Chest X-rays show clear lung fields but a wide mediastinum. Which of the following is the most likely diagnosis in this patient?

Acute lymphoblastic leukemia

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 10-month-old baby boy, recently adopted from Guyana, has a 5-hour history of crying, with intermittent drawing up of his knees to his chest. On the way to the emergency room he passes a loose, bloody stool. He has had no vomiting and has refused his bottle since the crying began. Physical examination is noteworthy for an irritable infant whose abdomen is very difficult to examine because of constant crying. His temperature is 38.8C 101.8F.. The rectal ampulla is empty, but there is some gross blood on the examining finger. Which of the following studies would be most helpful in the immediate management of this patient?

Air contrast enema

A 10-month-old baby boy, recently adopted from Guyana, has a 5-hour history of crying, with intermittent drawing up of his knees to his chest. On the way to the emergency room he passes a loose, bloody stool. He has had no vomiting and has refused his bottle since the crying began. Physical examination is noteworthy for an irritable infant whose abdomen is very difficult to examine because of constant crying. His temperature is 38.8°C 101.8°F.. The rectal ampulla is empty, but there is some gross blood on the examining finger. Which of the following studies would be most helpful in the immediate management of this patient?

Air contrast enema

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

The most common cause of gross hematuria is only one answer:

All above (Urinary tract infections, Meatal stenosis, Trauma, Glomerulonephritis)

Which of the following factors leads to neonatal hyperbilirubinemia?

All of the above (Shortened neonatal red cell life span, Impaired excretion of unconjugated bilirubin, Limited conjugation of bilirubin in the liver, Increased enterohepatic circulation)

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

A 12-year-old girl comes to the physician for chronic weight loss and fatigue. She has a history of bulky, floating, foul-smelling stools, flatulence and meteorism. She also has bone pain and easy bruising. Laboratory studies show anemia with serum iron: 25 mg/dl , ferritin: 25 mg/dl and serum total iron binding capacity 600 mg/dl normal 300-360 mg/dL.; PT is 16 sec. Physical examination shows loss of subcutaneous fat, pallor, hyperkeratosis and abdominal distention; bowel sounds are increased. Which of the following is most likely associated with this patient's condition?

Anti-endomysial antibodies

A 10-year-old boy, the star pitcher for the Salt Lake City Little League baseball team, had a sore throat about 2 weeks ago but did not tell anyone because he was afraid he would miss the play-offs. Since several children have been diagnosed with rheumatic fever in the area, his mother is worried that he may be at risk as well. You tell her that several criteria must be met to make the diagnosis but the most common finding is which of the following?

Arthralgia

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

A 1-week-old infant presents to her general pediatrician's office for a well-child visit. She was born at 37 weeks' gestation without complications. Her temperature is 37.0°C 98.6°F., pulse is 130/min, blood pressure is 72/54 mmHg, and respiratory rate is 28/min. She is currently at the 50th percentile for weight and 75th percentile for height. She is acyanotic and has a wide, fixed split S2, with a 2/6 systolic ejection murmur at the left upper sternal border. The remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

Atrial septal defect

The following features are true for tetralogy of Fallot, EXCEPT:

Atrial septal defect

What is the most common congenital heart defect with a left to right shunt causing congestive heart failure in the pediatric age group?

Atrioventricular canal

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

You ask the school nurse to help you calculate the BMI of the students. Which statement about BMI is false?

BMI can overestimate obesity in children because they are shorter; it is more accurate in adults

A6-year-old girl presents with unilateral nonpainful, nonsuppurative conjunctivitis and preauricular lymphadenitis. What is the most likely causative organism?

Bartonella henselae

A 24-month-old pale child is brought to the office by his mother, who says, "Doc, I think he is under some weird spell. He acts bizarre and always seems tired. He likes to eat wooden, painted toys." The child and her mother live in a relatively poor neighborhood. CBC reveals:WBC 8,600 /mm3, Hemoglobin 7.1 g/dl, Hematocrit 25%, Platelets 166,000 /mm3. His blood lead levels are elevated. Which of the following is most likely seen in this child's peripheral blood smear?

Basophilic stippling and microcytic, hypochromic anemia

A 12-year-old boy is brought to the emergency department with a temperature of 39.1 C 102.4 F. at home, difficulty speaking, and odynophagia for 2 days, Physical examination reveals marked erythema of the right tonsil pillar and edema of the uvula with deviation to the left. In addition to anaerobic bacteria, which of the following organisms is most likely to be isolated from a tonsillar pillar aspirate?

Beta-hemolytic Streptococcus

A 6-year-old boy is seen in the office for evaluation of polyuria. Further questioning reveals several months of headache with occasional emesis. Your physical examination reveals a child who is less than 5% for weight. He has mild papilledema. His glucose is normal, and his first urine void specific gravity after a night without liquids is 1.005 g/mL. Which of the following might also be expected to be seen in this patient

Bitemporal hemianopsia

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 4-day-old infant is brought to the physician for an outpatient follow-up visit. The mother's pregnancy and delivery were uncomplicated. The infant weighed 3.4kg 7 .5 lb. and was 19 in 48.2 cm. long at birth. He did well in the newborn nursery and was discharged from the hospital on day 2 of life. Today his mother reports that he is exclusively breastfed, and nurses for 10 minutes every 3 hours. He has 3-4 wet diapers a day, and has not had a bowel movement for two days. On examination, he weighs 2.95 kg 6.5 lb. and is 19 in 48.2 cm. long. He appears jaundiced on the face and chest. The remainder of the physical examination is unremarkable. Laboratory values are shown below. Total bilirubin 15 mg/dl, direct bilirubin 1 mg/dl, Infant's blood type O positive, Mother's blood type A positive. Which of the following is the most likely cause of this infant's hyperbilirubinemia?

Breastfeeding jaundice

A patient with Cushing syndrome might present with any of the following EXCEPT:

Bronze or hyperpigmented skin

The signs and symptoms of meningitis in an infant can be different than those in an adult.Which of the following signs and symptoms of meningitis is more helpful in an adult patient than in a 4-month-old?

Brudzinski sign

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

A 3-year-old boy is brought to the emergency department with sudden onset of difficulty walking. His mother reports that his right hand also seems "clumsy." The boy's past medical history is significant for a hospitalization one year ago for severe upper extremity pain and hand swelling. On physical examination, he has a blood pressure of 90/60 mmHg, heart rate of 120/min, temperature of 36.7°C 98°F., and respiratory rate of 22/min. Which of the following would be most helpful in diagnosing his condition?

CBC and reticulocyte count

AIDS is caused by a human retrovirus that kills

CD4-positive T lymphocytes.

A5-year-old girl suffers from a second episode with meningococcal meningitis. What is the best next laboratory study?

CH50

A 3-year-old girl with a ventricular septal defect VSD. presents to the emergency department after a 15-minute focal seizure of her left arm and leg. A brief history reveals that the child has no known seizure disorder and has been having a low-grade fever at home for about 4 days. She also has been less active and has had poor appetite. On physical examination, her temperature is 40.2 C 104.3 F., and her pulse is 82/min. She is not responsive to her name, but she is responsive to painful stimuli with withdrawal of her extremities. Cardiac examination is significant for a grade 3 systolic murmur best heard at the left lower sternal border. Neurologic examination reveals anisocoria with a dilated right pupil. After stabilization, which of the following is the most appropriate next step in diagnosis?

CT of the brain

A 2-year-old boy has been doing well despite his diagnosis of tetralogy of Fallot. He presented to an outside ER a few days ago with a complaint of an acute febrile illness for which he was started on a "pink antibiotic." His mother reports that for the past 12 hours or so he has had a headache and is more lethargic than normal. On your examination he seems to have a severe headache, nystagmus, and ataxia. Which of the following would be the most appropriate first test to order?

CT or MRI of the brain

A3-month-old infant is brought to the hospital because of altered mental status changes. Examination shows a sleepy baby who is difficult to arouse. Fundoscopic examination shows retinal hemorrhages. Examination otherwise is unremarkable. What is the best next diagnostic test?

CT-scan of the head

A 10-hour-old newborn is noted to have a swelling in the scalp which was not present at birth. The swelling is limited to the surface of one cranial bone. There are no visible pulsations, indentations of the skull, or discoloration of the overlying scalp. What is the most likely diagnosis?

Cephalohematoma

A 2-year-old boy is brought to the office by his mother because he has not started to walk yet. His birth history is significant for prolonged labor, and his APGAR scores at 1 and 5 minutes were 3 and 5, respectively. His older brother is 4 years old, and has a normal developmental history. On examination, the child has hypotonia, learning disabilities and hyperactive deep tendon reflexes. What is the most likely cause for the child's delayed milestones?

Cerebral anoxia

A 1-year-old boy is brought to the pediatrician for a routine visit. While talking to his mother, she reports that they moved into an old house several months ago and are in the process of renovating. The child eats table food and drinks whole milk. His height, weight, and head circumference are all at the 50th percentile for his age. Physical examination is normal. The results of a fingerstick blood test are shown below: Hemoglobin 10.5 g/dL, Hematocrit 30.0%, Lead level 12 μg/dL Normal < 10 μg/dL.. Which of the following is the most appropriate next step in management?

Check a serum lead level

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

A 4-week-old boy is brought to clinic by his mother because of a 1 day history of labored breathing. His birth was uneventful and immunizations have been up to date. His mother reports that the patient developed conjunctivitis on the fourth day of life. On physical examination, he is breathing rapidly at 40 breaths per minute and is afebrile. His chest reveals bilateral inspiratory crackles and a slight wheeze. On chest x-ray, bilateral pneumonia is evident. The leukocyte count is elevated at 15,000 with 40% eosinophils. Which of the following is the most likely pathogen causing the patient's symptoms?

Chlamydia trachomatis

A 6-week-old child arrives with a complaint of "breathing fast" and a cough. On examination you note the child to have no temperature elevation, a respiratory rate of 65 breaths per minute, and her oxygen saturation to be 94%. Physical examination also is significant for rales and rhonchi. The past medical history for the child is positive for an eye discharge at 3 weeks of age, which was treated with a topical antibiotic drug. Which of the following organisms is the most likely cause of this child's condition?

Chlamydia trachomatis

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

A 5-month-old infant is brought to the office for the evaluation of persistent vomiting, failure to thrive, and developmental delay. His antenatal and postnatal histories are not known to his Caucasian foster parents, who adopted him when he was 4 months old. The physical examination reveals an infant with blonde hair, fair skin and blue eyes. His urine has a peculiar musty odor. His plasma phenylalanine level is 40 mg/dl and tyrosine level is normal. His urinary phenylpyruvic and a-hydroxy phenylacetic acid levels are both increased. What is the most likely etiology of this child's symptoms?

Classic phenylketonuria

Emily is a 2-year-old girl. She presents to the Emergency Department with a 2-day history of fever, vomiting and 'smelly' urine. She has no significant medical history and is not on any medication. On examination she has a temperature of 39°C and has a heart rate of 126 beats/min. She has generalized tenderness over her abdomen. What is the best way to collect a urine sample from her? Select one answer only.

Clean catch

A3-year-old girl has a mild febrile illness with mild URI symptoms. She has an erythematous rash on both cheeks. Her pregnant mother had arthralgias of the hands wrists, knees, and ankles a week ago. What should be the next action?

Closely monitor the child's sibling who has spherocytosis.

A 5-month-old boy is brought in for a routine check-up. He was born at 37 weeks' gestation and has had persistent wheezing since shortly after birth despite inhaled bronchodilator and oral corticosteroid therapy. His diet consists of 32 ounces of iron-fortified cow's milk-based formula daily. On physical examination, the child appears well-nourished and happy. You note moderate relief of his wheezing with neck extension. Which of the following is the most likely mechanism of this infant's wheezing?

Compression of the airway by a vascular ring

A 10-day-old infant is brought to the office by her mother for the evaluation of purulent discharge from both eyes. The discharge appeared three days ago, after which the child developed a cough. On examination, the infant's eyes appear normal, except for the presence of purulent discharge. Auscultation reveals diffuse rales without wheezing. Chest radiograph shows a hyperinflated thorax. What is the most likely diagnosis?

Congenital chlamydial infection

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

A 2-year-old boy from Sudan has failure to thrive, chronic diarrhea, and severe candidiasis. You suspect HIV infection. Which of the following organisms would most likely be found on stool examination?

Cryptosporidium species

A 10-month-old infant on long-term aspirin therapy for Kawasaki disease develops sudden onset of high fever, chills, diarrhea, and irritability. A rapid swab in your office identifies influenza A, adding her to the long list of influenza patients you have seen this December. Over the next few days, she slowly improves and becomes afebrile. However, 5 days after your last encounter you hear from the hospital that she has presented to the emergency center obtunded and posturing with evidence of liver dysfunction. Which of the following statements about her current condition is correct?

Death is usually associated with increased intracranial pressures and herniation.

A 10-year-old boy has a long history of recurrent infections. These have included pneumonia, suppurative lymphadenitis, persistent rhinitis, dermatitis, diarrhea, and perianal abscesses. Involved organisms have included Staphylococcus aureus, Serratia, Escherichia coli, and Pseudomonas. Biopsy of skin and lymph nodes have demonstrated granulomatous lesions, even though the only species isolated were those noted above. Immunoglobulin levels are higher than normal. Which of the following findings would be most helpful in establishing the diagnosis?

Deficient nitroblue tetrazolium dye reduction in neutrophils

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 5-year-old boy suffers from a condition characterized by recurrent fungal and viral infections, thymic hypoplasia, tetany, and abnormal facies. Serum levels of immunoglobulins are mildly depressed, and lymph node biopsy shows lymphocyte depletion of T-dependent areas. Which of the following is the underlying pathogenetic mechanism?

Developmental defect of the third/fourth pharyngeal pouches

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

A 2-year-old boy is brought to the emergency department ED. in acute respiratory distress. He is afebrile, and has a heart rate of 100/min, respiratory rate of 80/min, and Sa02 of 84% on room air. He is sitting upright, and has significant nasal flaring and intercostal retractions. He is given supplemental oxygen in the ED. Chest x-ray reveal hyperinflation of the right lung, mediastinal shift to the left, and a severely hypoinflated left lung Which of the following is the most appropriate next step in management?

Direct laryngoscopy and rigid bronchoscopy

A 12-year-old boy is in a motor vehicle collision in which the car caught fire. He sustains significant inhalation injury and a circumferential burn without fractures or other soft tissue trauma to his left lower extremity during extrication from the burning vehicle. He is intubated and aggressively resuscitated in the intensive care unit. Which of the following is the most appropriate method of assessing for compartment syndrome of the left lower extremity?

Doppler signals of the left lower extremity

A 4-year-old child comes in for a health maintenance visit. His mother is concerned that he is not doing some things that other kids in his preschool do. Which of the following skills would be expected of a 4-year-old

Drawing a square

A 1-year-old child has repeated episodes of vomiting and abdominal distention. An x-ray shows obstruction at the second portion of the duodenum. Laparotomy is performed and an annular pancreas is discovered. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice?

Duodenostomy

A 10-year-old presents with 2 months history of heavy menstrual-like bleeding. Menarche occurred 6 months ago and this first menses consisted of spotting for 3-4 days without cramps. Subsequent periods were light in flow but lasted 6 to 8 days. Which of the following is the most likely cause of her bleeding?

Dysfunctional uterine bleeding

A 12-year-old male child comes to the office after being referred for a medical evaluation. His schoolteacher says that he has a problem concentrating during class. He stares in space for a few seconds several times a day, and appears totally absorbed in his thoughts. He is not disruptive in class, but appears forgetful. There is no history of trauma, infection or problems at birth. On examination, the child is alert with stable vital signs. There is no loss of motor or sensory perception. Which of the following can confirm the patient's diagnosis?

EEG studies

A 4-year-old male is brought to the physician with fever and headache. His symptoms began two days ago with low-grade fever, cough, and congestion. Last night, he developed a temperature of 102 F 38.9 C. and became fussy and less active. Today, he is crying and complaining of a headache. His parents report that he has vomited twice today. In the office, his temperature is 102.5 F 39 C., pulse is 110/min, and respiratory rate is 20/min. On examination, he is irritable and shows signs of photophobia. His oropharynx is erythematous. Nuchal rigidity is present and when the neck is flexed, the patient flexes his lower extremities. The remainder of the physical examination is normal. Lumbar puncture is performed and the results are shown below. CSF: Glucose 60 mg/dL, Protein 80 mg/dL, RBC 10/mm3, WBC 100/mm3, Neutrophils 10%, Lymphocytes 70%, Monocytes 20%, Gram stain negative. Which of the following organisms is most likely responsible for this patient's presentation?

Echovirus

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

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

You examine an 18-year-old male college student with a 5-day history of fever, sore throat, and fatigue. Physical examination reveals an exudative tonsillitis and bilateral enlarged and slightly tender posterior cervical lymph nodes. The spleen is palpable 3 cm below the rib cage. Which agent is most likely responsible for this patient's illness?

Epstein-Barr virus

A 10-year-old boy is brought to the emergency department due to abdominal pain and bloody diarrhea. The mother says that he was "fine" a few days ago, and then suddenly became ill. Physical examination shows a pale and jaundiced child. There is diffuse abdominal tenderness and 2+ pedal edema. Laboratory studies show anemia, thrombocytopenia and renal insufficiency. What is the most likely cause of the patient's symptoms?

Escherichia coli

Which microorganism is a common ethiology in endotoxic shock?

Escherichia coli

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

Ahealthy adolescent is found to have elevated blood pressure on several occasions. Which statement is correct?

Essential hypertension is the most common cause of hypertension among adolescents.

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 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

A 6-year-old Caucasian boy is hospitalized for acute sinusitis that was accompanied with intensive nasal bleeding. Past medical history is significant for recurrent pulmonary infections and several hospitalizations for parenteral antibiotic therapy. The sweat chloride test is positive. The blood tests reveal a prothrombin time PT. of 20 seconds. Which of the following coagulation factors is most likely to be deficient in this patient?

Factor VII

A 10-year-old child arrives with the complaint of new-onset bed-wetting. He has had no fever, his urine culture is negative, and he has had no new stresses in his life. He is well above the 95th percentile for weight as is much of his family. Which of the following is most helpful in making a diagnosis?

Fasting plasma glucose of 135 mg/dL

A 2950-g 6.5-lb. black baby boy is born at home at term. On arrival at the hospital, he appears pale, but the physical examination is otherwise normal. Laboratory studies reveal the following: mother's blood type A, Rh-positive; baby's blood type O, Rh-positive; hematocrit 38%; and reticulocyte count 5%. Which of the following is the most likely cause of the anemia?

Fetomaternal transfusion

A 10-year-old girl has bullous target lesions and mucosal erythema, which developed after her third dose of trimethoprim-sulfamethoxazole for a urinary tract infection. Which of the following is a likely associated clinical finding?

Fever

A 12-year-old girl is brought to the clinic due to a 2-month history of headaches. Her headaches last 1-2 hours and have no fixed time of occurrence. She denies nausea, vomiting, chills or fevers. She has no other medical problems and takes no medication. Her family history is significant for hypertension and diabetes. Her blood pressure is 156/90 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows an alert child in no distress. There is a soft to-and-fro bruit heard at the right costovertebral angle. Which of the following is the most likely cause of her hypertension?

Fibromuscular dysplasia

Polly is a 2-year-old girl who is receiving chemotherapy for her acute lymphoblastic leukaemia. She is known to be neutropenic and has developed a fever of over 38.5°C. What is the most appropriate course of action? Select one answer only.

Have blood cultures taken and be started on intravenous antibiotics

A 2-week-old neonate is brought to the office due to poor feeding and persistent vomiting. He had an episode of jerky movements of his limbs this morning. He was delivered at term with no complications and weighed 2.7kg 6 Ib. at birth. He appears lethargic, irritable and jaundiced. On examination, he weighs 2.2kg 5 Ib.. His liver and spleen are enlarged. Bilateral cataracts are evident. Which of the following is most consistent with these findings?

Galactose- 1-phosphate uridyl transferase deficiency

A newborn baby is diagnosed with a metabolic condition at 10 days of age, after she presented with vomiting, jaundice, hepatomegaly and liver failure. She was subsequently put on a lactose-free and galactose-free diet. Which enzyme is most likely to be deficient? Select one answer only.

Galactose-1-phosphate uridyl transferase

A 2-year-old boy who emigrated from Eastern Europe 1 year ago is brought to the physician because of fever, cough, and night sweats for 3 weeks. The child's grandmother, who lives with him, has similar symptoms. The child's temperature is 39.2 C 102.6 F., Wood pressure is 110/65 mm Hg, pulse is 90/min, and respirations are 28/min. A Mantoux test is reactive, and a chest x-ray film shows a right middle lobe infiltrate and hilar lymphadenopathy. Which of the following is the most appropriate next step in diagnosis?

Gastric aspiration

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 3-day-old, full-term baby boy is brought into the emergency department because of feeding intolerance and bilious vomiting. X-rays films show multiple dilated loops of small bowel and a "ground glass" appearance in the lower abdomen. The mother has cystic fibrosis. Which of the following diagnostic tests would also have therapeutic value?

Gastrografin enema

A 4-year-old previously well boy is brought to the office by his aunt. She reports that he developed pallor, dark urine, and jaundice over the past few days. He stays with her, has not traveled, and has not been exposed to a jaundiced person, but he is taking trimethoprim sulfamethoxazole for otitis media. The CBC in the office shows a low hemoglobin and hematocrit, while his "stat" serum electrolytes, blood urea nitrogen BUN., and chemistries are remarkable only for an elevation of his bilirubin levels. His aunt seems to recall his 8-year-old brother having had an "allergic reaction" to aspirin, which also caused a short-lived period of anemia and jaundice. Which of the following is the most likely cause of this patient's symptoms?

Glucose-6-phosphate dehydrogenase deficiency

Samina is 12-years-old and has hepatomegaly. She is short for her age, suffers from hypoglycaemia and needs an overnight feed via a nasogastric tube. What is the most likely diagnosis? Select one answer only.

Glycogen storage disorder

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

A 1-month-old male infant is brought to the emergency department by his mother due to a 3-day history of projectile vomiting. He has been formula- fed since birth, and his bowel movements are normal. He has never been ill before. His parents and 4-year-old sister are all healthy. One of his maternal uncles is mentally retarded. He weighs 3.1 kg 7 Ib.. Physical examination reveals fair hair and skin, blue eyes, eczematous rash, and mild signs of dehydration. His urine has a mousy odor. What is the most appropriate screening test for this patient's early diagnosis and treatment?

Guthrie test in urine

A 3-year-old boy is brought by his father to the Emergency Department with fever, headache and neck pain that developed over the past several hours. The father states he is not the birth father, and that he and his wife adopted the boy at 18 months of age after his birth mother abandoned him. Physical examination reveals a lethargic male with a temperature of 39.7 C 103.5 F.. There is photophobia, and mildly injected conjunctiva are appreciated. Pupils are equal and reactive and funduscopic examination is unremarkable. The patient has neck stiffness with a positive Kernig's sign. A complete blood count reveals a leukocyte count of 24,000/mm3 with 64 segmented neutrophils and 25 bands. A lumbar puncture is performed that reveals elevated CSF pressure, decreased glucose, and elevated protein. A Gram's stain shows gram-negative pleomorphic rods. There is no growth on blood agar. Growth on chocolate agar reveals white colonies. Which of the following is the most likely pathogen?

Haemophilus influenzae type b

A 2-year-old boy presents with fever, loss of appetite, sore throat, with red, blister-like lesions on the tongue, gums and inside of the cheeks and a red rash, without itching on the palms, soles and the buttocks. Which of the following disease, you think the most probably.

Hand-foot-mouth disease

A 9-year-old African-American child presents with anemia and stroke. What is the most likely finding with hemoglobin electrophoresis?

HbF 15%

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 4-year-old male presents with a 1-day history of abdominal pain and vomiting. He is afebrile and has no diarrhea. He complains of knee pain bilaterally, and there is some tenderness of the knee joints but no effusions. Within 24 hours he develops a rash on his legs and buttocks which is petechial and purpuric, and his platelet count is normal. What is the most likely diagnosis?

Henoch-Schönlein purpura

A 3-year-old-boy ingests 40 of his older sister's chewable vitamin tablets, as well as 3 tablets of 250 mg of acetaminophen. The ingredients in the multivitamin tablets are as follows: Vitamin A 3000 IU, Thiamine 1 mg, Vitamin C 75 mg, Vitamin B6 1 mg, Vitamin D 400 IU, Iron 12 mg, Fluoride 1 mg. The child is brought to the emergency department in no acute distress. Which of the following complications may occur if appropriate therapy is not undertaken?

Hepatic failure from iron toxicity

A 12-year-old girl comes to the physician for an annual examination. She has been in good health for the past year and has no complaints. She began having menses this year and, after a few irregular cycles, is now having a monthly period. Past medical history is significant for multiple episodes of otitis media as a child. Past surgical history is unremarkable. She takes no medications and has no known drug allergies. Physical examination is unremarkable. If not currently immune, which of the following immunizations should this patient most likely receive?

Hepatitis B virus immunization

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

A 6-month-old infant has been exclusively fed a commercially available infant formula. Upon introduction of fruit juices, however, the child develops jaundice, hepatomegaly, vomiting, lethargy, irritability, and seizures. Tests for urine-reducing substances are positive. Which of the following is likely to explain this child's condition?

Hereditary fructose intolerance

A 6-day-old female neonate is admitted to the hospital for the evaluation of jaundice. She was born to a 17-year-old German mother at 39 weeks gestation. Her mother's blood type is B+, and was treated for newborn jaundice due to presumed ABO incompatibility. Her other family members alsohad neonatal jaundice. The infant's vital signs are normal. On examination, she is visibly jaundiced, and her spleen tip is palpable. Her total bilirubin level is 25mg/dl and direct bilirubin level is 0.4mg/dl. Her hemoglobin was initially 15.7g/dl, but is now 10.7g/dl. Her reticulocyte count is 4% and platelet count is 230,000/mm3. The peripheral smear shows moderate schistocytes with burr cells and moderate spherocytes. Her blood type is B+ and Coombs' test is negative. Her stools are negative for occult blood. Her mother's incubated red cell osmotic fragility study is abnormal. What is the most likely cause of this neonate's symptoms?

Hereditary spherocytosis

A 1-year-old boy presents with the complaint from his parents of "not developing normally." He was the product of an uneventful term pregnancy and delivery, and reportedly was normal at birth. His previous health-care provider noted his developmental delay, and also noted that the child seemed to have an enlarged spleen and liver. On your examination, you confirm the developmental delay and the hepatosplenomegaly, and also notice that the child has short stature, macrocephaly, hirsutism, a coarse facies, and decreased joint mobility. Which of the following is the most likely etiology of his condition?

Hurler syndrome

A 1-year-old boy is brought to your office with necrotic periodontal infection. The past medical history is significant for recurrent cutaneous and sinus infections revealing S. aureus and P. aeruginosa isolates. The separation of the umbilical cord was delayed 4 weeks.. CBC shows leukocytosis and increased neutrophils. The number of peripheral lymphocytes is normal. Gamma-globulin level is increased on plasma protein electrophoresis. The Nitroblue tetrazolium NBT. test is normal. Which of the following is the most likely defect present in this patient

Impaired leukocyte adhesion

A 1-year-old boy is brought to the physician by his parents for evaluation of bruising and blood in his stool. The child has had multiple episodes of otitis media and has been hospitalized twice with pneumonia, but has never had bleeding or easy bruising in the past. He has been eating and drinking well with no vomiting or diarrhea. He is afebrile with a heart rate of 150/min and a blood pressure of 80/40 mmHg. On examination, he is well-developed, well-nourished, and has a fair complexion. There are dry, scaly patches on his cheeks and lower extremities. He also has bruising and purpura on his lower extremities. His diaper contains a small amount of occult blood positive stool, but no fissures are seen on rectal examination. The remainder of the physical examination is unremarkable. Laboratory studies show: Complete blood count: Hemoglobin 11 .5 g/dL, Platelet count 20,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 76%, Eosinophils 1%, Lymphocytes 13%, Monocytes 10%. A peripheral smear reveals a low number of platelets, and the platelets that are seen are small. Which of the following is the most likely cause of his bleeding?

Impaired platelet production

A 2-month-old male is brought to the emergency department for evaluation of cyanosis, which occurred earlier in the day while the infant was taking his bottle. Initially, he became fussy and sweaty, then his mother noticed that his lips turned blue. He became intermittently tachypneic and continued to cry. As the crying continued, the cyanosis worsened. His temperature is 37C 98.6 F., blood pressure is 80/50 mmHg, pulse is 150/min, and respiratory rate is 45/min. On examination, the child is alert, cyanotic, and tachypneic. Cardiac auscultation reveals a normal S 1 followed by a systolic ejection click. A grade 2/6 crescendo-decrescendo systolic ejection murmur is heard at the left upper sternal border. The patient is immediately placed in a knee-chest position. This maneuver will improve this patient's condition by which of the following mechanisms?

Increased systemic vascular resistance

A 10-year-old boy is brought to the emergency room by his mother with right hemiplegia of sudden onset. The mother says that the child fell on a pencil in his mouth, ten hours before the onset of symptoms. His past medical history is insignificant. Family history is not significant. His blood pressure 110/60 mmHg and heart rate is 90/min. Physical examination reveals dense right hemiplegia, right hemianesthesia, and mild motor aphasia. Cardiac auscultation reveals S3. What is the most probable cause of this patient's condition?

Internal carotid artery dissection

A 3-week-old African American boy is brought to the Emergency Department because of a generalized seizure 2 hours ago. The infant is highly irritable with incessant high pitched crying. The infant's weight is 2.5 kg 250 gm below birth weight., blood pressure is 70 /40 mm Hg, pulse is 145/min and respirations are 50/min. Laboratory results show: Blood glucose 120 mg/dL, Urea nitrogen 50 mg/dL, Serum sodium 170 mEq/L, Serum calcium 8.5 mg/dL, Serum magnesium 1.5 mg/dL. Which of the following is the most likely cause of this infant's seizure?

Intracranial hemorrhage

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 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

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

A 4-year-old child presents in the clinic with an illness notable for swelling in front of and in back of the ear on the affected side, as well as altered taste sensation. Correct statements about this condition include which of the following?

Involvement of the central nervous system CNS. may occur 10 days after the resolution of the swelling

A 1-month-old baby boy has bloody diarrhea. No infectious agent is identified, but the baby is found to be profoundly thrombocytopenic. The baby is also noted to have a skin rash, and a dermatologist diagnoses eczema. By three months of age, the baby begins to develop recurrent respiratory infections. If this child survives until adolescence, he is at particularly high risk of developing which of the following?

Lymphoma

A 2-year-old child is admitted to your hospital team. The child's primary care doctor has been following the child for several days and has noted her to have had high fever, peeling skin, abdominal pain, and a bright red throat. You are concerned because two common pediatric problems that could explain this child's condition have overlapping presenting signs and symptoms. Which of the following statements comparing these two diseases in your differential is true?

Pharyngeal culture aids in the diagnosis of one of the conditions

A 12-year-old, previously healthy girl presents to her physician with a chief complaint of early morning headaches. She states that these headaches wake her up from sleep 2-3 days a week. She also complains of some vomiting associated with the headaches. The headaches have been getting progressively worse for the past 2 months. She denies any photophobia, dizziness, or blurred vision. There is no history of a recent respiratory infection, runny nose, or cough. There is no history of recent trauma. In the office, her vital signs are within normal limits. Her examination shows pupils that are equal, round, and reactive, with no maxillary or frontal sinus tenderness. Her tympanic membranes are clear and intact. Her neck is supple with full range of motion. Neurologic examination shows a positive Romberg sign. Which of the following tests would most likely confirm the diagnosis?

MRI of the brain

A 2-year-old boy is brought to the clinic because of a swelling at the base of his neck on the left side. The family indicates that since he was born, they suspected he had some kind of a mass in his left supraclavicular area and behind the sternomastoid on that same side, but the area felt soft and mushy, was not always evident, and seemed to be painless, so they did nothing about it. Two weeks ago the child had an upper respiratory infection, and within a day or two the mass became larger and quite obvious. On physical examination he indeed has a soft, mushy, ill-defined mass occupying the entire left supraclavicular area and extending into the posterior triangle of the neck. He has no enlarged lymph nodes anywhere, and his spleen and liver are not palpable. Which of the following is the most appropriate next step in the evaluation?

MRI of the neck and chest

Hypertrophic pyloric stenosis is common in

Males

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

A 6-year-old child has had repeated episodes of otitis media. She undergoes an uneventful surgical placement of pressure-equalization PE. tubes. In the recovery room she develops a fever of 40C 104F., rigidity of her muscles, and metabolic and respiratory acidosis. Which of the following is the most likely explanation for her condition?

Malignant hyperthermia

Worldwide, which of the following factors is most important in predicting neonatal mortality? Select one answer only.

Maternal educational achievement

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

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 6-year-old African-American child is brought in by his father for complaints of easy fatigability and pallor. These symptoms occurred after the son was treated with "some medication" for a recent diarrhea. Physical examination is normal except for pallor and multiple petechiae. Laboratory values are as follows: Hb 8.0 g/dL, WBC 12,000/mm3, Platelets 50,000/mm3, Blood glucose 118 mg/dL, Serum Na 135 mEq/L, Serum K 5.3 mEq/L, Chloride 110 mEq/L, Bicarbonate 18 mEq/L, BUN 38 mg/dL, Serum creatinine 2.5 mg/dL, Total bilirubin 3 mg/dL, Direct bilirubin 0.5 mg/dL, PT 12 seconds, APTT 30 seconds, LDH 900 IU/L, Reticulocyte count 6%. A peripheral blood smear reveals giant platelets and multiple schistocytes. What is the most likely underlying pathophysiology for this boy's pallor?

Microangiopathic hemolytic anemia

You suspect the diagnosis of a brain tumor in a 2-year-old girl with a recent history of ataxia, slurred speech, and early morning vomiting. Which statement about childhood brain tumors is true?

Most are located in the midline and/or below the tentorium cerebri.

A 10-year-old boy was healthy until about 10 days ago when he developed 7 days of fever, chills, severe muscle pain, pharyngitis, headache, scleral injection, photophobia, and cervical adenopathy. After 7 days of symptoms he seemed to get better, but yesterday he developed fever, nausea, emesis, headache and mild nuchal rigidity. Cerebrospinal fluid CSF. shows 200 white blood cells WBC. per microliter all monocytes. and an elevated protein. Correct statements about this infection include which of the following?

Most cases are mild or subclinical

A 3-week-old female is brought into the emergency department with a fever and irritability. She was born after a normal pregnancy and delivery. Her mother had routine prenatal care and has no history of sexually transmitted infections. The infant's mother is 14 years old and the father is 17 years old. They are not married, and the father is not involved in the care of the infant. The infant lives with her mother and maternal grandparents at the maternal grandparents' home. You are concerned about meningitis and decide to do a lumbar puncture. The mother and maternal grandparents are present in the emergency department. Informed consent should be obtained from which of the following individuals?

Mother

A 1-day-old infant appears dusky in the newborn nursery during feeding. Oxygen is immediately administered by nasal cannula. Shortly afterward, she develops tachypnea. On physical examination, her blood pressure from the right upper arm is 50/30 mm Hg, her pulse is 180/min, and her respirations are 60/min. An echocardiogram is consistent with hypoplastic left heart syndrome. Which of the following would likely be found on auscultation?

No murmur, precordial hyperactivity, loud second heart sound

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

A fully immunized 2-year-old presents to the emergency room with several days of low-grade fever, barking cough, and noisy breathing. Over the past few hours he has developed a fever of 40°C 104°F. and looks toxic. He has inspiratory and expiratory stridor. The family has not noticed drooling, and he seems to be drinking without pain. Direct laryngoscopy reveals a normal epiglottis. The management of this disease process includes which of the following?

Observation in a cool mist tent

A 3-year-old boy of African descent is brought to your office by his stepfather because of easy bruising. He says that the child bruises easily even without trauma. The child started playing games by himself recently. He has a past history of clavicular fracture, which the stepfather attributes to a fall down a set of stairs. The history of the biological father is unknown. On examination, there is a right knee effusion with decreased range of motion, and multiple soft tissue hematomas on the thigh. What is the most appropriate diagnostic step in management?

Obtain factor VIII level

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 4-month-old infant boy has gained only 10 ounces since birth. He has failed to gain weight with multiple formula preparations. His stools have been loose and fatty. An older sister had similar symptoms and has been repeatedly hospitalized for failure to thrive and recurrent pulmonary infections. Which of the following is the most likely cause of this patient's gastrointestinal symptoms?

Pancreatic exocrine insufficiency

A14-year-old boy has had several measurements of blood pressure. His systolic blood pressure has been above 99th percentile for age and diastolic blood pressure has ranged between 90th to 94th percentile. What should you advise this young man?

Participation in competitive sports need to be restricted until hypertension is under adequate control.

A 10-year old girl is brought to the office by her mother for the evaluation of recent changes in behavior. She has been sleeping poorly at night and has started wetting her bed. Her school grades have dropped significantly, and she has become irritable and cranky. She refuses to sleep at night until her father returns home and goes to bed. Her father works as a taxi driver, and is an alcoholic. Her mother is a close friend of yours, and appears very concerned. Prior to this office visit, you have known this girl to be cheerful and lively; however, as you attempt to talk to the young girl in the office, she suddenly bursts into tears. Which of the following should you consider at this point?

Physical abuse

A 2-day-old male infant is jaundiced. He was born at term from an uncomplicated pregnancy, and was normal at birth. He otherwise appears healthy and is feeding well. Vital signs are stable. Physical examination shows jaundice. There is no organomegaly. Laboratory investigations show: Hemoglobin 17.0 g/L, MCV 88 fl, Platelets 220,000/mm3, Leukocyte count 4,500/mm3, Total bilirubin 7.5 mg/dL, Indirect bilirubin 6.0 mg/dL. What is the most likely cause of this patient's jaundice?

Physiologic jaundice

A 10-year-old boy is brought to the office by his parents because he is developing dark facial hair, deepening of the voice and a rapid height increase. He also complains of persistent headaches which are resistant to over-the-counter analgesics for the past 2 weeks. He denies nausea, vomiting or visual disturbances. His medical history is unremarkable. Physical examination reveals coarse pubic and axillary hair. Other pertinent findings include lid retraction, paralysis of upward and downward gaze, and poor pupillary reaction to light. His deep tendon reflexes are normal, Babinski sign is negative, and there are no focal neurologic signs. What tumor is most likely responsible for this child's symptoms?

Pinealoma

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

Worldwide, which of the following conditions is most likely to result in the death of an individual child before their fifth birthday? Select one answer only.

Prematurity

A 1-day-old full-term boy is in the neonatal intensive care unit with cyanosis. His BP is 80/40 mmHg in all 4 extremities, HR is 140/min, and respirations are 55/min. Pulse oxymetry shows 80% and does not improve with 100% inspired oxygen by face mask. He is breathing comfortably, but his fingertips and oral mucosa are blue. A continuous machine-like murmur is heard on auscultation. Chest x-ray shows clear lung fields bilaterally. Which of the following is the best next step in management of this patient?

Prostaglandin E1

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 3-year-old boy is admitted for seizure-like activity. He has been a healthy child and has been meeting all development milestones. His immunization schedule is up-to-date. Examination is notable for an erythematous throat and fever. His convulsions require IV administration of a benzodiazepine. Serum analysis reveals a normal white cell count with mild basophilic stippling. The lumbar puncture reveals elevated CSF pressure. Head CT scan is notable for cerebral edema. Which of the following is the next diagnostic step?

Protoporphyrin level

A 1-month old boy is brought to the emergency department by his mother, who states that he has been having what she describes as "projectile vomiting" for the past several days. She states that he vomits every time she feeds him, and the situation seems to be getting worse, although he does not seem to be in pain. She describes the vomitus as non-bilious, and he has had normal stools with no blood in them. On examination, the infant appears to be mildly dehydrated, his abdomen is soft, and there is a palpable, olive-sized, firm moveable mass in the right upper quadrant. Which of the following is the most likely diagnosis?

Pyloric stenosis

A 1 -year old child is brought in for a well-baby check-up. His parents report that he has been of good health and began walking a few weeks earlier. They are concerned that he tends to bump into things and falls more than his older sister did. Family history is significant for retinoblastoma. On examination, the pediatrician notes leukocoria of the left eye. No significant lymphadenopathy is present, and there is no enlargement of the liver or spleen. The child's height and weight are normal for age. Which of the following is the most appropriate next step in management?

Refer to ophthalmologist

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

Jonathan is an 8-year-old boy. He has a medical history of urinary tract infections. On this occasion he presents to hospital with acute spasmodic pain on the left side of his abdomen. He says it is the worst pain he has ever experienced. He played football yesterday but had not hurt himself. On examination he is afebrile and his abdomen is soft with no guarding. He is tender in his left loin and there are no palpable masses. He has 2+ of haematuria on dipstick of his urine but no protein or leucocytes. He is not on any medication. What is the most likely cause of his pain? Select one answer only.

Renal stone

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

The most common cause of bronchiolitis is:

Respiratory syncytial virus

An 8-year-old girl presents with well-controlled, moderately persistent asthma. Her therapies consist of occasional use of short-acting β-agonists, daily inhaled steroids, and a leukotriene inhibitor. She presents with white patches on her buccal mucosa. You recommend which of the following?

Rinse her mouth after use of her inhaled medications

A 3-year-old girl presents to a health center with a fever for the past 36 hours. Maximum temperature was 40°C at 2 am, which decreased to38.7°F with children's ibuprofen. Her appetite andfluid intake have decreased during the past 24 hours. Physical examination shows an ill-appearing child.Her temperature is 37.2°C. The skin has a macular-papular petechial rash on the chest and back. Theremainder of the physical examination is normal. Which one of the following antibiotics would you consider in the treatment of this condition?

Rocephin

A 2-year-old boy is brought to the office by his parents due to severe diarrhea since yesterday. He has had approximately 20 episodes of non-bloody, non-mucoid stool passage in the last twenty hours, and one episode of bilious vomiting. He is also feeding less than usual. He is febrile, tachycardic and moderately dehydrated. What is the most likely cause of his presentation?

Rotavirus

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

A 2-year-old girl presents with fever of 39.3 C and irritability. She has had an upper respiratory tract infection for 4 days. On examination, the right ear is bulging and has poor movement on insufflation. Which of the following organisms is most likely responsible for these findings?

S. pneumoniae

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

6-month-old male is brought to the office due to fussiness and tugging at his right ear for the past 2 days. He has had a fever of 39.4° C 103° F. for the past 2 days. His past medical history is significant for recurrent ear and lung infections, oral candidiasis, and persistent diarrhea by rotavirus. His temperature is 39.4° C 103° F., pulse rate is 150/min, respirations are 28/min, and blood pressure is 80/60mm Hg. Physical examination reveals an erythematous, bulging right tympanic membrane with poor mobility on pneumatic otoscopy. His lymph nodes are not palpable, and his tonsils are not visualized. His B and T lymphocyte levels are markedly reduced. The chest x-ray reveals an absent thymic shadow. What is the most likely etiology of this patient's condition?

Severe combined immune deficiency

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 6-month-old male is brought to the office due to fussiness and tugging at his right ear for the past 2 days. He has had a fever of 39.4 C 103 F. for the past 2 days. His past medical history is significant for recurrent ear and lung infections, oral candidiasis, and persistent diarrhea by rotavirus. His temperature is 39.4 C 103F., pulse rate is 150/min, respirations are 28/min, and blood pressure is 80/60mm Hg. Physical examination reveals an erythematous, bulging right tympanic membrane with poor mobility on pneumatic otoscopy. His lymph nodes are not palpable, and his tonsils are not visualized. His B and T lymphocyte levels are markedly reduced. The chest x-ray reveals an absent thymic shadow. What is the most likely etiology of this patient's condition?

Severe combined immune deficiency

A 15-month child is brought to you fordiarrhea, with an average 7 loose stools per day for the past 4 days. The stool is watery without any mucus or blood. He also vomited several times during the first 2 days but now it appears to be subsiding. He has been drinking fluids but has not had much appetite for food. For the past 2 days, he has been running a "low-grade fever" and appears to have some abdominal discomfort. He attends a local day care, where some of the children have had similar symptoms.On physical examination, the child is active without any fever. He has dry, cracked lips with moist oral mucosa. The ears, throat, lungs, and abdomen are normal. There are no abdominal masses and no palpable tenderness. What is the most common bacterial cause of diarrhea in children?

Shigella

An 18-month-old child presents to the emergency center having had a brief, generalized tonicclonic seizure. He is now postictal and has a tem- perature of 40°C 104°F.. During the lumbar puncture which ultimately proves to be normal., he has a large, watery stool that has both blood and mucus in it. Which of the following is the most likely diagnosis in this patient?

Shigella

A mother comes to your office with her 5-year-old boy who has developed severe crampy diarrhea and mild fever. The family has just returned from a trip inMondulkiri province; the child became sick on the third day. He was apparently drinking water from a local stream. What is the most likely diagnosis in this patient?

Shigellagastroenteritis

A 4196 g 9 lb 4 oz. infant is delivered via vaginal delivery to a 31-year-old mother with gestational diabetes. The delivery was complicated by shoulder dystocia. He is taken to the newborn nursery where his initial plasma glucose level is 20 mg/dL. The initial spun hematocrit is 65%. Which of the following congenital anomalies is this baby most likely to have?

Small left colon

A2-year-old child is referred to you for evaluation of child abuse. On physical examination, you find a pale child with diffuse petechiae and bilateral proptosis with periorbital ecchymoses. Which of the following statements is true about this condition?

Spontaneous regression has occurred in some children.

A 3-year-old male is brought to the emergency department for evaluation of right neck swelling. His parents noticed a lump on his right neck yesterday, which has since increased in size and is now erythematous and tender. He has been previously healthy except for mild upper respiratory tract symptoms last week. His temperature is 38C 100.4F., pulse is 90/min, and respiratory rate is 25/min. On examination, he is nontoxic appearing. A 5-cm anterior cervical lymph node is palpated on the right side. It is poorly mobile, warm, erythematous, and tender to palpation. There is no fluctuance or induration. What is the most likely organism causing these symptoms?

Staphylococcus aureus

The most common organism in patients with empyema purulent pleurisy is:

Staphylococcus aureus

A 4-year-old boy, recently adopted through an international adoption service, is noted to have intermittent watery diarrhea, nausea, belching, and abdominal pain. His weight is less than the fifth percentile for his age. Which of the following studies would be most helpful in making the diagnosis?

Stool microscopy for ova and parasites

A 12-year-old boy is brought to the office due to a 2-day history of high-grade fever and chills. He was apparently well before the onset of fever. He has no bone pain. He has sickle cell disease and has had 4 hospitalizations for painful crises and one episode of osteomyelitis. His blood pressure is 90/60 mm Hg, pulse is 100/min, respirations are 22/min and temperature is 38.9 C 102F.. He appears drowsy. His laboratory report shows a total WBC count of 16,000/mm3 with 12% bands and Hb of 9.0 g/dl. Which of the following is the most likely cause of this patient's condition?

Streptococcus pneumoniae

A 3-year-old child is brought to the office for cough and fever. He has been sick for the past 4 days, but symptoms acutely worsened this morning. Appetite and activity levels are both decreased. Past medical history is unremarkable and immunizations are current. He lives at home with two brothers and goes to day care during the week. There are no sick contacts. On physical examination, he has a temperature of 38.5°C, pulse of 120 beats/minute, respiratory rate of 60 breaths/minute, and normal blood pressure. He appears mildly toxic but not cyanotic. Ears, nose, and throat are unremarkable. Retractions, grunting, and accessory muscle use are noted on the lung exam. Localized rales and wheezing are noted over the right lower lung zones. What is the most common bacterial cause of CAP after the neonatal period?

Streptococcus pneumoniae

A 4-year-old boy is sent to the emergency room because of clinical suspicion of meningitis. He has been ill for 2 days with fever and lethargy. On examination, he is febrile, the neck is stiff, and papilledema is present. There is no rash, the lungs are clear, and heart sounds normal. Which of the following is the most likely causative organism?

Streptococcus pneumoniae

What physical exam sign/symptom is most suggestive of foreign body aspiration?

Stridor

A 6-week-old male infant, who was born at 32 weeks' gestation with a birth weight of 1500 g, has had an average weight gain of 8 g/day since birth. He takes an iron-fortified formula that is 24kcal/oz. His calorie intake is about 125kcal/day. It is noted that his stool is poorly formed and bulky. Which of the following dietary modifications will most likely result in decreased steatorrhea and improved weight gain?

Substitute medium-chain triglycerides for long-chain triglycerides

Treatment of bronchiolitis should include all of the following EXCEPT:

Supplemental oxygen for infants with hypoxia.

A 20-month-old male is brought to the emergency department for evaluation of rectal bleeding after his parents discovered a substantial amount of maroon colored stool when changing his diaper. He has no history of hematochezia. The patient has been otherwise healthy and has not appeared to be in any pain. He has been eating and drinking well. His temperature is 37 C 98.6 F., blood pressure is 85/50 mmHg, pulse is 130/min, and respiratory rate is 20/min. On examination, the abdomen is soft, nondistended, and nontender. On rectal examination, there are no fissures or masses present. A fecal occult blood test is positive. The remainder of the physical examination is normal. Which of the following is the best test to confirm the diagnosis?

Technetium-99m pertechnetate scan

A 10-year-old boy is brought to clinic because of increasing weakness and dyspnea over the past 6 months. He has been previously healthy and is on no medications. There is no significant family history of illness. On examination, he appears pale. His hematocrit is 20%, mean corpuscular volume MCV. is 60/mm3, and iron level is normal. Smear reveals basophilic stippling. Hemoglobin electrophoresis is consistent with the absence of one beta-globin gene. Which of the following is the most likely diagnosis?

Thalassemia

A 1-week-old male newborn is seen in the office for "noisy breathing." The mother says that the "noisy breathing" is more prominent when the infant is lying on his back, and improves when he is in a prone position with his chin up. The newborn is afebrile and has no cough, vomiting, or cyanosis. There are no inspiratory retractions or wheezes. On direct laryngoscopy, the epiglottis is rolled in from side to side. Which of the following statements is true about the child's condition?

The child should be held in an upright position for 30 minutes after feeding and never fed while lying down

A 1-year-old child is brought to the physician for a routine visit. He was born full term with a birth weight of 71b 8oz 34 kg. and a birth length of 20 in 50.8cm.. He has had no major illnesses or hospitalizations His parents report that he was breastfed exclusively for 6 months. He now eats a variety of baby foods and is being transitioned to whole milk. He can pull up to stand and cruise around holding onto objects, but cannot walk independently yet. He can feed himself small pieces of table food with his thumb and first finger. The only words he knows are mama, dada, and ball. His parents are concerned about his growth because some of the other children in his day care class are bigger than him. On physical examination, he weighs 221bs 10 kg. and is 30 in 76.2cm. long. A complete examination is unremarkable. Which of the following should you tell his parents?

The child's growth and development are normal

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 2-year-old boy is being followed for congenital cytomegalovirus CMV. infection. He is deaf and developmentally delayed. The child's mother informs you that she has just become pregnant and is concerned that the new baby will be infected and may develop serious consequences. Which of the following is true?

The mother has antibodies to CMV that are passed to the fetus

Tariq, who is 6 weeks old, is admitted directly from the cardiology clinic with heart failure. He has a large ventricular septal defect. The cardiologist has recommended treatment with furosemide and spironolactone. His mother wants to know why he has only now started to have problems. Which of the following statements provides the best explanation? Select one answer only.

The pulmonary vascular resistance falls after birth and now flow from left to right across the septal defect is much greater

A 1-week-old female infant is brought to the office by her 30-year-old mother because she has been "crying a lot." She was born at term. Her mother was diagnosed with gestational diabetes mellitus GDM. at 24 weeks gestation and had been on insulin injections since. During labor, there was a prolonged second stage due to difficulty in delivering the shoulders. Her Apgar scores were 8 and 10 at 1 and 5 minutes, respectively. Her birth weight is 3.8 kg 8.5 Ib.. On examination, the infant is active. On sudden extension of the head, there is extension of all the extremities, except for the left upper extremity. There is crepitus over the left clavicular bone. Which of the following statements is true for this baby?

This is a common outcome with large babies and related to gestational diabetes

A neonate is noted to have an abnormally shaped face with a very small jaw. Several hours after birth, the baby develops convulsions and tetany. Serum chemistries show the following: Sodium 1 40 mEq/L, Potassium 4 mEq/L, Chloride 100 mEq/L, Bicarbonate 24 mEq/L, Magnesium 2 mEq/L, Calcium 5 mg/dL, Glucose 100 mg/dL. This child's disorder is associated with aplasia or hypoplasia of which of the following organs?

Thymus

Which of the following causes of death in childhood is likely to increase most in the next 15 years? Select one answer only.

Trauma

A cyanotic newborn is suspected of having congenital heart disease. He has an increased left ventricular impulse and a holosystolic murmur along the left sternal border. The ECG shows left-axis deviation and left ventricular hypertrophy LVH.. Which of the following is the most likely diagnosis?

Tricuspid atresia

Among children, short stature and infertility are most commonly associated with which of the following?

Turner syndrome

A 4-year-old boy falls from the jungle gym at preschool. He sustains minor abrasions and contusions, and is taken care of by the school nurse. His parents take him that same afternoon to his regular pediatrician and demand "a thorough check-up" for possible internal injuries. The pediatrician complies, and a complete physical examination is normal. His hemoglobin is 14 g/dL, and a urinalysis shows the presence of microhematuria. Which of the following is the most appropriate next step in management?

Urologic workup, starting with a sonogram

A 3-year-old girl is brought to the pediatrician with complaints of abdominal pain and fever. Her mother states that the fever started 2 days ago, with the highest temperature being 39.0 C 102.2 F.. She has had no vomiting or diarrhea. The mother states that her daughter has been complaining of pain on urination. On examination, she is tender in her lower abdomen, and there is some right-sided costovertebral angle tenderness. A urinalysis confirms the suspicion of a urinary tract infection. Which of the following would be the most appropriate diagnostic procedure?

VCUG in 1-2 months

A mother brings her child in for a 2-month visit. She gives a history of no prenatal care and a normal vaginal delivery. The baby has received no medical care since discharge. The infant has a large, protruding tongue; short palpebral fissures; and epicanthal folds. He has a simian palmar crease and a large space between the first and second toes. On cardiac examination, you note a harsh III/VI systolic murmur on the left sternal border. Your leading cardiac diagnosis is

VSD

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

A 20-month-old male is brought to ER with high fever, confusion and a skin rash suggestive of measles. He has a history of recurrent respiratory infections over the last 6 months. The patient's family has recently emigrated from a rural Russian province. Which of the following forms of vitamin supplementation should be considered in this patient?

Vitamin A

A 6-year-old Asian boy is brought by his parents to the office due to high-grade fever and rash for the last 9 days. A brick-red, maculopapular rash first appeared on his face and subsequently spread to his trunk and extremities. Prior to the outbreak of the rash, he had a non-productive cough, tearing of eyes, runny nose, sneezing, and intermittent nasal obstruction. Laboratory findings are as follows: Hct 46%, WBC 2,000/mm3, Platelets 160,000/mm3. Which of the following has been shown to reduce the morbidity and mortality rates of patients with this kind of infection?

Vitamin A

A 3-year-old boy is brought to the office by his parents for the evaluation of dry eyes and photophobia. He has some difficulty in adapting to darkness. He is a very poor eater, and his diet consists mainly of canned foods, and very rarely, fresh vegetables or milk. Examination reveals dry, scaly skin, follicular hyperkeratosis in the extensor surfaces of the extremities, and dry, silver-gray plaques on the bulbar conjunctiva. What is the most likely diagnosis of this patient?

Vitamin A deficiency

A 15-year-old vegetarian being treated for tuberculosis develops periph- eral neuropathy. For presented child above, choose the one most appropriate vitamin or trace element replacement therapy to treat the described condition.

Vitamin B6

A 2-year-old girl is brought to the emergency department with a fever, chills, poor appetite, and vomiting. On examination, she is irritable and diaphoretic. Her temperature is 39.2 C 102.5 F., blood pressure is 80/48 mm Hg, pulse is 88/min, and respirations are 17/min. She is tender at the left costovertebral angle. Initial laboratory tests show the following: Leukocyte count 16,300/mm3, Hemoglobin 12.5 g/dL, Platelet count 245,000/mm3, Blood urea nitrogen 6 mg/dL, Creatinine 0.5 mg/dl. Urinalysis is positive for leukocyte esterase and nitrite, with 150 white blood cells/hpf. After TV antibiotic administration and stabilization, what is the most appropriate diagnostic study?

Voiding cystourethrography

A 3-year-old boy is brought to the emergency department three hours after having a seizure. He has been having severe diarrhea for the last three days. His mother recently read about the importance of maintaining adequate hydration during diarrhea, so she had been giving him a lot of milk mixed with water. On examination, his vital signs are stable and mucus membranes are moist. Initial lab results are: Hb 13 g/dl, WBC 6,000/mm3, Platelets 300,000/mm3, Blood Glucose 98 mg/dl, Serum Na 120 mEq/L, Serum K 3.4 mEq/L, Chloride 92 mEq/L, BUN 22 mg/dl, Creatinine 1.2 mg/dl. What is the most likely cause of this patient's seizure?

Water intoxication

A 6-year-old boy is brought to the clinic for the evaluation of a large, red, circular rash on his left thigh which has been present since two weeks and has been enlarging. He has a mild headache and myalgia, but is afebrile. Three weeks ago, he and his family visited relatives at a rural farm in Connecticut and went hiking in the woods. His temperature is 37.2 C 99 F. and pulse is 90/min. He is alert, active, appears non-toxic, and not in distress. On the anterior surface of his left thigh, there is a red ring that is 7 cm in diameter with central clearing, and a central brownish-red macule that is 3 mm in diameter. Which of the following measures would have prevented this condition?

Wearing light-colored clothing. Long-sleeved shirts and tucking pants into socks or boot tops

A 6-month-old male presents with failure to thrive, eczema, and a history of recurrent bacterial infections. On evaluation, a thrombocyte count of 20,000/mm3 is noted. The peripheral smear reveals microthrombocytes. Which of the following is the most likely condition causing these signs and symptoms?

Wiskott-Aldrich syndrome

A full term neonate with Down syndrome and esophageal atresia admitted in Pediatric intensive care unit PICU.. The parents want "no interference" approach. Of the following, the BEST response is to

Work for the patient best interest

A 3-year- old boy is brought to the ER with a two-day history of decreased appetite, neck swelling, and irritability. He keeps his head rotated slightly to the right side. He resists passive flexion of the neck and rotation to the left side. Which of the following is the best next step in managing this patient?

X-ray of the neck

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

You examine a school-age child because of itchy scalp and note minute white-gray structures firmly attached to the hair shafts. You recommend which of the following?

a 1% permethrin cream rinse

A 3-year-old female presents for her routine visit. The physician notes pallor and bruising. On physical examination, the vital signs are normal but there is a generalized lymphadenopathy and hepato-splenomegaly. A complete blood count CBC. reveals a white blood cell WBC. count of 33,000/mm3 and a platelet count of 81,000/mm3. The peripheral blood smear shows blasts, and the lactate dehydrogenase activity is elevated. CBC shows blasts as well as hypochromic red blood cells. Which of the statements regarding the disease described in here is true?

a CBC with differential is the most useful initial test

A 7-year-old female presents to your office with a history of 1 week of gradually increasing chest tightness and mild dyspnea. She has had nasal drainage and a nighttime cough. Her mother states that she has had no fever and has been going to school. Her medical history is significant for only oneprevious episode of wheezing for which she was treated with an antibiotic and an inhaler. Her familyhistory is significant for an older brother with asthma. Her father is a smoker.On examination, she has a temperature of 38°C, blood pressure of 90/50 mmHg, respiratoryrate of 20 breaths/minute, and pulse of 100 beats/minute. She appears in no distress but is audibly wheezing. She has mild nasal turbinate swelling, postnasal drainage, and diffuse expiratorywheezes. After a nebulizer treatment with albuterol, she feels much better, and her lungs are completely clear. Which of the following do you advise the patient and her parent?

a and d (she may or may not have asthma, but she has symptoms of airway reactivity; you prescribe an albuterol inhaler with a spacer device and advisethat her father must stop smoking immediately or ensure she is not exposed to any cigarette smoke, she needs to follow-up with you in a short period of time to determine if further treatment is necessary and should call immediately if she is worsening)

A positive tuberculin skin test a delayed hypersensitivity reaction. indicates that

a cell-mediated immune response has occurred.

Compared to other methods of dialysis, peritoneal dialysis offers many advantages for children and their families including increased autonomy and flexibility, with resultant enhanced school attendance and peer interactions.Peritoneal dialysis is less costly than hemodialysis and can be used to treat even small infants. The major complication of peritoneal dialysis, either continuous ambulatory CAPD. or continuous cycling CCPD, is

a high incidence of peritonitis

An 8-year-old child is hospitalized because of paroxysms of severe colicky abdominal pain which does not radiate to the back or the groin. Physical examination is unremarkable except for generalized abdominal tenderness. An exploratory laparotomy reveals an edematous intestine without specific lesions. The appendix appears normal but is removed. Postoperatively the abdominal pain persists, and hematuria develops. Values for BUN and creatinine are​​ normal. On the second postoperative day, tender swelling of both ankles and knees is noted. Which of the following additional findings would most likely be present in this child?

a purpuric rash

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. You explain to her that the following pathologic changes. isare. found in the airways of patients with asthma, with or without symptoms:

a, b, and c (airway remodeling, airway smooth muscle hypertrophy, airway epithelial cell destruction)

A 3-year-old female presents for her routine visit. The physician notes pallor and bruising. On physical examination, the vital signs are normal but there is a generalized lymphadenopathy and hepato-splenomegaly. A complete blood count CBC. reveals a white blood cell WBC. count of 33,000/mm3 and a platelet count of 81,000/mm3. The peripheral blood smear shows blasts, and the lactate dehydrogenase activity is elevated. CBC shows blasts as well as hypochromic red blood cells. Which of the following increases the risk of a child developing AML?

a, b, and c (previous exposure to benzene, previous exposure to ionizing radiation, neurofibromatosis)

A 2-year-old male presents for a checkup. His parents tell you that he has been doing well, but he has had episodes of wheezing four times during the past year. He is the product of an uncomplicated pregnancy and delivery, but he was hospitalized at age 6 months for bronchiolitis. Both parents have a history of allergies, and his father has asthma. His mother smoked during pregnancy but quit smoking last year. The child was never breast-fed. Which of the following is included in the diagnosis of asthma in children?

a, b, and c (symptoms of episodic airflow obstruction, at least partially reversible airflow obstruction, wheezing with allergic rhinitis)

Diagnosis of autistic spectrum disorder ASD. depends partly but importantly on assessment of language. All the following may raise your concern regarding language development and may indicate ASD EXCEPT

absent babbling by 6 months

A 14-year-old male is brought into the office by his mother. For the past 2 weeks, he has been very tired and has felt short of breath. The mother tells you that she thinks he has been losing weight. On physical examination, the child is alert and in nodistress; vital signs are normal, but he has lost 3.5 kg since his last visit 6 months ago. The lungs are clear bilaterally, and the heart examination is normal. You palpate an enlarged supraclavicular node. Chest radiography reveals a large mediastinalmass. The most common malignancy in childhood is which of the following?

acute lymphoblastic leukemia ALL.

A 3-year-old female presents for her routine visit. The physician notes pallor and bruising. On physical examination, the vital signs are normal but there is a generalized lymphadenopathy and hepato-splenomegaly. A complete blood count CBC. reveals a white blood cell WBC. count of 33,000/mm3 and a platelet count of 81,000/mm3. The peripheral blood smear shows blasts, and the lactate dehydrogenase activity is elevated. CBC shows blasts as well as hypochromic red blood cells. The most common leukemia among children is which of the following?

acute lymphocytic leukemia

A parents came to your clinic complaining that their 5-year-old boy had attacks of frightening with imagination of a snake crawling over him and he is acting as trying to remove it. You assessed the child and find no acute physical illness and he is cooperative and quite intelligent. Of the following, the MOST appropriate explanation for the child behavior is

acute phobic hallucination

A 13-year-old adolescent female attained out-patient department OPD., with a complaint of feeling fat especially over the stomach and thighs; she is also feeling cold, tired, weak, and lacking energy. Examination reveals, heart rate 46 beats/min, blood pressure 70/40 mm Hg, weight below 3rd centile, dry skin, and lanugo-type hair growth on face; lab investigations shows hypokalemia and hypophosphatemia. Of the following, the MOST appropriate next action is

admission to the hospital

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. Which of the following statements is correct,according to the most recent guidelines for asthma management?

advise consultation with an asthma specialist for all patients with mild persistent asthma

On routine examination, a 2-month-old African- American male infant is noted to have a moderate size umbilical hernia. The contents of the hernia are easily reduced, and it is noted that the abdominal wall defect easily admits one examining finger but not quite two. The remainder of the examination is normal and the infant is asymptomatic. What is the most appropriate next step in management?

advise the parent that the defect will probably close spontaneously

A mother comes to your office with her 5-year-old boy who has developed severe crampy diarrhea and mild fever. The family has just returned from a trip inMondulkiri province; the child became sick on the third day. He was apparently drinking water from a local stream. All of the following factors are associated with an increased risk of gastroenteritis except

age older than 5 years

A 14-year-old male is brought into the office by his mother. For the past 2 weeks, he has been very tired and has felt short of breath. The mother tells you that she thinks he has been losing weight. On physical examination, the child is alert and in nodistress; vital signs are normal, but he has lost 3.5 kg since his last visit 6 months ago. The lungs are clear bilaterally, and the heart examination is normal. You palpate an enlarged supraclavicular node. Chest radiography reveals a large mediastinalmass. Which of the following is commonly associated with non-Hodgkin's lymphoma?

airway obstruction

For which of the following would laboratory testing for group Astreptococcus GAS. be recommended in the United States?

all household contacts of a child with documented poststreptococcal glomerulonephritis

A 5-year-old is brought to the office with a 3-day history of fever, nonproductive cough, coryza, and conjunctivitis. This morning, a rash appeared on his forehead and behind the ears, and it appears to be spreading to his upper arms and chest. On physical examination, you note a fine maculopapular rash over the face that appears to be spreading to the back and thighs. What are the hallmark signs and symptoms of this infection?

all of the above (Koplik's spots, coalescing erythematous maculopapular rash, suboccipital and postauricular lymph node enlargement, conjunctivitis)

A 15-month child is brought to you fordiarrhea, with an average 7 loose stools per day for the past 4 days. The stool is watery without any mucus or blood. He also vomited several times during the first 2 days but now it appears to be subsiding. He has been drinking fluids but has not had much appetite for food. For the past 2 days, he has been running a "low-grade fever" and appears to have some abdominal discomfort. He attends a local day care, where some of the children have had similar symptoms.On physical examination, the child is active without any fever. He has dry, cracked lips with moist oral mucosa. The ears, throat, lungs, and abdomen are normal. There are no abdominal masses and no palpable tenderness. Which of the following infectious agents may produce bloody diarrhea in infants and children?

all of the above (Shigella, Salmonella, enteroinvasiveE. coli)

A 15-month child is brought to you fordiarrhea, with an average 7 loose stools per day for the past 4 days. The stool is watery without any mucus or blood. He also vomited several times during the first 2 days but now it appears to be subsiding. He has been drinking fluids but has not had much appetite for food. For the past 2 days, he has been running a "low-grade fever" and appears to have some abdominal discomfort. He attends a local day care, where some of the children have had similar symptoms.On physical examination, the child is active without any fever. He has dry, cracked lips with moist oral mucosa. The ears, throat, lungs, and abdomen are normal. There are no abdominal masses and no palpable tenderness. Which of the following is a common causes. of antibiotic-associated diarrhea in infants and children?

all of the above (ampicillin, clindamycin, amoxicillin, cephalosporins)

A 3-year-old child is brought to the office for cough and fever. He has been sick for the past 4 days, but symptoms acutely worsened this morning. Appetite and activity levels are both decreased. Past medical history is unremarkable and immunizations are current. He lives at home with two brothers and goes to day care during the week. There are no sick contacts. On physical examination, he has a temperature of 38.5°C, pulse of 120 beats/minute, respiratory rate of 60 breaths/minute, and normal blood pressure. He appears mildly toxic but not cyanotic. Ears, nose, and throat are unremarkable. Retractions, grunting, and accessory muscle use are noted on the lung exam. Localized rales and wheezing are noted over the right lower lung zones. Which of the following signs is suggestive of hypoxemia?

all of the above (inability to feed, altered mental status, cyanosis, head nodding)

A 3-year-old is brought to your office with fatigue andirritability and a low-grade fever that he has had for3 days. The child attendsday care, where a virus is reportedly "going around." The child was treated by acetaminophen, which has helped to decreaseirritability; although the child's appetite is suppressed,he is still taking in a good amount of fluids. On physical examination, the child does not lookill. His temperature is 38°C. His skin examinationshows scattered small vesicles on an erythematousbase. The rash was seen first on the face and seemsto be spreading to the trunk. What is a complications. associated withvaricella infection?

all of the above (scarring, secondary bacterial infection with staphylococcusand streptococcus, pneumonia, encephalitis and cerebellar ataxia)

A 10-year-old boy is brought in with a chief complaint of multiple colds. On further questioning, you elicit a history of chronic, clear nasal discharge with no seasonal variation. Other symptoms include sneezing, itching of the nose and eyes, as well as tearing and occasional eye redness. Some relief is obtained with an over-the-counter cold medicine containing antihistamine and a decongestant. His history suggests which of the following?

allergic rhinitis

A 4-year-old child with a runny nose, congestion, sneezing, and a nonproductive cough comes to your office with his mother. These symptoms started 4 days ago with a sore throat that has since resolved. His appetite is mildly decreased, but he is well otherwise. He has had no fever, chills, or any other symptoms. On examination, the child's temperature is 37.6°C. His ears are clear, and his throat is slightly hyperemic. He has grayish thick nasal discharge and the nasal mucosa appears swollen with erythematous nasal turbinates. His lung fields are clear, there is no significant cervical lymphadenopathy, and no other localizing signs are present. The child's history is unremarkable, and he has had no significant medical illnesses. His immunizations are up to date. What is the most likely diagnosis in this child?

allergic rhinitis

A 6-month-old infant is brought to your office by her mother with nasal congestion for 5 days. The child had a clear runny nose at 1st but now the drainage is thick and yellow and she seems tobe having difficulty with taking the bottle. The baby has had only low-gradetemperatures of less than 38°C. The mother tells you that the baby seems cranky but is consolable and has had difficulty sleeping because of the breathing. On examination, the infant is afebrile. There is no tachypnea. The conjunctivae are slightly hyperemic but without purulent exudates. The nose is congested with erythematous mucosa and thick yellow drainage bilaterally. The ears are clear. The throat is pink, but postnasal drip is noted. The chest is without retractions and is clear to auscultation. What is the diagnosis?

allergic rhinitis

A 7-year-old child is brought to the office because of chronic nasal obstruction. Examination reveals bilateral, clear, serous discharge from the nose, but is otherwise unremarkable. Which of the following is the most likely​​ diagnosis?

allergic rhinitis

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. You check an influenza swab, which is negative, and treat the child with inhaled albuterol with a spacer, an inhaled corticosteroid, and a short course of oral steroids. When he returns in 3 days, he has already improved dramatically and has a normal physical exam. Which of the following is true concerning monitoring of asthma in children?

although some studies are inconclusive, a written action plan has been shown to improve asthma management and outcomes

A 2-year-old male presents with upper respiratory symptoms for 3 days and 1 day of fever, irritability, and right ear pain. Examination reveals a temperature of 39°C, clear rhinorrhea,a bulging immobile right tympanic membrane with absent light reflex. What is the most appropriate initial therapy?

amoxicillin

Unilateral multicystic dysplastic kidney in an infant usually presents with which of the following?

an abdominal mass

A 5-year-old pedestrian is hit by a car in a mall parking lot and he is brought to the emergency department. There was loss of consciousness for less than 1 minute. On evaluation, the child has no neurologic deficits and a CT scan of the head reveals no intracranial abnormalities and no obvious skull fractures. The parents want to know what possible long-term problems there might be. You remember that problems after head trauma may include the development of seizures and that the risk of developing posttraumatic epilepsy is increased by which of the following?

an acute intracranial hemorrhage

A2-month-old infant presents with irritability and congestive heart failure. An ECG is interpreted as characteristic of myocardial infarction. Which of the following is the most likely explanation for these findings?

anomalous origin of the left coronary artery

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days but worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 3kg and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 38°C, pulse of 120 beats/minute, blood pressure within normal limits, and a respiratory rate of 60 breaths/minute. The infant is well hydrated but ill appearing. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical exam. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. Which of the following statements regarding antibiotic use in bronchiolitis is true?

antibiotics likely benefit infants with severe bronchiolitis who require mechanical ventilation

Which of the following is the most common indication for surgical repair of pectus excavatum?

cosmetic appearance

A 4-year-old child with a runny nose, congestion, sneezing, and a nonproductive cough comes to your office with his mother. These symptoms started 4 days ago with a sore throat that has since resolved. His appetite is mildly decreased, but he is well otherwise. He has had no fever, chills, or any other symptoms. On examination, the child's temperature is 37.6°C. His ears are clear, and his throat is slightly hyperemic. He has grayish thick nasal discharge and the nasal mucosa appears swollen with erythematous nasal turbinates. His lung fields are clear, there is no significant cervical lymphadenopathy, and no other localizing signs are present. The child's history is unremarkable, and he has had no significant medical illnesses. His immunizations are up to date. Which of the following statements regarding treatment of the condition described in this case is true?

antihistamine-decongestant combinations have been shown to be effective in reducing symptoms

A3-year-old girlpresent s with a 6 weeks of runny nose, congestion, sneezing, andcough. The child seems to havelong colds especially during spring, early summer,and, occasionally, late summer. The child also hadan episode of difficulty breathing a few days ago forwhich they visited a local emergency room and weregiven an inhaler. Which of the following therapies for allergic rhinitishas the fewest side effects?

antihistamines

A 16-year-old G1P1 mother complaining of reduced milk production and breasts engorgement. She stated that she feels unhappy and scared most of the times. Her husband is a soldier and she is living with his family. Of the following, the MOST appropriate action is to

apply Edinburgh postnatal scale

A concerned parents of an 18-month-child which expressed a brief tonic movement after being upset and cried. All the following are true advices EXCEPT

arrange for home rectal diazepam

A 6-month-old infant is brought to your office by her mother with nasal congestion for 5 days. The child had a clear runny nose at 1st but now the drainage is thick and yellow and she seems tobe having difficulty with taking the bottle. The baby has had only low-gradetemperatures of less than 38°C. The mother tells you that the baby seems cranky but is consolable and has had difficulty sleeping because of the breathing. On examination, the infant is afebrile. There is no tachypnea. The conjunctivae are slightly hyperemic but without purulent exudates. The nose is congested with erythematous mucosa and thick yellow drainage bilaterally. The ears are clear. The throat is pink, but postnasal drip is noted. The chest is without retractions and is clear to auscultation. Which of the following statements about the treatment of this condition in infants is true?

aspirin should be avoided

A newborn infant with stigmata of Down syndrome has a heart murmur. Which of the following cardiac lesions is most likely in this baby?

atrioventricular defect

A 2-year-old child is admitted because of weakness proceeding to coma. According to the parents, he had been well until several hours prior to admission, when they noted diarrhea, cough, wheezing, and sweating. Physical examination reveals a comatose child with diffuse weakness and areflexia. Pupils are pinpoint and unresponsive. Examination of the chest reveals generalized wheezing. Oral secretions are copious. Which of the following should you administer at this time?

atropine

An 8-year-old boy is referred for new-onset seizures. Which of the following would mostly support a diagnosis of complex partial psychomotor. seizures?

automatisms

A14-month-old boy has severe eczema, recurrent sinus and ear infections, and thrombocytopenia. What is the inheritance pattern of this disorder?

autosomal dominant

The pattern of inheritance of achondroplasia is which of the following?

autosomal dominant

You have just confirmed the diagnosis of cystic fibrosis in a 3-year-old child. The parents are concerned about future pregnancies. You explain to them that the pattern of genetic transmission of cystic fibrosis is

autosomal recessive

A 4-year-old child with a runny nose, congestion, sneezing, and a nonproductive cough comes to your office with his mother. These symptoms started 4 days ago with a sore throat that has since resolved. His appetite is mildly decreased, but he is well otherwise. He has had no fever, chills, or any other symptoms. On examination, the child's temperature is 37.6°C. His ears are clear, and his throat is slightly hyperemic. He has grayish thick nasal discharge and the nasal mucosa appears swollen with erythematous nasal turbinates. His lung fields are clear, there is no significant cervical lymphadenopathy, and no other localizing signs are present. The child's history is unremarkable, and he has had no significant medical illnesses. His immunizations are up to date. What is the most effective preventive measure against the common cold?

avoiding all contact with children and adults who have a cold

A 2-week-old infant presents with apnea. The infant was born at term after an uncomplicated pregnancy. The mother of this baby had rhinorrhea and cough that started 3 weeks ago and now she has a severe persistent cough with post-tussive emesis. Which treatment should be initiated?

azithromycin

A previously healthy 5-year-old girl has acute onset of edema and oliguria. Laboratory studies reveal hypoalbuminemia and hypercholesterolemia. Which of the following is the major cause for mortality with this condition?

bacterial peritonitis

An 8-month-old child has vomiting and screaming episodes for 12 hours. Physical examination reveals a sausage-shaped mass in the right upper quadrant. Which of the following would be most useful?

barium enema study

A 2-year-old male presents for a checkup. His parents tell you that he has been doing well, but he has had episodes of wheezing four times during the past year. He is the product of an uncomplicated pregnancy and delivery, but he was hospitalized at age 6 months for bronchiolitis. Both parents have a history of allergies, and his father has asthma. His mother smoked during pregnancy but quit smoking last year. The child was never breast-fed. Which of the following is true concerning treatment of this child?

because of recurrent episodes of wheezing, with a strong family history, this child should be treated with inhaled corticosteroids

An 23-month-old infant is brought to the emergency department by his mother. He has had diarrhea and vomiting for the past 3 days and appears to be at least 15% dehydrated. His eyeballs are sunken, and his skin is doughy. The child has no satisfactory veins in which to place an IV line. What should you do now?

begin an inter-osseous infusion

A 4-year-old female presents with a limp. The week prior she had an upper respiratory infection. There is no history of trauma. She has no history of fever. Examination reveals limitation of motion of the right hip joint, especially with internal rotation. X-ray reveals some swelling in soft tissues surrounding the hip joint. A complete blood count and sedimentation rate are normal. What would be the next most appropriate step?

begin nonsteroidal anti-inflammatory agents

A mother of 4-month-old baby boy complaining that the baby never goes to sleep unless he is rocked for quite long time. She needs to repeat the same issue whenever he is awake at night. She was surprised as no one of her previous babies had the similar behavior. She feels tired because of insufficient sleep. Of the following, the MOST common cause of this baby problem is

behavioral insomnia of childhood, sleep-onset association

Most patients with XYY constitution are which of the following?

behaviorally normal

A2-year-old child develops apnea, cyanosis, and loss of consciousness with repeated generalized clonic jerks after being scolded by his mother. On examination, the child appears completely normal. What is the best treatment option?

counseling of parents

A 3-year-old is brought to your office with fatigue andirritability and a low-grade fever that he has had for3 days. The child attendsday care, where a virus is reportedly "going around." The child was treated by acetaminophen, which has helped to decreaseirritability; although the child's appetite is suppressed,he is still taking in a good amount of fluids. On physical examination, the child does not lookill. His temperature is 38°C. His skin examinationshows scattered small vesicles on an erythematousbase. The rash was seen first on the face and seemsto be spreading to the trunk. What is the most outstanding feature of this illness?

benign nature of this infection

The peak age of onset of childhood nephrotic syndrome associated with minimal-change morphology is which of the following?

between 2 and 5 years of age

Febrile seizures occur most frequently at what age?

between 6 months and 5 years of age

A 12-year-old child presents with severe abdominal pain, nausea and vomiting, abdominal distension, and epigastric tenderness.Chest roentgenogram reveals a small pleural effusion. The child is afebrile but blood count reveals a marked leukocytosis. Which of the following is the most likely cause for this condition?

blunt abdominal trauma

A 6-month-old infant is brought to your office by her mother with nasal congestion for 5 days. The child had a clear runny nose at 1st but now the drainage is thick and yellow and she seems tobe having difficulty with taking the bottle. The baby has had only low-gradetemperatures of less than 38°C. The mother tells you that the baby seems cranky but is consolable and has had difficulty sleeping because of the breathing. On examination, the infant is afebrile. There is no tachypnea. The conjunctivae are slightly hyperemic but without purulent exudates. The nose is congested with erythematous mucosa and thick yellow drainage bilaterally. The ears are clear. The throat is pink, but postnasal drip is noted. The chest is without retractions and is clear to auscultation. Which of the following agents is the least likely cause of the condition?

bordetella pertussis

A mother calls to inform you that her previously well 4-year-old child has been complaining of headaches for about a month. For the past 2 weeks he has been keeping his head in a tilted position, and for the past few days he has been vomiting in the morning. The most likely diagnosis is which of the following?

brain tumor

A 12-year-old girl develops jaundice, progressive tremors, and emotional lability. You are most likely to find which of the following during physical examination?

brown discoloration of the limbic region of the cornea

A 9-year-old male with good school performance and normal behavior. In the last 2 months he had changed his classroom. His teacher observed that he became introverted and his school performance reduced dramatically. He was always described by some of his new school mates as a "weak". Of the following, the MOST likely diagnosis is

bullying

Retinal hemorrhages are an important marker of abusive head trauma AHT.. Whenever AHT is being considered, a dilated indirect eye examination by a pediatric ophthalmologist should be performed. All the following are characteristic of retinal hemorrhage caused by AHT EXCEPT

central

A young couples of a 2-month-old baby girl with excessive crying seek your medical advice. Mother said that the baby is crying about 3 hr in a day, 2-3 days per week. She is intermittently spitting but she is gaining weight adequately. She is bottle fed baby. Of the following, the LEAST important advice is to

change milk formula

A 1-day-old infant who received silver nitrate eye drops in the delivery room is suffering from bilateral purulent conjunctival discharge. Which of the following is the most likely cause of this child's condition?

chemical irritation

A 3-year-old child is brought to the office for cough and fever. He has been sick for the past 4 days, but symptoms acutely worsened this morning. Appetite and activity levels are both decreased. Past medical history is unremarkable and immunizations are current. He lives at home with two brothers and goes to day care during the week. There are no sick contacts. On physical examination, he has a temperature of 38.5°C, pulse of 120 beats/minute, respiratory rate of 60 breaths/minute, and normal blood pressure. He appears mildly toxic but not cyanotic. Ears, nose, and throat are unremarkable. Retractions, grunting, and accessory muscle use are noted on the lung exam. Localized rales and wheezing are noted over the right lower lung zones. Which of the following interventions provides the most useful information at this time?

chest radiograph

A 2-year-old male presents for a checkup. His parents tell you that he has been doing well, but he has had episodes of wheezing four times during the past year. He is the product of an uncomplicated pregnancy and delivery, but he was hospitalized at age 6 months for bronchiolitis. Both parents have a history of allergies, and his father has asthma. His mother smoked during pregnancy but quit smoking last year. The child was never breast-fed. Which of the following is true concerning this child?

children who have four or more episodes of wheezing and a clinical picture consistent with asthma should be diagnosed and treated according to current guidelines once other causes of wheezing have been excluded

A 13-year-old female athlete presents with anterior knee pain of 2-3 weeks' duration. She has no history of trauma. On examination, she has good flexibility of lower extremities. There are no effussions. There is no tenderness over the tibial tubercle, or at the inferior pole of the patella. She has a positive patella glide test. Of the following causes of anterior knee pain, which is most likely in this patient?

chondromalacia patellae

You are specialist explaining the developmental implication of a 6-month-old baby boy who "transfers object hand to hand" to college students. Of the following, the BEST statement describing that is a/an

comparison of objects

A 5-year-old girl presents with fever and headache. Imaging of the brain reveals a ringenhancing lesion. Which of the following is the most likely underlying condition in this child?

congenital cyanotic heart disease

The presence of bilateral renal masses and a midline suprapubic mass in a newborn male infant is most suggestive of which of the following?

congenital urethral or bladder neck obstruction

An 18-year-old boy presents with acute severe chest pain. EKG and enzyme studies confirm an acute myocardial infarction. Cardiac catherization reveals a coronary artery aneurysm with thrombosis. Which constellation of symptoms in his past could explain this finding?

conjunctivitis, fever, cervical lymphadenopathy

You are treating acutely ill 6-year-old child with ascending paralysis, he eventually needs mechanical ventilation. Now you are in a situation of using the last bed in respiratory care unit RCU.. Of the following, the BEST approach is to

consider this case as potential treatable condition and use the last bed

A 2-month-old infant is brought to the emergency department with irritability and lethargy. The parents state that he was well until he rolled off the couch on to the floor yesterday. On examination, he is inconsolable and afebrile. The fontanels are full and tense. He has a generalized tonic-clonic seizure. Which of the following is the most important initial diagnostic study to order?

cranial computed tomography CT. scan

A12-year-old girl presents with headache, visual changes, and papilledema. ACT scan reveals a mass lesion in the region of the anterior pituitary gland which of the following is the most likely diagnosis?

craniopharyngioma

On a 6-month well-child visit, you note a healthy well-grown male with a normal physical examination except for a closed anterior fontanelle. Which of the following should you consider?

craniosynostosis

A 4-year-old girl presents with a 1-year history of monthly episodes of fever and aphthous stomatitis. A CBC 6 months prior was reportedly normal, but a CBC now reveals a total neutrophil count of less than 200/mm3. The remainder of the CBC is normal. Physical examination reveals an inflamed pharynx and oral mucosa with several aphthous lesions on the gingival and buccal mucosa. There are bilateral, tender anterior cervical lymph nodes, the largest of which is about 4 cm in diameter. The remainder of the physical examination is normal. The most likely diagnosis is which of the following?

cyclic neutropenia

A 4-year-old boy has failed to grow and has evidence of exocrine pancreatic insufficiency.What is the most likely cause for this?

cystic fibrosis

Anewborn with abdominal distension is found to have a meconium ileus. Which of the following conditions is most likely present in this neonate?

cystic fibrosis

Most nasal polyps in children are due to which of the following?

cystic fibrosis or allergy

A 6-year-old Hispanic male presents with a first-time generalized seizure lasting less than 5 minutes. There is no history of trauma or illness. The family recently immigrated to the United States from Mexico. The child is afebrile, and his examination is completely normal. Of the following, which would be the most likely cause for the seizure?

cysticercosis

On routine examination of the children of a migrant farm worker, you notice that a 12-year-old child who has received little previous medical care is short and mentally retarded. Physical examination reveals that the liver is enlarged to 5 cm below the right rib cage, and the spleen is enlarged 6 cm below the left rib cage. Lumbodorsal kyphosis is prominent. The child has a peculiar facies​ with thick lips and a large tongue. Attempts to visualize the retina are unsuccessful because of clouding of the corneas. You expect that examination of this child's urine will reveal which of the following?

dermatan and heparan sulfate

A17-year-old boy with cystic fibrosis complains of a 5-10 lb weight loss over the past month, unaccompanied by changes in his pulmonary or gastrointestinal symptoms. You suspect that he has developed which of the following?

diabetes mellitus

Four months later, she comes in for a visit because she is having a nighttime cough. After a complete history, you find that she has continued to have chest tightness and dyspnea several days a week, especially after running in gym class, and two or three nights each month she cannot sleep well due to coughing. She has no fever, rhinorhea, or other symptoms. She finished her inhaler a month ago, after which her symptoms increased. She has a completely normal physical exam and her peak flow is 90% predicted. Which of the following diagnoses and treatments are correct?

diagnose her with exercise-induced asthma only; renew her albuterol inhaler and instruct her in management of exercise-induced asthma

A12-year-old child is seen because of a rash and severe headache which began 2 weeks after returning from vacation in Massachusetts. The skin lesion began as a red macule on the thigh, which gradually expanded over 1 week to reach approximately 15 cm in diameter with red borders and central clearing. The lesion is slightly painful. Afew days after the onset of the skin manifestation, the child developed severe headache, myalgias, arthralgias, and malaise. Low-grade fever was present. The mother recalls that the child was bitten by a tick about 1 week prior to the onset of symptoms. This patient's disorder is probably best treated with which of the following?

doxycycline

A 2-year-old girl has severe dental caries of the upper and lower incisors. Her teeth are brushed twice daily with a small amount of fluoride-containing toothpaste. What is the feeding practice most likely to result in this pattern of dental caries?

drinking a bottle of juice in bed

A2-year-old girl is listless and pale. You obtain a complete blood count and find that the patient has severe megaloblastic anemia. What additional history explains this?

drinks exclusively goat milk

A 3-year-old female child with repeated admissions as bleeding tendency in a form of spontaneous ecchymosis and bleeding through the nose and urine. She had another daughter who died because of similar undiagnosed illness. The mother is a staff nurse and she is highly concerned about her child illness. Lab investigations usually show either PT and/or PTT prolongation with normal platelets, which usually normalized after empiric vitamin K administration. The father is a petrol engineer and never seen accompanying the family. Of the following, the MOST helpful investigation is

drug level

Four months later, she comes in for a visit because she is having a nighttime cough. After a complete history, you find that she has continued to have chest tightness and dyspnea several days a week, especially after running in gym class, and two or three nights each month she cannot sleep well due to coughing. She has no fever, rhinorhea, or other symptoms. She finished her inhaler a month ago, after which her symptoms increased. While discussing elimination of triggers with the child and her parents, you mention all of the following as possible triggers. Which of these is most commonly implicated in causing exacerbations, and possibly even influencing the development of asthma in populations as a whole?

dust mites and tobacco smoke

The most common cause of congenital hypothyroidism is which of the following?

dysgenesis of the thyroid gland

What is the most common cause of school absenteeism among adolescent females?

dysmenorrhea

The diagnosis of cystic fibrosis is usually confirmed by the finding which of the following?

elevated sweat chloride

A 4-month-old baby is in for a well-child check and routine immunizations. The baby had a fever of 39°C the day he received his 2-month immunizations. The parents have read about the vaccine on the Internet and express their concerns. Which of the following is an absolute contraindication to giving the diphtheria and tetanus toxoids and acellular pertussis DTaP?

encephalopathy within 7 days of administration of previous dose of vaccine

A female-appearing infant is operated on for bilateral inguinal hernias only to have the surgeon discover that the masses are undescended testes. Chromosomal analysis reveals XY constitution. The patient's adolescent sister has primary amenorrhea. Chromosomal analysis of the sister also reveals XY constitution. The most likely cause of this syndrome in the patient and sister is​​ which of the following?

end-organ insensitivity to androgens

The most consistent finding in lymphocytic thyroiditis Hashimoto thyroiditis. is which of the following?

enlargement of the thyroid gland

A 5-year-old male presents with a 48-hour history​​​ of headache, and meningismus. Evaluation​ of the CSF reveals clear fluid with normal protein and glucose content. The CSF cell count reveals 300 WBC/hpf, 90% lymphocytes. Which of the following is the most likely etiologic agent?

enterovirus

A 6-month-old boy is found to have very low levels of IgG, IgM, and IgA. Which of the following organisms is most likely to cause problems in this patient?

enterovirus

A 10-year-old boy presents with fever, headache, photophobia, and neck discomfort in the middle of summer. He is alert and oriented, but has neck pain with flexion and extension of the head. His fundi are normal, and there are no focal neurologic findings or skin changes. A lumbar puncture reveals normal protein and glucose with a cell count of 240/mL 90% lymphocytes.. Which of the following is the most likely causative organism?

enterovirus coxsackievirus or echovirus.

A healthy 2-day-old infant has multiple, firm, yellow-white papules on an erythematous base that are widely dispersed over much of the skin. What will be the most likely microscopic finding?

eosinophilic infiltrate

A 10-day-old infant is evaluated for recurrent blisters and sores, mostly on the extremities at areas of friction or trauma. The child has been afebrile and well except for irritability. Examination is unremarkable except for blisters, varying in stage from fresh to ruptured and crusted, mostly on the extremities, especially the dorsal surfaces of the hands and feet. Which of the following would be highest on​ your differential diagnosis?

epidermolysis bullosa

Apatient with streptococcal pharyngitis develops tender red bumps along her entire tibia. What is the most likely diagnosis?

erythema nodosum

You follow a patient with craniosynostosis and congenital malformations of the head and face in your clinic. What other congenital malformations will you most likely find in this patient?

extremity malformations

You suspect the diagnosis of Werdnig-Hoffman disease in an infant with severe hypotonia. Which other finding will support this diagnosis?

fasciculations of the tongue

A5-year-old female presents with intoeing. Her mother states the child is very limber and has no complaints of pain. On examination, with the child in prone position and knees flexed 90 degrees the child can easily place her lateral malleoli on the table. What is the most likely condition described here?

femoral anteversion

Infants fed exclusively goat milk are susceptible to which of the following?

folate deficiency

A7-year-old boy has chronic fecal soiling but only rarely has a voluntary bowel movement. What is the most common explanation for his problem?

functional fecal retention

A mother comes to your office with her 5-year-old boy who has developed severe crampy diarrhea and mild fever. The family has just returned from a trip inMondulkiri province; the child became sick on the third day. He was apparently drinking water from a local stream. Which of the following is the most common cause of acute abdominal pain in children?

gastroenteritis

The most common roentgenographic abnormality in a child with asthma is which of the following?

generalized hyperinflation

You have just prescribed phenytoin for a 12- year-old boy with new onset of epilepsy. Of the following side effects, which is most likely to occur in this patient?

gingival hyperplasia

A 7-year-old boy presented to the out-patient department with fever and cough, you have diagnosed him as a case of pneumonia and decided to admit and give parental therapy, the child refused. Of the following, the BEST response is to

give the chance for oral antibiotics and accept the child decision

A 3-month-precious baby of a keen and highly educated family presented with history of URTI followed by deterioration of level of consciousness and seizure. CT brain shows intracranial bleeding with no evidence of skull fracture. Fundocscopy was normal. Mother gives history of difficult labour but with normal development, mild hypotonia, and macrocephaly which was reassured initially by general Pediatrician. Of the following, the MOST likely diagnosis is

glutaric aciduria type 1

The Fanconi syndrome is characterized by which of the following?

glycosuria, aminoaciduria, and phosphaturia

A 2-week-old male presents with irritability, decreased feeding, and fever. Cerebrospinal fluid examination reveals cloudy fluid with 5500 WBC/mm3 and a low glucose. Gram stain revealed no bacteria. Which of the following is the most likely causative agent?

group B streptococcus

A3-year-old girlpresent s with a 6 weeks of runny nose, congestion, sneezing, andcough. The child seems to havelong colds especially during spring, early summer,and, occasionally, late summer. The child also hadan episode of difficulty breathing a few days ago forwhich they visited a local emergency room and weregiven an inhaler. Which of the following is not a physiologically based treatment for allergic rhinitis?

guaifenesin

A3-month-old infant is hospitalized because of recurrent right focal seizures that are now generalized in nature. Birth and perinatal history are unremarkable. You note that the child has a flat, purplish-red skin lesion on the left side of the face extending onto the forehead. The remainder of the examination including a complete neurologic​ examination is within normal limits. The results of a lumbar puncture are normal. You order a CT scan of the head and anticipate seeing which of the following?

gyriform calcifications

A 4-month-old female infant has generalized hypotonia, small ears, inner epicanthal folds, clinodactyly, and wide-spaced first and second toes. For which of the following problems is she most at risk?

hearing loss

A 2-year-old male presents for a checkup. His parents tell you that he has been doing well, but he has had episodes of wheezing four times during the past year. He is the product of an uncomplicated pregnancy and delivery, but he was hospitalized at age 6 months for bronchiolitis. Both parents have a history of allergies, and his father has asthma. His mother smoked during pregnancy but quit smoking last year. The child was never breast-fed. Which of the following differential diagnoses should you exclude in this child?

heart disease

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days but worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 3kg and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 38°C, pulse of 120 beats/minute, blood pressure within normal limits, and a respiratory rate of 60 breaths/minute. The infant is well hydrated but ill appearing. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical exam. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. All of the following are associated with increased risk of severe bronchiolitis except

hemodynamically insignificant atrial septaldefect

A 2-year-old African-American child presents with painful swelling of the hands and feet. Laboratory evaluation reveals hemoglobin of 9 g/dL with white blood cell count of 11,500 and platelet count of 250,000. Which additional laboratory test will support your diagnosis?

hemoglobin electrophoresis

Which of the following is the most common manifestation of alpha1-antitrypsin deficiency in infancy?

hepatic cirrhosis

Among adolescents of 15-19 years of age, motor vehicle accidents cause the greatest number of deaths each year. Which of the following is the second leading cause of death in this age group?

homicide and legal intervention

You have followed a 7-month-old infant who has failed to gain weight. Birth weight was 3250 g; the child currently weighs 5.5 kg. In your office, the baby takes an 8-oz bottle with ease and does not vomit. What is the next best step?

hospitalization of the child with unlimited feedings

A 3-year-old is brought to your office with fatigue andirritability and a low-grade fever that he has had for3 days. The child attendsday care, where a virus is reportedly "going around." The child was treated by acetaminophen, which has helped to decreaseirritability; although the child's appetite is suppressed,he is still taking in a good amount of fluids. On physical examination, the child does not lookill. His temperature is 38°C. His skin examinationshows scattered small vesicles on an erythematousbase. The rash was seen first on the face and seemsto be spreading to the trunk. What is the causative agent of this infection?

human herpesvirus

A3-week-old infant is admitted with vomiting of​ 5 days' duration. Physical examination reveals a rapid heart rate, evidence of dehydration, and ambiguous genitalia. Serum electrolytes are Na+ 120 meq/L, K+ 7.5 meq/L, HCO3− 12 meq/L,BUN 20 mg/dL. In addition to intravenous fluid replacement with normal saline, administration of​ which of the following would be most important?

hydrocortisone

A significant number of children with recurrent gross or microscopic hematuria, normal renal ultrasound, and normal tests of renal function have which of the following?

hypercalciuria

A newborn girl with ambiguous genitalia has severe vomiting with weight loss. What will be the most likely finding?

hyponatremia and hyperkalemia

A 1-year-old patient is in the office for a health maintenance visit and is ready for immunizations. The child has a mild upper respiratory infection and a low-grade fever. The mother does not want the child to receive vaccine because she has been told that the vaccine could make the illness worse. You tell her the only true contraindication to vaccination is which of the following?

if the child has hypersensitivity to a vaccine component

A mother to a well 2-year-old girl with thumb sucking behavior, she is worried that the behavior may continue or may cause dental problem. Of the following, the BEST response is to

ignore thumb sucking and encouraging a substituted behavior

A 14-year-old girl has irregular menstrual bleeding since menarche 1 year ago. What is the most common cause for this?

immature hypothalamic-pituitaryovarian axis

A 3-year-old girl presents to a health center with a fever for the past 36 hours. Maximum temperature was 40°C at 2 am, which decreased to38.7°F with children's ibuprofen. Her appetite andfluid intake have decreased during the past 24 hours. Physical examination shows an ill-appearing child.Her temperature is 37.2°C. The skin has a macular-papular petechial rash on the chest and back. Theremainder of the physical examination is normal. What would you do next concerning this patient?

immediate hospitalization

A 10-year-old male presents with an acute episode of nausea, vomiting, and severe testicular pain. On examination, scrotal edema and erythema with lack of cremasteric relex are noted. Color-flow Doppler ultrasonography confirms the suspected diagnosis. What is the initial treatment of choice?

immediate surgical exploration

The major concern regarding chronic otitis media with effusion is the development of which of the following?

impaired speech and language development

A mother comes to your office with her 6 weeks of age infantwhohas been "spitting up"all of her formula "since birth." She is afraid the infant is malnourished. The baby weighs 5 kg. Her birth weight was 3.5 kg. At this time, you should advise the mother to do which of the following?

increase the time spent burping the infant and keep the infant semiupright after feedings

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days but worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 3kg and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 38°C, pulse of 120 beats/minute, blood pressure within normal limits, and a respiratory rate of 60 breaths/minute. The infant is well hydrated but ill appearing. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical exam. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. Pathologic features of acute bronchiolitis include all but

increased mucous clearance

An 11-week-old male presents with a 1-week history of poor feeding and constipation. On examination, you note poor head control and a weak cry. Though the infant's face is expressionless, he displays a paradoxical alertness and has normal features. The most likely condition of this infant is which of the following?

infantile botulism

A 4-year-old child with a runny nose, congestion, sneezing, and a nonproductive cough comes to your office with his mother. These symptoms started 4 days ago with a sore throat that has since resolved. His appetite is mildly decreased, but he is well otherwise. He has had no fever, chills, or any other symptoms. On examination, the child's temperature is 37.6°C. His ears are clear, and his throat is slightly hyperemic. He has grayish thick nasal discharge and the nasal mucosa appears swollen with erythematous nasal turbinates. His lung fields are clear, there is no significant cervical lymphadenopathy, and no other localizing signs are present. The child's history is unremarkable, and he has had no significant medical illnesses. His immunizations are up to date. Which of the following statements regarding the common cold is true?

infants with older siblings in school or day care have an increased incidence of colds

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days but worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 3kg and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 38°C, pulse of 120 beats/minute, blood pressure within normal limits, and a respiratory rate of 60 breaths/minute. The infant is well hydrated but ill appearing. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical exam. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. Which of the following statements about RSV is untrue?

infection with RSV confers life-long immunity in healthy individuals

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. Based on the history of this patient, which Medicine do you recommend for maintenance?

inhaled corticosteroid with a long-acting Beta2-agonist

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. Written action plans for asthma patients should include all of the following except

instructions on self-adjusting allergy immunotherapy based on symptoms

An 18-month-old toddler has microcytic anemia. Which dietary history finding best explains this?

intake of large amounts of unmodified cow's milk

Aterm infant is born to a mother who has been using crack cocaine. This infant is at increased risk for which of the following?

intrauterine growth retardation

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days but worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 3kg and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 38°C, pulse of 120 beats/minute, blood pressure within normal limits, and a respiratory rate of 60 breaths/minute. The infant is well hydrated but ill appearing. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical exam. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. Which statement regarding management of this condition is true?

intravenous fluids are required for infants younger than 1 year of age

A 3-year-old girl develops petechiae and bruises on her extremities while she is recovering from a cold. She is brought to medical attention after she has a transient nosebleed. Physical examination shows a toddler with widespread petechiae and bruising who otherwise looks healthy. What is the best treatment for this patient?

intravenous gammaglobulin

An irritable 12-month-old male has a 1-week history of high fevers and macular truncal rash. Examination reveals bulbar conjuctivitis, bright red cracked lips, and cervical adenopathy.What is the most appropriate next step?

intravenous gammaglobulin

What are the blood requirements for transfusion of a patient with hypocalcemia, heart defect, and recurrent infections?

irradiated

A 2-year-old boy presents with extremity swelling and proteinuria and is found on urine analysis. Minimal-change disease is suspected and you explain to the child's parents that this diagnosis

is the most common cause of nephrotic syndrome in childhood

Which of the following best describes an inguinal hernia in a 2-month-old girl?

it may contain an ovary

A 12-year-old girl complains of decreasing visual acuity and a slight feeling of discomfort in both eyes. Examination by an ophthalmologist reveals anterior uveitis. You suspect that the child may have which of the following?

juvenile idiopathic arthritis

What is the most important test to obtain a diagnosis in a 14-year-old girl with primary amenorrhea, and short stature, who has a history of repaired coarctation of the aorta in infancy?

karyotyping

A 3-month-old infant has persistent stridor. What is the most likely cause?

laryngomalacia

A2-month-old infant has had inspiratory stridor since the first month of life, but has been otherwise​ well. Physical examination is unremarkable​ except for moderate inspiratory stridor and retractions,​ which are worse when the infant is supine or agitated and better when he is prone and quiet.​What is the most likely cause of these findings?

laryngomalacia

Parents of a 4-year-old boy complaining that he is refusing to go to bed, he remains active and playing. Of the following, the MOST likely cause of this child problem is

limit setting; behavioral insomnia of childhood

A 15-year-old boy is bitten on the hand by a snake, which he then kills and brings to the emergency room. The snake is identified as a copperhead measuring 14 in. in length. The most likely complication to be expected in this child would be which of the following?

local tissue necrosis

A 3-year-old girl presents to a health center with a fever for the past 36 hours. Maximum temperature was 40°C at 2 am, which decreased to38.7°F with children's ibuprofen. Her appetite andfluid intake have decreased during the past 24 hours. Physical examination shows an ill-appearing child.Her temperature is 37.2°C. The skin has a macular-papular petechial rash on the chest and back. Theremainder of the physical examination is normal. Which laboratory testing would you order at this time?

lumbar puncture

A14-year-old female has progressive headaches. Examination shows bilateral papillary edema.CT-scan of the brain is normal. What should be the next diagnostic test?

lumbar puncture with opening pressure

A 15-month-old male child with failure to thrive, diarrhea, and fatty stool. Of the following, the MOST common possible cause of his illness is

malabsorption

A2-day-old male presents with upper abdominal distension and bilious vomiting. He passed a normal meconium stool shortly after birth. Abdominal x-rays suggest duodenal obstruction. An upper gastrointestinal contrast study reveals a "bird's beak" appearance of the distal portion of the duodenum. Which of the following is most likely?

malrotation with midgut volvulus

A petechial rash is noted in a 10-hour-old newborn who is otherwise appearing normal and vigorous. There is no hepatosplenomegaly and radii are present. There are no risk factors for sepsis. A complete blood count reveals a normal WBC count with differential hemoglobin 17 g/dL; and platelet count 11,000/mm3 with large platelets present. Which of the following would be the most appropriate next step?

maternal platelet count

Of the following, which is a significant risk factor for SIDS?

maternal smoking during pregnancy

Breath-holding spells are best described by which of the following?

may terminate in cyanosis and loss of consciousness

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 previously healthy 9-year-old boy has had diarrhea for 6 weeks that started after he returned from camp. He has had anorexia, abdominal cramps with abdominal distension,and a 4 pound weight loss. His stools are large, foul-smelling but do not contain blood. What is the best treatment?

metronidazole

A 12-month-old patient has allergies to multiple foods. The child's mother has eliminated the foods from the diet and wants to know if these allergies will be lifelong. You tell her that some allergies do get better if the food is eliminated for 1-2 years. In which of the following is the allergy most likely to resolve, with elimination of the food from the diet?

milk

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. Goals of asthma therapy according to recentrecommendations. include all of the followingexcept

minimal use of any medications

A 1-cm carcinoma of the breast is diagnosed by an excisional biopsy in a 36-year-old woman at 14 weeks' gestation. The axillary nodes are negative. Which of the following is the best management of this patient?

modified radical mastectomy at the time of diagnosis

Which of the following is characteristic of a night terror?

most often occur during the first onethird of the night

A 4-year-old child with a runny nose, congestion, sneezing, and a nonproductive cough comes to your office with his mother. These symptoms started 4 days ago with a sore throat that has since resolved. His appetite is mildly decreased, but he is well otherwise. He has had no fever, chills, or any other symptoms. On examination, the child's temperature is 37.6°C. His ears are clear, and his throat is slightly hyperemic. He has grayish thick nasal discharge and the nasal mucosa appears swollen with erythematous nasal turbinates. His lung fields are clear, there is no significant cervical lymphadenopathy, and no other localizing signs are present. The child's history is unremarkable, and he has had no significant medical illnesses. His immunizations are up to date. What investigation should be done at this time?

nasal smear

A 2-year-old toddler has a large abdominal mass and pancytopenia. Which of the following diagnoses would most likely be established by bone marrow aspiration?

neuroblastoma

A 3-year-old male presents with random eye movements, ataxia, and developmental delay. Of the following, which is most likely the diagnosis?

neuroblastoma

A 3-year-old is brought to your office with fatigue andirritability and a low-grade fever that he has had for3 days. The child attendsday care, where a virus is reportedly "going around." The child was treated by acetaminophen, which has helped to decreaseirritability; although the child's appetite is suppressed,he is still taking in a good amount of fluids. On physical examination, the child does not lookill. His temperature is 38°C. His skin examinationshows scattered small vesicles on an erythematousbase. The rash was seen first on the face and seemsto be spreading to the trunk. What is the current recommendation for thetreatment and prevention of this condition?

no antiviral, no antibiotics, two vaccinations inchildhood

A16-year-old boy presents with fever, fatique, and sore throat. Examination reveals exudative pharyngitis, generalized lymphadenopathy, and mild splenomegaly. Laboratory studies show elevated WBC count with presence of atypical lymphocytes. What is the best action?

no participation in contact sports for next 2-4 weeks

A previously well 9-year-old boy develops an intensely pruritic rash consisting of raised hivelike lesions with pink edges and pale centers. Lesions are well circumscribed and range in size from 2 to 6 cm in diameter. The history is unremarkable and physical examination is unrevealing except for the rash. Careful diagnostic workup probably will disclose which of the following?

no specific cause for the rash

A 7-year-old child brought by his father to your clinic, the child often express fear of being injured by a car accident during transport to school. He expresses this fear to his teachers and parents. Of the following, the TRUE description of his reaction is

non pathological anxiety

A 5-year-old is brought to the office with a 3-day history of fever, nonproductive cough, coryza, and conjunctivitis. This morning, a rash appeared on his forehead and behind the ears, and it appears to be spreading to his upper arms and chest. On physical examination, you note a fine maculopapular rash over the face that appears to be spreading to the back and thighs. What would be the recommendations for the exposed members of the family?

none

A 2-year-old male presents for a checkup. His parents tell you that he has been doing well, but he has had episodes of wheezing four times during the past year. He is the product of an uncomplicated pregnancy and delivery, but he was hospitalized at age 6 months for bronchiolitis. Both parents have a history of allergies, and his father has asthma. His mother smoked during pregnancy but quit smoking last year. The child was never breast-fed. In discussing treatment plans with the parents, they ask about various medications used in asthma therapy. Which of the following medications has been shown to be most effective in the treatment of asthma in children and should be used at firstline treatment if maintenance therapy is begun?

none of the above (leukotriene inhibitor, nedocromil, long-acting 2-agonist inhaler or nebulizer, inhaled corticosteroids as an inhaler or nebulizer)

A 3-year-old child is brought to the office for cough and fever. He has been sick for the past 4 days, but symptoms acutely worsened this morning. Appetite and activity levels are both decreased. Past medical history is unremarkable and immunizations are current. He lives at home with two brothers and goes to day care during the week. There are no sick contacts. On physical examination, he has a temperature of 38.5°C, pulse of 120 beats/minute, respiratory rate of 60 breaths/minute, and normal blood pressure. He appears mildly toxic but not cyanotic. Ears, nose, and throat are unremarkable. Retractions, grunting, and accessory muscle use are noted on the lung exam. Localized rales and wheezing are noted over the right lower lung zones. Which of the following statements about CAP in neonates is false?

nontoxic neonates may be managed as outpatients with close follow-up

A7-year-old boy has abdominal pain and a rash that started several days ago. On examination, you notice a palpable purpuric rash over his calves and buttocks with swelling of both ankles. Abdominal examination is unremarkable. What is the most likely laboratory finding?

normal clotting parameters

A3-year-old girlpresent s with a 6 weeks of runny nose, congestion, sneezing, andcough. The child seems to havelong colds especially during spring, early summer,and, occasionally, late summer. The child also hadan episode of difficulty breathing a few days ago forwhich they visited a local emergency room and weregiven an inhaler. In patients with significant allergic rhinitis, qualityof life is

not impaired in any way

A 15-month child is brought to you fordiarrhea, with an average 7 loose stools per day for the past 4 days. The stool is watery without any mucus or blood. He also vomited several times during the first 2 days but now it appears to be subsiding. He has been drinking fluids but has not had much appetite for food. For the past 2 days, he has been running a "low-grade fever" and appears to have some abdominal discomfort. He attends a local day care, where some of the children have had similar symptoms.On physical examination, the child is active without any fever. He has dry, cracked lips with moist oral mucosa. The ears, throat, lungs, and abdomen are normal. There are no abdominal masses and no palpable tenderness. nvestigations at this time should include which of the following?

nothing at this time

A 15-month child is brought to you fordiarrhea, with an average 7 loose stools per day for the past 4 days. The stool is watery without any mucus or blood. He also vomited several times during the first 2 days but now it appears to be subsiding. He has been drinking fluids but has not had much appetite for food. For the past 2 days, he has been running a "low-grade fever" and appears to have some abdominal discomfort. He attends a local day care, where some of the children have had similar symptoms.On physical examination, the child is active without any fever. He has dry, cracked lips with moist oral mucosa. The ears, throat, lungs, and abdomen are normal. There are no abdominal masses and no palpable tenderness. What is the treatment of choice in this infant at this time?

observation in the hospital and oral rehydration therapy

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

A 15-month-old is seen in your office for the 4th time this month with unexplained intermittent episodes of fever of 39°C. The mother has used children's ibuprofen to treat the fever and has been able to bring the temperature down to 38°C. However, the mother is now frustrated because thisis her 4th visit to the office and nobody knows why her child is continuing to have these fevers. The child is not in day care and has no history of any serious illnesses, travel, or sick contacts. The child has had no symptoms of an upper respiratory infection. On examination, the child is actively playing with his toys. He does not look ill. His rectal temperature is 39°C. The head, neck, lungs, cardiovascular, abdominal, neurologic, and musculoskeletal examination are all normal.Your clinical judgment is that the child looks well and has no serious illness.What is the most appropriate next step in the workup of this patient?

obtain an immediate consultation with an infectious disease specialist

A newborn is noted to have a large head and short limbs. On further examination, short broad fingers, a small face, and low-normal length are noted. The trunk appears long and narrow. What should be your first step to confirm the diagnosis?

obtain skeletal radiographs

A 4-month-old infant is brought to your clinic by his mother . The mother said that when she took the babyfor a 2-month examination at a health center, the nurse said the baby had a "cold" and could not receive his immunizations. The baby has gotten only his 1stOral Polio and hepatitis B immunization in the hospital.The baby has had ARI for the past week, but according to the mother he is happy, interactive, afebrile, and feeding well. On physical examination, the baby is appropriate weight and length for age, smiles and interacts, and the rest of the exam is completely normal with the exception of minimal clear nasaldischarge. Which of the following statements regarding vaccination against poliomyelitis is true?

oral polio vaccine OPV. is a an inactivated killed. vaccine

A 15-month-old boy has strabismus and a white pupillary reflex. Ophthalmologic examination reveals a white retinal mass. This patient is at increased risk for development of which other tumor?

osteosarcoma

A6-year-old girl with short stature has webbing of the neck, a low posterior hairline, a broad chest, and cubitus valgus. Which organ is affected most frequently in patients with this syndrome?

ovaries

You are asked to evaluate a term infant in the delivery room. He was born a few minutes earlier by spontaneous vaginal delivery with Apgar scores of 9 and 9. The mother had good prenatal care and a normal pregnancy. No significant family history is noted. On physical examination, the infant appears alert and is active and crying. Acrocyanosis is noted on extremities. A grade II/VI soft, systolic murmur is audible at the left upper sternal border. Otherwise, the exam is completely normal. What would you do about the murmur at this time?

perform a second detailed physical exam at 24 hours

Which of the following is the most common presentation of Enterobius vermicularis infection?

perianal pruritus

A2-month-old male presents with a cough that has persisted for over 2 weeks. Mother has noted he coughs in spells and at the end of these spells, he vomits. She feels he has lost weight. On examination, you note a thin male infant who otherwise appears normal. Complete blood count reveals 30,000 white blood cells with 95% lymphocytes. Which of the following is the most likely diagnosis?

pertussis

A 13-year-old male presents with a 3 cm annular scaling lesion on his right posterior trunk unresponsive to 2 weeks of a topical antifungal.On follow-up visit he presents with dozens of elliptical scaling lesions on his trunk. He has no palmoplantar or mucous membrane lesions and no adenopathy. What is the most likely diagnosis?

pityriasis rosea

A 5-year-old is brought to the office with a 3-day history of fever, nonproductive cough, coryza, and conjunctivitis. This morning, a rash appeared on his forehead and behind the ears, and it appears to be spreading to his upper arms and chest. On physical examination, you note a fine maculopapular rash over the face that appears to be spreading to the back and thighs. Which of the following is a relatively common complication of this infection?

pneumonia

A 3-year-old child is brought to the office for cough and fever. He has been sick for the past 4 days, but symptoms acutely worsened this morning. Appetite and activity levels are both decreased. Past medical history is unremarkable and immunizations are current. He lives at home with two brothers and goes to day care during the week. There are no sick contacts. On physical examination, he has a temperature of 38.5°C, pulse of 120 beats/minute, respiratory rate of 60 breaths/minute, and normal blood pressure. He appears mildly toxic but not cyanotic. Ears, nose, and throat are unremarkable. Retractions, grunting, and accessory muscle use are noted on the lung exam. Localized rales and wheezing are noted over the right lower lung zones. Which of the following statements about childhood pneumonia is true?

pneumonia accounts for approximately 5% of childhood deaths worldwide

An 8-year-old child develops an intensely pruritic rash on the legs only. There are patches of erythematous papules and vesicles and several streaks of erythematous vesiculation. The child is afebrile and otherwise well. The most likely diagnosis is

poison ivy dermatitis

Anewborn boy was diagnosed prenatally with bilateral hydronephrosis, distended bladder, and oligohydramnios. What will be the most likely diagnosis?

posterior urethral valves

A child with polyosteotic fibrous dysplasia of the bones and abnormal skin pigmentation is diagnosed with McCune-Albright syndrome. What other problem is this patient most likely to develop?

precocious puberty

A 10-year-old boy has been having episodes of repetitive and semipurposeful movements of the​ face and shoulders. The parents believe these movements are worse when the child is under emotional stress. They also volunteer that they have never noted the movements while the patient is asleep. The movements have been present for more than 6 months. The parents are now especially concerned because the child has developed repetitive episodes of throat clearing and snorting. Physical and neurologic examinations are entirely normal. During the examination you note that the child has some blinking of the right eye, twitching of the right face, and grimacing. You ask him to stop these movements, and he is temporarily successful in doing so, but the movements recur. The home situation, social history, and child's development and social adjustment appear normal. A head CT scan is normal. Of the following, which would be the most appropriate next step?

prescribe haloperidol

A 13-month-old toddler has a tibia fracture after an insignificant fall. Other family members have blue sclerae and recurrent fractures in childhood. For what other problem is this toddler at increased risk?

presenile hearing loss

A 2-year-old child has had recurrent episodes of fever, cough, and pulmonary infiltrates on chest roentgenograms. Diagnostic evaluation reveals a normal sweat test, barium swallow, and serum immunoglobulins, but a severe microcytic, hypochromic anemia. The child's diet is normal for age. Which of the following would be highest on your list of differential diagnoses?

primary pulmonary hemosiderosis

The most consistent abnormality in von Willebrand disease is which of the following?

prolonged bleeding time

Congenital hypothyroidism should be included in the differential diagnosis of a newborn with which of the following?

prolonged jaundice

A 7-year-old boy presented with recurrent eye blinking behavior and recurrent extension of extremities, mother describe the movement as sudden, rapid, and repetitive movements, it was present in the last 9 months. Of the following, the MOST appropriate diagnosis is

provisional tic disorder

A 3-month-old baby girl admitted to pediatric intensive care unit with severe head injury evident by CT scan., the history given by parents was trivial and not informative. You suspected child abuse. Of the following, the MOST helpful study to support your suspicion is

radionuclide bone scan

A 14-month-old boy has a 4-month history of intermittent diarrhea. He frequently has explosive bowel movements containing food particles. He is growing well, is otherwise healthy, and has a normal physical examination. What should be the next step?

reassurance of parents

You are evaluating a 5-year-old child with breath holding spells, the history given includes pallor with abnormal limb movement lasted for 5 minutes followed by sleep. All the following are true responses/advices EXCEPT

reassurance, behavioral instruction to parents and follow up

An 8-month-old infant with confirmed diagnosis of spinal muscular atrophy type 1 referred back from tertiary care center with "DNAR" status. This means during acute illness or an emergency the child should

receive supportive care

A 13-year-old girl is brought to your office with a history of recurring abdominal pain. She has had episodes of abdominal pain at least once or twice a week for the past 3 months. These episodes last approximately 6 to 8 hours. You have seen her for the same problem on many occasions. The following were done previously and all results were normal: complete blood count CBC.; erythrocyte sedimentation rate ESR.; urinalysis; stool for ova and parasites; an ultrasound of the kidneys, ureter, and bladder; and an abdominal plain film. The pain is described as umbilical in location with a quality described as a "dull ache." She rates the pain at a baseline quantity of 6/10, with increases to 8/10 and decreases to 4/10. It is not associated with any food intake, and it is not associated with any diarrhea or constipation. Her mother says that she has been missing school because of the pain. On physical examination, the girl is in no apparent distress. Her vital signs, height, and weight are normal for her age. On abdominal exam there is slight tenderness in the area of the peri-umbilical region. There is no hepatosplenomegaly and no other masses. What is the most likely diagnosis in this patient?

recurrent abdominal pain RAP. syndrome

A school nurse called you to see a 6-year-old boy with school refusal, he is always crying after parental leaving, refuses to stay in the class room, the school nurse informed you that she tried her best during the last 4 weeks; and she met with the parents frequently. Of the following, the BEST action is to

refer the child to a pediatrics psychologist

A3-year-old girlpresent s with a 6 weeks of runny nose, congestion, sneezing, andcough. The child seems to havelong colds especially during spring, early summer,and, occasionally, late summer. The child also hadan episode of difficulty breathing a few days ago forwhich they visited a local emergency room and weregiven an inhaler. What is the first step in treatment that you would recommend to these patients?

refer to an allergist

A 15-month child is brought to you fordiarrhea, with an average 7 loose stools per day for the past 4 days. The stool is watery without any mucus or blood. He also vomited several times during the first 2 days but now it appears to be subsiding. He has been drinking fluids but has not had much appetite for food. For the past 2 days, he has been running a "low-grade fever" and appears to have some abdominal discomfort. He attends a local day care, where some of the children have had similar symptoms.On physical examination, the child is active without any fever. He has dry, cracked lips with moist oral mucosa. The ears, throat, lungs, and abdomen are normal. There are no abdominal masses and no palpable tenderness. Which of the following statements about the treatment of the condition described here is true?

rehydration can be accomplished in most patients via the oral route

A newborn has been diagnosed with aniridia. Which of the following tests should be performed on this patient?

renal ultrasound

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. Which of the following statements concerninguse of oral corticosteroids in children with asthmais true?

repeated short courses of oral corticosteroidsat 1 mg/kg/day to treat acute exacerbationsof asthma have not shown any effect on adrenal function, bone mineralization, or bone metabolism

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days but worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 3kg and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 38°C, pulse of 120 beats/minute, blood pressure within normal limits, and a respiratory rate of 60 breaths/minute. The infant is well hydrated but ill appearing. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical exam. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. The most common cause of bronchiolitis is

respiratory syncytial virus RSV.

A 4-year-old child with a runny nose, congestion, sneezing, and a nonproductive cough comes to your office with his mother. These symptoms started 4 days ago with a sore throat that has since resolved. His appetite is mildly decreased, but he is well otherwise. He has had no fever, chills, or any other symptoms. On examination, the child's temperature is 37.6°C. His ears are clear, and his throat is slightly hyperemic. He has grayish thick nasal discharge and the nasal mucosa appears swollen with erythematous nasal turbinates. His lung fields are clear, there is no significant cervical lymphadenopathy, and no other localizing signs are present. The child's history is unremarkable, and he has had no significant medical illnesses. His immunizations are up to date. What is the most frequent pathogen associated with this condition?

respiratory syncytial virus RSV.

An 18-month-old female presents for a wellchild visit. On examination, there is an asymmetric red reflex, with the left appearing normal and the right appearing cream colored. Of the following, which is the most likely diagnosis?

retinoblastoma

Four months later, she comes in for a visit because she is having a nighttime cough. After a complete history, you find that she has continued to have chest tightness and dyspnea several days a week, especially after running in gym class, and two or three nights each month she cannot sleep well due to coughing. She has no fever, rhinorhea, or other symptoms. She finished her inhaler a month ago, after which her symptoms increased. The patient returns for regular follow-up but she continues to have symptoms that require her to use the rescue medication four or five times a week. She now has daily symptoms and coughs more than one night a week. Which of the following would be appropriate to recommend?

review triggers and try to eliminate them

A 5-year-old boy has severe pharyngitis and culture is positive for group Astreptococci. Of the following suppurative and nonsuppurative complications of group A streptococcal pharyngitis and skin infections, which is associated only with pharyngeal infections?

rheumatic fever

A 1-year-old infant is in for well-child care. He is primarily breast-fed. His parents do not give him much solid food because he has no teeth. He receives no medications or supplements. His parents are concerned about his bowed legs. On examination, you note some other bony abnormalities including frontal bossing, enlargement of the costochondral junctions, a protuberant sternum pigeon chest., and severe bowing of the legs. You obtain x-rays to confirm your clinical diagnosis and also note a healing fracture of the left femur. Which of the following is the most likely diagnosis?

rickets

Malignant hyperthermia is an acute hypermetabolic syndrome that is triggered by inhalational anesthetic agents and succinylcholine. Of the following, the MOST recognized clue to the risk of malignant hyperthermia is

rigid clenching of the masseter muscles

A 5-year-old is brought to the office with a 3-day history of fever, nonproductive cough, coryza, and conjunctivitis. This morning, a rash appeared on his forehead and behind the ears, and it appears to be spreading to his upper arms and chest. On physical examination, you note a fine maculopapular rash over the face that appears to be spreading to the back and thighs. What is the most likely diagnosis in this patient?

rubeola

A3-year-old girlpresent s with a 6 weeks of runny nose, congestion, sneezing, andcough. The child seems to havelong colds especially during spring, early summer,and, occasionally, late summer. The child also hadan episode of difficulty breathing a few days ago forwhich they visited a local emergency room and weregiven an inhaler. What do you think this child has?

seasonal allergic rhinitis

A worried mother of a 4-year-old boy describing attacks of inconsolable crying episodes of her child, taking long time, she stated also that he prefers to play alone. Of the following, the MOST appropriate action is to

seek more history regarding other skills and developmental domains

Which study is the most important to obtain in a 2-year-old child with Beckwith-Wiedemann syndrome and an abdominal mass?

serum alpha-fetoprotein level

A 12-year-old girl has had progressive muscle weakness over the past weeks. She has also developed an erythematous, scaly rash on the face, arms and thighs, and a lacy rash on her upper eyelids. What is the next best laboratory study

serum creatinine kinase

Pseudohypoparathyroidism is associated with which of the following?

short stature

A 6-month-old infant is brought to your office by her mother with nasal congestion for 5 days. The child had a clear runny nose at 1st but now the drainage is thick and yellow and she seems tobe having difficulty with taking the bottle. The baby has had only low-gradetemperatures of less than 38°C. The mother tells you that the baby seems cranky but is consolable and has had difficulty sleeping because of the breathing. On examination, the infant is afebrile. There is no tachypnea. The conjunctivae are slightly hyperemic but without purulent exudates. The nose is congested with erythematous mucosa and thick yellow drainage bilaterally. The ears are clear. The throat is pink, but postnasal drip is noted. The chest is without retractions and is clear to auscultation. Which of the following is the most common bacterial complication of this condition?

sinusitis

A2-year-old girl has persistent seborrheic dermatitis in the diaper area. In addition she has chronically draining infected ears. In which location do bony lesions most often occur in patients with this disorder?

skull

A 16-year-old adolescent has morbid obesity.Which of the following conditions is the most common cause for pulmonary insufficiency in obese adolescents?

sleep apnea

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. All of the following statements concerning treatment of asthma in children have highest level Cevidence except

sublingual immunotherapy is as effective as traditional immunotherapy injections.

It is recommended that young infants should sleep in the supine rather than in the prone position. This is based on data suggesting that the prone position is associated with an increased incidence of which of the following?

sudden infant death

Which of the following is the most common cause of deaths in infants under 12 months of age each year in the United States?

sudden infant death syndrome SIDS.

A 5-year-old is brought to the office with a 3-day history of fever, nonproductive cough, coryza, and conjunctivitis. This morning, a rash appeared on his forehead and behind the ears, and it appears to be spreading to his upper arms and chest. On physical examination, you note a fine maculopapular rash over the face that appears to be spreading to the back and thighs. What treatment recommendations will you make to the child?

supportive care

A 14-year-old boy has an acutely painful and swollen scrotum. What should be the next step?

surgical exploration

A12-year-old boy just returned from Boy Scout Camp in Wisconsin. He now has fever, myalgia, and a 10-cm skin lesion which looks like a target. You suspect Lyme disease, most likely contracted by which of the following?

the bite of a tick

A 3-year-old is brought to your office with fatigue andirritability and a low-grade fever that he has had for3 days. The child attendsday care, where a virus is reportedly "going around." The child was treated by acetaminophen, which has helped to decreaseirritability; although the child's appetite is suppressed,he is still taking in a good amount of fluids. On physical examination, the child does not lookill. His temperature is 38°C. His skin examinationshows scattered small vesicles on an erythematousbase. The rash was seen first on the face and seemsto be spreading to the trunk. The father is concerned about his 5-year-old childcontracting the disease. What will you tell him?

the child will get herpes zoster infection

The classic radiologic finding in duodenal atresia is which of the following?

the double bubble sign

A 13-year-old girl is brought to your office with a history of recurring abdominal pain. She has had episodes of abdominal pain at least once or twice a week for the past 3 months. These episodes last approximately 6 to 8 hours. You have seen her for the same problem on many occasions. The following were done previously and all results were normal: complete blood count CBC.; erythrocyte sedimentation rate ESR.; urinalysis; stool for ova and parasites; an ultrasound of the kidneys, ureter, and bladder; and an abdominal plain film. The pain is described as umbilical in location with a quality described as a "dull ache." She rates the pain at a baseline quantity of 6/10, with increases to 8/10 and decreases to 4/10. It is not associated with any food intake, and it is not associated with any diarrhea or constipation. Her mother says that she has been missing school because of the pain. On physical examination, the girl is in no apparent distress. Her vital signs, height, and weight are normal for her age. On abdominal exam there is slight tenderness in the area of the peri-umbilical region. There is no hepatosplenomegaly and no other masses. The mother of the patient is extremely anxious and wants to know if the investigations need to be repeated at this time. You tell her which of the following?

the next step will be to perform an upper gastrointestinal endoscopy EGD. to "rule out all possibilities"

The finding of a low serum concentration of C3 component of complement in a child with nephrotic syndrome indicates which of the following?

the presence of membranoproliferative glomerulonephritis

Between 2-6 months of life, the infant start to achieve a regular sleep-wake cycles.All the following are true about infant sleep during this period EXCEPT

the sleep cycle time is similar to that of adults

A 3-year-old is brought to your office with fatigue andirritability and a low-grade fever that he has had for3 days. The child attendsday care, where a virus is reportedly "going around." The child was treated by acetaminophen, which has helped to decreaseirritability; although the child's appetite is suppressed,he is still taking in a good amount of fluids. On physical examination, the child does not lookill. His temperature is 38°C. His skin examinationshows scattered small vesicles on an erythematousbase. The rash was seen first on the face and seemsto be spreading to the trunk. This infection can occur in adulthood. Which of thefollowing is a unique feature in this recurrence?

there is no long-term sequelae with therecurrence

A 16-year-old high school soccer player complains of chronic knee pain that has not been associated with an injury. The pain is worse upon going upstairs and after sitting for prolonged periods. The only abnormal finding on examination is peripatellar tenderness. What is the best next action?

thigh strengthening exercise

A 13-year-old boywas diagnosed with asthma at age 8 years, and has had one or two exacerbations a year. He was hospitalized 3 days for "pneumonia and asthma" at age 10 years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father's house and currently he does not have any medications. The child complains of "a little" fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of cough syrup in the past 3 days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or eegophony. Which of the following statements is true?

this child likely has an acute exacerbation of asthma due to viral infection, superimposed on untreated mild or moderate persistent asthma

Peak height velocity for girls most often occurs around which sexual maturity rating SMR.

three

A 2-month-old infant has severe dyspnea and cyanosis. Chest roentgenogram reveals minimal cardiomegaly and a diffuse reticular pattern of the lung fields. Which of the following best explains these findings?

total anomalous pulmonary drainage with venous obstruction

The well-child care anticipatory guidance. intends to promote the physical and emotional well-being of children. The tasks of each well-child visit which usually takes 18 min time. include all the following EXCEPT

treatment plans

A mother to a 4-year-old child who has pauses and repetitions of initial sounds visited outpatients department. Of the following, the MOST appropriate advice is

tries to reduce pressures associated with speaking

A newborn boy has deficiency of the abdominal muscles and urinary tract abnormalities. What other anomaly will you most likely find?

undescended testes

What laboratory abnormality do you expect to find in a 3-year-old child with severe mental retardation, coarse facies, hazy corneas, hepatosplenomegaly, and multiple skeletal x-ray abnormalities?

urinary excretion of dermatan sulfate and heparan sulfate

A7-year-old girl develops secondary nocturnal enuresis. What is the next best study?

urine analysis

A 5-day-old infant boy is jaundiced. The total bilirubin level is 14 mg/dL and the direct bilirubin is 4 mg/dL. Which of the following tests is the most appropriate?

urine analysis and culture

An 23-month-old infant is brought to the emergency department by his mother. He has had diarrhea and vomiting for the past 3 days and appears to be at least 15% dehydrated. His eyeballs are sunken, and his skin is doughy. The child has no satisfactory veins in which to place an IV line. Which of the following investigations should not be performed on any child who has ongoing diarrhea and severe dehydration?

urine-specific gravity

You are managing a 10-year-old child with spastic quadriplasia, who is globally retarded, had recurrent seizures, and severe recurrent chest infections which requires frequent admissions to respiratory care unit RCU. and ventilation. You are trying to convince the mother about non-benefit of future RCU admissions. All of the following statements are true EXCEPT

use an obligations of no bed availability

Four months later, she comes in for a visit because she is having a nighttime cough. After a complete history, you find that she has continued to have chest tightness and dyspnea several days a week, especially after running in gym class, and two or three nights each month she cannot sleep well due to coughing. She has no fever, rhinorhea, or other symptoms. She finished her inhaler a month ago, after which her symptoms increased. Disease severity in asthma is not determined by which of the following?

use of rescue medications

A5-year-old girl diagnosed with pauciarticular juvenile idiopathic arthritis has a positive antinuclear antibody test. Which of the following would most likely be found in this patient?

uveitis

A 3-year-old is brought to your office with fatigue andirritability and a low-grade fever that he has had for3 days. The child attendsday care, where a virus is reportedly "going around." The child was treated by acetaminophen, which has helped to decreaseirritability; although the child's appetite is suppressed,he is still taking in a good amount of fluids. On physical examination, the child does not lookill. His temperature is 38°C. His skin examinationshows scattered small vesicles on an erythematousbase. The rash was seen first on the face and seemsto be spreading to the trunk. What is the most likely diagnosis in this child atthis time?

varicella-zoster

A 3-year-old girl presents to a health center with a fever for the past 36 hours. Maximum temperature was 40°C at 2 am, which decreased to38.7°F with children's ibuprofen. Her appetite andfluid intake have decreased during the past 24 hours. Physical examination shows an ill-appearing child.Her temperature is 37.2°C. The skin has a macular-papular petechial rash on the chest and back. Theremainder of the physical examination is normal. Which of the following best describes your clinical impression at this time?

viral syndrome

A4-year-old presents for a well-child visit. The parents state their family has practiced a strict vegan diet since the child was 2 years of age. Of the following, which is most likely to be deficient now or in the near future?

vitamin B12

The earliest indicators of Cushing syndrome glucocorticoid excess. in children are which of the following?

weight gain and growth arrest

A 6-month-old infant is found to be lethargic and cyanotic. Blood obtained by venipuncture appears chocolate brown and does not become bright red when shaken in the presence of air.It is especially important to seek a history of exposure to which of the following?

well water

A3-year-old girlpresent s with a 6 weeks of runny nose, congestion, sneezing, andcough. The child seems to havelong colds especially during spring, early summer,and, occasionally, late summer. The child also hadan episode of difficulty breathing a few days ago forwhich they visited a local emergency room and weregiven an inhaler. The mother of the child calls your office andrequests "blood work" to confirm the diagnosis before she starts the child on the medications yourecommended. You call back and tell her which of the following?

you will order nasal smear, complete bloodcount CBC., and serum IgE levels

A 6-month-old male presents with diaper rash that is resistant to therapy. He has intermittent diarrhea. He is breastfeeding, and rarely seems interested in solid foods. Mother is a vegetarian.On examination, he is thin and listless. He has dry, plaque-like, sharply demarcated lesions around his mouth and eyes. His hair is coarse and scanty. A deficiency of which of the following could explain this condition?

zinc

On a routine-screening CBC, a 1-year-old is noted to have a microcytic anemia. A follow-up hemoglobin electrophoresis demonstrates an increased concentration of hemoglobin A2. The child is most likely to have which of the following?

β-Thalassemia trait

A mother calls you frantic because she has just been diagnosed with chicken pox. She delivered 7 days ago a term infant that appears to be eating, stooling, and urinating well. The child has been afebrile and seems to be doing well. Which of the following is the most appropriate step in management?

Advise the mother to continue regular well-baby care for the infant.

An awake, alert infant with a 2-day history of diarrhea presents with a depressed fontanelle, tachycardia, sunken eyes, and the loss of skin elasticity. Which of the following is the correct percentage of dehydration?

5% to 9%