CP4003 CLIPPs Questions
A 5-year old previously healthy boy is brought to his pediatrician with complaints of intermittent abdominal pain, right ankle pain, and a purpuric rash over his buttocks and lower extremities. His mom says she thinks he may recently have recovered from an upper respiratory infection. Which of the following statements is true? • A. CBC would likely reveal thrombocytopenia • B. This disease is classified as a small vessel vasculitis • C. Urinalysis is not warranted for this patient's work-up • D. Treatment options include IVIG • E. This disease is equally common in girls and boys
B. This disease is classified as a small vessel vasculitis
A 12-day-old baby girl is brought to the ED by her foster mother due to fussiness and tactile fevers. The baby's teenage biological mother did not receive prenatal care and delivered her baby at home. On further questioning, you find out that the patient has had only two wet diapers per day and two loose green stools per day. On exam, the patient is irritable and her anterior fontanelle is tense. Which of the following diagnoses are of emergent concern at this time? • A. Down syndrome • B. Fetal alcohol syndrome • C. Group B strep sepsis/meningitis • D. Meconium ileus • E. Poor weight gain
C. Group B strep sepsis/meningitis
Steven, a 5-year-old boy with no significant past medical history, was in his usual state of health until last night when he developed abdominal pain. This morning his mother noticed a red and blotchy rash on his buttocks and lower extremities and his abdominal pain has worsened. Otherwise, he has no other symptoms and except for an upper respiratory tract infection last week, he has been in good health recently. On exam, the presence of palpable purpura and petechiae over the buttocks is confirmed. Laboratory studies are normal and, after a clinical diagnosis is made, he is discharged home the same day and given instructions to return for follow-up. Which of the following is important to measure at the first follow-up visit? • A. BP and urinalysis • B. Platelet count • C. PT/PTT • D. White blood cells and haemoglobin • E. Signs of intracranial haemorrhage
A. BP and urinalysis
A 3-week-old baby boy is brought to his pediatrician with a chief complaint of light tan-colored stools and worsening jaundice. His is exclusively breastfed and has 6-8 wet diapers per day. On exam, he appears to have scleral icterus and jaundice. Upon further workup, he is found to have an elevated direct bilirubin. What is his most likely diagnosis? • A. Biliary atresia • B. Breastfeeding jaundice • C. G6PD deficiency • D. Physiologic jaundice • E. Caput succedaneum
A. Biliary atresia
A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests? • A. Chest x-ray and tuberculin skin test • B. CT of nasal sinuses • C. Spirometry, before and after bronchodilator therapy • D. Chest x-ray and methacholine challenge • E. None needed, patient likely has habitual cough
A. Chest x ray and tuberculin skin test
A 19-year-old female in her 38th week of pregnancy goes into active labor. Shortly after birth her baby is noted to have a *high-pitched cry, tremulousness, hypertonicity, and feeding difficulties*. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. What is the drug the baby's mother likely used during her pregnancy? • A. Heroin • B. Alcohol • C. Marijuana • D. Cocaine • E. Tobacco
A. Heroin
A 3-hour-old infant boy, born by C-section at 36 weeks to a 30-year-old G1P1 with Apgars of 8 and 9 at 1 and 5 minutes, respectively, is found to be *tachypneic* in the newborn nursery. His mother has a history of *Type II diabetes that was poorly controlled* during her pregnancy. She was compliant with prenatal vitamins and took no other drugs during her pregnancy. Prenatal labs, including GBS, were negative. The mother's membranes ruptured 9 hours prior to delivery, she was afebrile, and the amniotic fluid had no meconium. On physical exam, the infant is *large for gestational age*. He has good air movement through the lungs bilaterally, without retractions or nasal flaring. He appears well perfused with normal cardiac exam. He is not in a flexed posture and has a *weak suck reflex*. A screening test at 3 hours of life reveals *blood glucose of 39 mg/dL*. What is the most likely diagnosis? • A. Hypoglycaemia • B. Transposition of the great arteries • C. Transient tachypnoea of the newborn • D. Neonatal sepsis • E. Pneumothorax
A. Hypoglycaemia (~50-110 mg/dl is normal)
A mother brings her 8-year-old son to his primary care physician for pain in his knees and ankles that have been present for the past three days. She also notes that he has had a rash since yesterday, but otherwise feels well. The patient has no chronic illnesses, but he was brought in three weeks ago for an upper respiratory infection. Exam is significant for pain elicited on passive movement of the ankles and knees. Additionally, the patient is found to have an erythematous, slightly raised, non-blanching, maculopapular rash over the legs, buttocks, and posterior portion of the elbows. CBC shows WBC 8.9, Hgb 12.5, Hct 36.1, and Plt 327. Urinalysis is unremarkable. Skin biopsy shows leukocytoclastic vasculitis with IgA deposition. Which of the following is the best next step in management? • A. Observation • B. Corticosteroids • C. Intravenous immunoglobulin (IVIG) • D. Intravenous hydration • E. Platelet transfusion
A. Observation
A mother brings her 20-day-old male infant to your clinic for the child's first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been *vomiting 2 to 3 times per day*, and the mother reports that her son seems *fussier* than her friends' infants. On exam, you note an *eczematous rash* and a *musty odor to the infant's skin and urine*. Which enzyme deficiency would you expect the infant to display? • A. Phenylalanine hydroxylase • B. Cystathionine synthase • C. Sphingomyelinase • D. Alpha-L-iduronidase • E. Glucose-6-phosphatase
A. Phenylalanine hydroxylase
A previously healthy 14-year-old female presents to the ED with a one-day history of fever and altered mental status. Vital signs on presentation include: BP 115/70 mmHg, HR 145 bpm, RR 42 bpm, temp 39.7 C, oxygen sat 93%. Physical exam reveals nuchal rigidity, cool extremities, 1+ distal pulses, diffuse petechial rash, and capillary refill > 2 seconds. What is the important first step in management? • A. Place IV and start NS bolus • B. Order CBC, CMP, PT, and INR • C. Start empiric antibiotic therapy with IV ceftriaxone • D. Obtain a head CT • E. Order blood cultures
A. Place IV and start NS bolus
You have accepted a part-time tutoring job for first-year medical students. One of your students asks if you would please clarify the details of normal fetal circulation. Which of the following best describes the path of the majority of oxygenated blood that enters the right atrium? A 5-year-old boy is noted to have a grade II systolic murmur and a widely split S2 murmur on cardiac exam. His vital signs are stable and he has been asymptomatic. Which of the following statement is accurate regarding this patient's presentation and likely condition? • A. No further work-up for a presumed venous hum • B. Chest x-ray, ECG, and echocardiogram would be indicated as next steps to work up a presumed ventricular septal defect • D. The patient should be scheduled now for cardiac catheterization • A. RA > foramen ovale > LA > LV > systemic circulation • B. RA > RV > VSD > LV > systemic circulation • C. RA > RV > pulmonary circulation > LA > LV > systemic circulation • D. RA > RV > ductus arteriosus > LV > systemic circulation • E. RA > RV > ductus arteriosus > systemic circulation
A. RA > foramen ovale > LA > LV > systemic circulation
A 3-month-old male presents to the ED with a fever that started the previous day. Mother reports that he was fussy and had decreased oral intake. He had had five fewer diaper changes than usual. He had no vomiting, diarrhea, or respiratory difficulty. On physical exam his temperature is 101.6 F, pulse 110 bpm, RR 24 bpm, and BP 95/67 mmHg. The baby seems irritable and is not consolable by the parent. HEENT exam was significant for dry mucous membranes. Other than his irritability, the rest of the physical exam was unremarkable. CBC showed WBC 3.5, but was otherwise normal. BMP was within normal limits. Urinalysis showed positive leukocyte esterase, positive nitrite, and WBCs > 10/hpf. An LP was performed, and urine and CSF culture results are pending. The patient is placed on IV fluids and is started on cefotaxime. What is the next best step in evaluation? • A. Renal bladder ultrasound • B. Kidney-ureter-bladder (KUB) x-ray • C. Intravenous pyelogram • D. VCUG • E. Oral ampicillin
A. Renal bladder ultrasound
You see a 6-year-old male in the ED who presents with a history of a 10-second episode of jerking movements of his extremities with unresponsiveness, observed by both of his parents. His parents claim he has had abdominal pain and small quantities of bloody diarrhea for two days. The child has no significant past medical history, has taken no medications recently, has no pets, and has not traveled outside of California in the past year. He attends kindergarten. Which organism is the most likely cause of the child's symptoms? • A. Shigella sonnei • B. Rotavirus • C. Clostridium difficile • D. Enterotoxigenic E. coli (ETEC) • E. Vibrio cholerae
A. Shigella sonnei
Question A male infant weighing 3200 grams is born to a G1P1 female at 39 weeks' gestational age via planned C-section. Maternal PMH is unremarkable, and GBS status is unknown. Apgars are 7 and 8 at 1 and 5 minutes of life, respectively. The delivery is uncomplicated, and the infant initially appeared in good condition. However, one hour following delivery the infant develops increasing respiratory distress. RR is assessed as 90 breaths/min. All other vital signs are within normal limits. On exam, the infant is acyanotic with rapid respirations and robust capillary refill. Chest x-ray shows bilateral lung fields with the appearance of "a radio-opaque line of fluid in the horizontal fissure of the right lung." No air bronchograms are noted. What is the most likely etiology of the infant's respiratory distress? • A. TTN • B. Respiratory distress syndrome (RDS) • C. Neonatal sepsis • D. Meconium aspiration
A. TTN
A 7-year-old boy presents with a five-year history of intermittent vomiting, vertigo, and throbbing unilateral headaches that seem to be induced by emotional stress and when his teacher wears perfume. He reports that the pain is not worsened by long naps or coughing. His mother reports that she has a history of headaches that started as a child and wonders if her son inherited this from her. His neurological exam shows no focal deficits. What is the next step in diagnosis or treatment? • A. Trial of prophylactic medication for migraine headaches • B.MRI • C. NSAIDs • D. Referral to an ENT surgeon
A. Trial of prophylactic mediation for migraine headache
A 6-month-old female with normal birth and developmental history presents with fever for the past two days, fussiness, and decreased appetite. ROS is negative. No abnormalities are noted on the physical examination. A urinalysis from a bag specimen is positive for leukocytes and nitrite, which suggests the presence of a UTI; a culture from this sample is pending. The patient is ill-appearing, dehydrated, and unable to retain oral intake. She is hospitalized, receives a 20 cc/kg NS bolus and is placed on maintenance IV fluids with clinical improvement. What is the best next step for management of this patient? • A. Urinary catheterization • B. Renal bladder ultrasound • C. Begin parenteral antimicrobials • D. Midstream clean catch urine collection • E. Increase intravenous fluid administration rate to flush the kidneys
A. Urinary catheterisation
Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of *rhinorrhea* and *non-productive cough*. When he was born he was large for gestational age, and his exam then was notable for *macrocephaly, macroglossia, and hypospadias*. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an *abdominal mass* on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? • A. Wilms' tumor • B. Teratoma • C. Renal cell carcinoma • D. Hepatoblastoma
A. Wilm's tumour
You are working overnight call in the ED when Charlie, a 3-year-old male infant, arrives after his parents witnessed an episode of convulsions at home. His parents report that Charlie was in his usual state of good health until three days ago when he developed fever, cough, and rhinorrhoea. This evening they found him in bed with his eyes rolled upward, jerking all four of his extremities uncontrollably. He was unarousable from this state, which self-resolved after about two minutes. This has never happened before. Currently, Charlie is sleepy but arousable and complains of nausea. His vitals include T 103.2 F, P 112 bpm, BP 100/60 mmHg, RR 22 bpm, O2 sat 99% on room air. Aside from rhinorrhoea and erythematous mucous membranes, the remainder of his physical exam is unremarkable. What is the next best step in management? • A. Workup for source of fever • B.EEG • C. MRI brain • D. Abdominal ultrasound • E. Administration of valproic acid
A. Work up for source of fever
A 19-year-old G1P0 presents in labor to the ED at 38 gestational weeks. On interview it is discovered that the patient had irregular prenatal care, drank a couple of *beers* every weekend, and *smoked* 4 cigarettes a day. She delivers a baby boy who is *small for gestational age*. On exam, it is noted the baby has *microcephaly*, a *smooth philtrum*, and a *thin upper lip*. What do you suspect caused these features in the baby? • A. Tobacco exposure • C. Congenital rubella • D. Vertically transmitted HIV • E. Congenital CMV infection • B. Alcohol exposure
B. Alcohol Exposure
A 10-month-old infant is brought to the Peds ED by her parents, who say she has been coughing persistently for the last three hours. The parents were watching a movie at home when they first noticed their daughter coughing. Patient is a vaccinated, well-nourished infant in moderate distress with retractions, nasal flaring, and grunting. On auscultation, you immediately notice diminished breath sounds in the right lung with normal breath sounds on the left. What other associated physical exam finding do you expect to hear? • A. Stridor • B. Asymmetric breath sounds and wheezing • C. Rhonchi • D. Crackles • E. Bronchial breath sounds
B. Asymmetric breath sounds and wheezing
A 6-month-old baby boy is referred to your clinic because he has not been gaining weight appropriately. His mother denies any difficulty with feeding or reduced appetite, yet his weight has still dropped from the 30th to the 3rd percentile. Mother also complains that he has loose, malodorous stools. After a thorough workup, a diagnosis of cystic fibrosis (CF) is made. Which of the following is a TRUE statement regarding CF • A. CF is an autosomal dominant disorder • B. CF is caused by a mutation in CTFR, resulting in defective salt balance • C. CF is a disease that exclusively involves the respiratory system • D. Gene therapy is now the primary source of CF therapy • E. It is important to provide calories at a lower level than recommended dietary allowance for a given age in order to prevent GI upset
B. CF is cuased by a mutation in the CTFR resulting in defect salt balance
A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks' gestation. The newborn is noted to have *dysmorphic cranial features* and his *head circumference* is 28.5 cm *(< 5th percentile)*. What is another associated abnormality you might expect to see in this newborn? • A. Hepatosplenomegaly • B. Cardiac Defects • C. Absent red reflex • D. Chorioretinitis • E. Tremors
B. Cardiac Defects
Susie is a 3-year-old girl brought into the clinic by her mother because she has a gradually worsening cough and she has been having trouble breathing. Her mother says Susie sounds like she is barking when she coughs. Susie is up to date with her vaccinations. Susie's mom always watches her when she's playing. On physical exam, you note that Susie has inspiratory stridor. She does not have wheezing, there are no retractions, and she has symmetrical breath sounds. No pseudomembranes are appreciated on physical exam. What is Susie's most likely diagnosis? • A. Epiglottis • B. Croup (laryngotracheobronchitis) • C. Pertussis • D. Pneumonia • E. Foreign body aspiration
B. Croup (laryngotracheobronchitis)
A 7-year-old boy is brought by ambulance to the ED with altered consciousness. The EMT said he found the boy in a pool of vomit. He is unable to answer questions coherently and he is alone. Physical exam findings indicate dry mucous membranes, tachypnea, tachycardia, and moaning on palpation of the abdomen. His physical exam is otherwise normal, including a normal blood pressure. What is the most likely cause of his condition? • A. Appendicitis • B. DKA • C. Narcotic overdose • D. Non-accidental trauma • E. Sepsis
B. DKA
Question A 4-day-old baby boy presents for his first pediatric well child visit. His birth history consists of an uncomplicated normal spontaneous vaginal delivery after 7 hours of labor-no vacuum or forceps assistance were used. The patient is the first child to a 30-year-old mother of Mediterranean descent. Mom is very concerned that her baby has started to look "yellow" since leaving the hospital. She has been breastfeeding every 2-3 hours and says that the baby latches on for 1-5 minutes for each feed. He has had few wet diapers, and mom is concerned he is not getting enough to eat. Which of the following would most aid in narrowing the differential diagnoses? • A. Newborn screen results • B. Fractionated bilirubin • C.WBC • D. Blood smear • E. No further workup is needed, as this is likely physiologic jaundice
B. Fractionated bilirubin
At a routine well-child visit, the frantic mother of your 4-year-old male patient states that she thinks her son has some developmental delays based on what she hears from other parents. Although he knows how to do such things as throw a ball and copy a circle, he cannot brush his teeth on his own, tie his shoes, or hop on one foot. According to the AAP's Bright Futures, which of the following are *development milestones for typical 4-year-olds*? • A. Throw a ball overhand, ride tricycle, build tower of 6-8 cubes • B. Hop on 1 foot, copy a cross, brush teeth • C. Tie a knot, copy squares • D. Mature pencil grasp, print some letters and numbers • E. Skip, draw a person with 6 or more body parts
B. Hop on 1 foot, copy a cross, brush teeth
You are called down to the nursery to evaluate a newborn girl who is ready to be discharged. The mom is concerned because this 3-day-old has become lethargic and doesn't want to feed. She has vomited twice and is showing no interest in feeding. On physical exam you note a lethargic infant with an enlarged liver and worry about an inborn error of metabolism. Which test would be diagnostic for an ornithine transcarbamylase (OTC) deficiency? • A. Hypoglycemia • B. Hyperammonemia and elevated urine orotic acid • C. Elevated 17-OH progesterone • D. Elevated TSH • E. Hyponatremia
B. Hyperammonemia and elevated urine orotic acid
A full-term, 6-week-old baby is brought to the family physician for routine follow-up. At birth her weight, height, and head circumference were at the 50th percentile; she is now at the 5th, 10th, and 25th percentiles, respectively. She and her twin sister are exclusively breastfed; their mother has maintained a rigid every-four-hour feeding schedule since birth. Physical exam reveals a thin but otherwise healthy infant. What is the most likely cause of this infant's failure to thrive? • A. Congenital heart disease • B. Inadequate caloric intake • C. Cystic fibrosis • D. Milk protein allergy • E. Inborn error of metabolism
B. Inadequate caloric intake
Rashid is a 5-week-old baby boy who presents to clinic with 4 days of repeated, forceful, non-bilious, non-bloody vomiting without diarrhea. He has 8 to 9 episodes of vomiting per day immediately following breastfeeding. The episodes started 2 weeks after the entire family suffered from severe viral gastroenteritis. His birth history is uncomplicated (full term, NSVD, unremarkable 30-week ultrasound) and birth weight was 3.6 kg (50th percentile). On exam, his vitals are: T 36.7°C, HR 185, BP 85/45, RR 36, Wt 4.1 kg (25th percentile). On exam, his eyes are moderately sunken without production of tears, his lips are cracked, and his throat is without erythema. His capillary refill is ~3 seconds, and his pulse is thready. What is your first step in management? • A. Close observation in the office for 6 hours and encourage PO intake until vitals normalize. • C. Intravenous 20 mL/kg boluses of 1⁄4 normal saline solution until baseline clinical status is achieved, then closely monitor vitals for 6 hours while encouraging PO formula intake. • B. Intravenous lactated Ringer's solution of 20mL/kg boluses until baseline clinical status is achieved, then 100 mL/kg oral rehydration solutions over next 4 hours. • D. Observe for 6 hours with normal PO intake and administer 60-120 mL of oral rehydration solution for every episode of vomiting. • E. Administer 75 mL/kg of oral rehydration solution over 3-4 hours and 60-120 mL of oral rehydration solution for every episode of vomiting.
B. Intravenous lactated ringers solution of 20ml/kg blouses
An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy? • A. Only rescue inhaler PRN • B. Low dose inhaled corticosteroids • C. Medium dose inhaled corticosteroids and course of oral corticosteroids • D. Medium dose inhaled corticosteroids, LABA, and course of oral corticosteroids • E. Course of oral corticosteroids
B. Low dose inhaled corticosteroids
An 8-year-old girl comes to the clinic with a chief complaint of a "cold" for the past two weeks. On further questioning, she developed a fever of 38.7°C, purulent nasal secretions, malodorous breath, and a nocturnal cough three days ago. Examination of the nose reveals pus bilaterally in the middle meatus, and tenderness over the mid-face. Which of the following is the most likely diagnosis? • A. Allergies • B. Maxillary sinus • C. Asthma • D. Frontal sinusitis • E. Middle ear infection
B. Maxillary sinus
A previously healthy and developmentally normal 16-month-old male comes to the urgent care clinic with his father with a chief complaint of his first reported seizure. The child was reported to have dropped to the floor with loss of consciousness and had sporadic twitchy movements of his legs and arms that lasted for five minutes. The child has had URI symptoms for the past two days, with a fever to 103 degrees F without any changes in mental status. Neither parent has a seizure disorder, but the child's mother reports having a single seizure as a young girl once after developing a high fever after a cold. What is the most likely diagnosis? • A. Epilepsy • B. Simple febrile seizure • C. Complex febrile seizure • D. Absence seizure • E. Cyanotic breath-holding spell
B. Simple febrile seizure
A 9-year-old male is brought to the ED in a coma secondary to diabetic ketoacidosis. Which of the following laboratory results would NOT likely be found in this patient? • A. Anion gap of 20 mEq/L • B. Potassium of 3.3 mEq/L • C. Venous pH of 7.1 • D. Sodium of 132 mEq/L • E. Creatinine of 1.0 mEq/
B. Potassium of 3.3 mEq/L
You are seeing a 1-month-old male who is < 3rd percentile for weight. He is breastfed every 2 hours and latches on well. However, he has frequent non-bilious episodes of vomiting that have been increasing over the past week despite his mother taking "reflux precautions." He does not have mucus or blood in his stool. Physical exam reveals a small, olive-sized mass in his abdomen. What is the most likely diagnosis? • A. Cleft palate • B. Pyloric stenosis • C. Cystic fibrosis • D. Non-organic failure to thrive • E. Munchausen syndrome by proxy
B. Pyloric stenosis
Question A newborn baby boy is born at 30 5/7 weeks' gestation after induction of labor for the severe maternal preeclampsia. He is noted to have subcostal and intercostal retractions, grunting, nasal flaring, persistent cyanosis, and tachypnea 30 minutes after delivery. Apgars were 6 (-2 for color, -1 for breathing and -1 for tone) and 7 (-2 for color and -1 for breathing) at 1 and 5 minutes, respectively. Due to lack of prenatal care and the mother's presentation with severe preeclampsia, betamethasone x 1 was given during induction, but she did not receive a second dose prior to delivery. A chest x-ray is obtained, which reveals diffuse ground-glass appearance and air bronchograms bilaterally. What is the most likely diagnosis? • A. Meconium aspiration syndrome (MAS) • B. Respiratory distress syndrome (RDS) • C. Persistent pulmonary hypertension (PPHN) • D. Transient tachypnea of the newborn (TTN) • E. Bronchopulmonary dysplasia (BPD)
B. RDS
Question Adam is a newborn male who was just born to a G2P1 mother at 36.2 weeks' gestation via a vaginal delivery. The mother reports that she did not receive prenatal care because she did not have insurance. She says that she thinks her "water broke" about two days ago, but she did not have any contractions after that, so she decided not to come to the hospital. She did not start having contractions until 19 hours before she delivered. After delivery, Adam did not cry vigorously, was tachypneic, cyanotic, and febrile to 100.5 F. Amniotic fluid did not contain meconium. His chest x-ray is normal. Given Adam's birth history, what is the most likely cause of his symptoms? • A. Transient tachypnea of the newborn (TTN) • B. Sepsis secondary to prolonged rupture of membranes • C. Meconium aspiration syndrome • D. Hypothermia • E. Pneumothorax
B. Sepsis secondary to prolonged rupture of membranes
A 10-month-old asymptomatic infant presents with a *RUQ mass*. Work-up reveals a *normocytic anemia*, elevated *urinary HVA/VMA*, and a *large heterogeneous mass* with *scant calcifications* on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? • A. Sheets of lymphocytes with interspersed macrophages • B. Small round blue cells with dense nuclei forming small rosettes • C. Hypersegmented neutrophils • D. Stacks of RBCs • E. Enlarged cells with intranuclear inclusion bodies
B. Small round blue cells with dense nuclei forming small rosettes (Neuroblastoma)
The mother of a 5-year-old boy calls your office asking if she should take her son to the emergency room or wait another day. She states that her son suddenly developed a "high fever" and is extremely tired. When you ask about her son's behaviour, she states that he also seems very confused. She also noticed he had developed reddish-purplish spots on his extremities. What is the next best step in management of this patient? • A. Have the patient make an appointment to come to your office today • B. Tell the mother to take her son to an ED immediately • C. Have the patient hydrate well over the weekend and follow up with you in a few days • D. This patient most likely ingested something. Recommend ipecac to induce emesis and call 911
B. Tell the mother to take her son to an ED immediately
A 12-year-old girl presents to her PMD complaining of a headache of gradual onset x 3 hours, non- provoked and described as a "big rubber band around my whole head" and a 5 out of 10 on the pain scale. The pain is not throbbing, and there is no associated photophobia, nausea or vomiting. The patient is afebrile, and there are no neurologic deficits during physical exam. Her mother states her pain is typically relieved with ibuprofen, but her mother is concerned that patient may have migraines because she has a few headaches every month after school. The child is otherwise healthy. What is the most likely cause of this girl's headaches? • A. Migraine • B. Tension-type headache • C. Brain tumour • D. Sinusitis • E. Pseudo-tumour cerebri
B. Tension type headache
A 3-year-old boy presents for a follow-up visit after being diagnosed with iron deficiency anaemia. He is currently receiving oral iron supplements, 2 mg/kg of elemental iron daily. He has a dietary history of eating mostly sweet, bland, low-texture foods. What strategies may be used to improve his diet? • A. Continue bottle-feeding • B. Encourage eating small amounts of food throughout the day (grazing) • C. Gradually introduce new foods and slowly decrease his old favourites • D. Bargain and cajole with the child • E. No change is needed; bland, low-texture foods are optimal for a child this age
C. Gradually introduce new foods and slowly decrease his old favourites
A 7-year-old girl is brought to her pediatrician because of recurrent puffy eyes. She presented one week ago because of the same problem and was diagnosed with allergies. She was started on an intranasal steroid with no relief. Her mother states she has become increasingly tired and mentions that she has recently outgrown all of her shoes. The patient has no other symptoms and is at the 50th percentile for height and weight, is afebrile, and non-toxic appearing. Her heart and lung exam are normal. She has no hepatomegaly and no evidence of rash. What is your next step in diagnosis/management? • A. Echocardiogram • B. Urinalysis • C. Flonase trial for an additional week • D. CBC with manual differential • E. Liver enzymes
B. Urinalysis
Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to *run*, make a *tower of 2 cubes*, has *6 words* in his vocabulary, and can *remove his own garments*. What would you estimate Sammy's age to be based upon his developmental milestones? • A. 12 months • B. 15 months • C. 18 months • D. 30 months • E. 36 months
C. 18 months
A 10-month-old male is brought to the emergency room by his very concerned and frantic grandmother. Earlier that day, she retrieved the child from his mother's new boyfriend, who had been watching him while his mother was at work. The grandmother makes it very clear she does not approve of this new boyfriend, and she is concerned that he is rough with her grandson. She demands that her grandson be worked up for injuries and that a restraining order be placed against the boyfriend. Which of the following finding does NOT indicate that a child is being physically abused? • A. Retinal haemorrhages on fundoscopy • B. A concaved, crescent-shaped mass on head CT • C. A spiral fracture of the tibia • D. Two posterior rib fractures • E. A metaphyseal fracture of the wrist
C. A spiral fracture of the tibia
Question A woman brings her 8-year-old son to the pediatrician after witnessing him stare blankly into the distance at dinner the previous week. He was unresponsive to her calling his name or any other stimuli, and it lasted for about 10 or 20 seconds. His teacher reports he does seem to daydream often in class but is able to keep up with schoolwork and excels in his studies. She doesn't note him being disruptive or impulsive in class. His mother is concerned about these blank stares and unresponsive episodes. Which of the following is the most likely diagnosis? • A. Generalized tonic-clonic seizure • B. Atonic seizure • C. Absence seizure • D. Simple partial seizure • E. Complex partial seizure
C. Absence seizure
A 10-year-old male comes to the clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhoea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup? • A. Response to inhaled beta-agonist • B. Hyperinflation in one lung field • C. Alveolar consolidation in the RLL • D. Positive PCR for pertussis • E. Fluffy bilateral infiltrates and a large heart on chest x-ray
C. Alveolar consolidation in the RLL
A 12-year-old male presents to the ED with complaints of anorexia, weight loss, and persistent cough, with nocturnal coughing fits that have been waking him from sleep for the past three weeks. He denies fever, chills, myalgia, sore throat, or rhinorrhea. The patient presented to his primary care physician one week prior with the same complaint, and was treated with amoxicillin and bronchodilator therapy. His chest x-ray was negative for infiltrates at that visit. The patient's symptoms did not improve with this regimen. The cough became more frequent, sometimes causing emesis. Which of the following is the most likely diagnosis? • A. Reactive airway disease • B. Infection with Bordetella pertussis in the catarrhal stage • C. Infectio with Bordetella pertussis in the paroxysmal stage • D. Atypical pneumonia due to Mycoplasma pneumoniae • E. Laryngotracheobronchitis
C. Bordetella in the paroxysmal stage
A two-month-old female presents to clinic for a well-baby checkup. Mom has been happy because the "baby rarely cries and sleeps all the time." On exam, the baby has yellowing of the skin, decreased activity, appears to have decreased tone, and a large anterior fontanel. What is the most likely diagnosis? • A. Sepsis • B. Congenital adrenal hyperplasia • C. Congenital hypothyroidism • D. Shaken baby syndrome • E. Neonatal lupus
C. Congenital hypothyroidism
A 5-year-old female, previously healthy, presents with an erythematous, vesicular rash on the palms and soles and a high fever for several days. Upon examination, she is also found to have ulcers in her mouth. A few days later, the fever and rash resolve. What is the most likely pathogen? • A. Herpes simplex virus 1 (HSV-1) • B.HIV • C. Enterovirus • D. Human herpesvirus 6 (HHV-6) • E. Group A strep
C. Enterovirus
A 9-year-old female is brought to clinic by her mother because of two days of abdominal pain and vomiting. She has vomited six times today and has had decreased appetite, but no diarrhea, fevers, sick contacts, or changes in diet. Her mom states that she has been otherwise healthy apart from increased thirst and occasional bedwetting over the last few weeks. Of note, patient's maternal grandmother suffers from celiac disease. On exam, patient is afebrile and has a HR of 180 bpm, BP 90/60 mmHg, RR 50 bpm, and O2 saturation of 98%. She is lying in bed appearing slightly drowsy, taking rapid, deep breaths and is slow to respond to questions. Her heart and lung exams are normal apart from being tachycardic, and abdominal exam reveals mild diffuse tenderness to palpation with no rebound or guarding. Which of the following would be the most appropriate next step in management? • A. Chest x-ray • B. Urine culture • C. Fingerstick glucose • D. Abdominal ultrasound • E. Gastric lavage
C. Fingerstick glucose
A 39-year-old G2P1 woman with a pre-pubertal 10-year-old boy with intellectual disability comes to the clinic for information on prenatal . The 10-year-old boy was born with large ears and long face but no other congenital malformations. The mother is worried that she will have a second child with similar problems. If she were to have a second male child with developmental impairment, what would be the most likely reason if maternal serum testing and fetal ultrasound were both normal? • A. Down syndrome • B. Trisomy 13 • C. Fragile X syndrome • D. Turner syndrome • E. Kleinfelter syndrome
C. Fragile X syndrome
A 6-month-old male comes to clinic with a chief complaint of several weeks of vomiting after large feedings. The vomiting has become blood-streaked, which is when the mom became concerned and brought him in. The baby's PO intake has been down and he has been losing weight. Abdominal exam is normal, with no masses palpated. What is the most likely diagnosis? • A. Pyloric stenosis • B. Gastroenteritis • C. GERD • D. Volvulus • E. Intussusception
C. GERD
An 18-month-old female is brought to her pediatrician by her mother who notes that she has been has been fussy for the past three days and has been pulling on her ears. The child is up to date with her hepatitis B, rotavirus, DTaP, H. influenza type B, pneumococcus, and polio vaccines. Her temperature is 102.2 F. Otoscopic exam of her left ear shows a yellow, opaque, and bulging tympanic membrane. Which of the following organisms is the most likely cause of the child's condition? • A. Streptococcus pyogenes • B. Candida albicans • C. Haemophilus influenzae • D. Rhinovirus • E. Moraxella catarrhalis
C. Haemophilus influenza
A 2-month-old male is brought to the ED after his mother found him in his crib not breathing. She says he had no colour and was still when she found him, but quickly regained his colour. While you are examining him he starts having a tonic-clonic seizure and subsequently is found to have a temperature of 96 F, HR 200 bpm, and RR 18 bpm. On exam he cries intermittently, does not track you with his eyes, has a tense, full fontanelle, and decreased tone throughout. You also notice a healing bruise on his left arm. After assessing circulation, airway, and breathing you obtain IV access. What is the next step in your diagnostic workup? • A. Skeletal survey • B. Lumbar puncture • C. Head CT • D. Head MRI • E. Social work consult
C. Head CT
A *9-month old* baby boy comes to the clinic for a well child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit? • A. Influenza, Hep B, IPV, DTaP • B. Influenza, IPV • C. Influenza, Hep B, IPV • D. Hep B, DTaP, IPV • E. Hep B, IPV, and MMR
C. Influenza, Hep B, IPV
A 9-year-old male presents to the ED in an ambulance after he was found unconscious at a local playground. In the ED he is arousable but extremely obtunded. He is able to minimally verbalize that his head hurts and his stomach feels uncomfortable. He states the pain is constant and non-radiating. He vomits clear liquid twice over the course of 30 minutes. Vital signs are as follows: T 37.6 C, P 66 bpm, BP 155/80 mm Hg, RR 18 bpm. You further notice that his breathing is irregular with brief episodes of apnea. On physical exam you are unable to reproduce the abdominal pain and there is no rebound tenderness or guarding. The rest of the physical exam is unremarkable. What is the most likely diagnosis? • A.DKA • B. Appendicitis • C. Intracranial haemorrhage • D. Gastroenteritis • E. Small bowel obstruction
C. Intracranial haemorrhage
A 3-year-old male presents with fever to 103 F for the past week, injected eyes, and a refusal to walk for the past two days. On physical exam, you note conjunctival injection without pus or exudates bilaterally, prominent papillae of his tongue with redness as well as redness of his hands, and feet. He also has a new non-diffuse maculopapular rash on his torso that gets worse with fever. On examination of the swollen extremities, you are unable to elicit any tenderness or effusions in any joints. Which of the following is the most likely diagnosis? • A. Rocky Mountain Spotted Fever (RMSF) • B. Bone or joint infection • C. Kawasaki disease • D. Scarlet fever • E. Systemic onset juvenile idiopathic arthritis
C. Kawasaki disease
An 11-month-old boy is brought to the ED by ambulance. His father called 911 after the patient's eyes deviated to the left as his arms and legs were twitching. During this time he was unresponsive. He has had a tactile fever for three days, and parents mention that he has not been as playful as usual during this time as well. His parents have not had him vaccinated due to personal beliefs. In the ED his vital signs are T 39.1°C, HR 155 bpm, RR 28 bpm, BP 100/65 mmHg, O2 100% (on RA). He does not cry but whimpers during most of your physical exam (including when you look in his ears). You order a CBC and metabolic panel, which are significant for a leukocytosis with a left shift and mild acidosis. Urinalysis and blood/urine cultures are pending. Which of the following additional studies would you obtain? • A. Chest x-ray • B. Toxicology screen • C. Lumbar puncture • D. Electroencephalogram (EEG)
C. Lumbar puncture
A 7-year-old boy with a past medical history of headaches presents with increased frequency and severity of headaches along with new onset vomiting. When the patient was walking into the room, he had a wide stance and nearly tripped twice. Which of the following is the most appropriate next step? • A. Daily headache diary • B. Computed tomography • C. Magnetic resonance imaging • D. Lumbar puncture • E. Intraventricular pressure monitoring
C. Magnetic resonance imaging
An 18-month-old presents with yellow and poorly mobile tympanic membranes. Four months prior he presented then with several days of nasal congestion, cough, decreased eating and ear tugging. His exam then revealed a red, nonmobile tympanic membrane and he was treated with amoxicillin. Based on the history and physical exam, what is the most likely diagnosis now? • A. Mastoiditis • B. Acute otitis media • C. Otitis media with effusion • D. Otitis externa • E. Viral encephalitis
C. Otitis media with effusion
A 45-day-old infant is brought in by his mother due to lethargy, constipation, and yellow skin color noted since birth. The mother and the baby moved to the U.S. from a foreign country that does not screen its newborns. The baby has been fed only formula since birth. Physical exam of the neonate reveals additional findings of large fontanelles, umbilical hernia, a large tongue, and abdominal distension. What is the next best step in diagnosis? • A. Phototherapy • B. Exchange transfusion • C. TSH • D. Head ultrasound • E. Obtain a family history of jaundice to rule in or out a defect in bilirubin metabolism
C. TSH
You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a *few colds*, has been generally healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in *short, two or three-word sentences.* His speech is understandable. He can *draw a circle*, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient? • A. Perform a brain-stem auditory evoked potential hearing screen • B. Perform a screening exam for autism • C. Reassure the parents that the boy's development appears normal • D. Refer the child to a developmental specialist for comprehensive evaluation • E. Refer the child to a specialist for evaluation of his delayed motor development
C. Reassure the parents that the boys development appears normal
Rosy is an 18-month-old previously healthy baby girl who presents to clinic with congestion for three days. Today, her vitals are: T 101.2°F, BP 100/60 mmHg, P 80 bpm, RR 28 bpm. On physical exam, Rosy has clear mucus coming from both nostrils. Both turbinates show erythema. Her oropharynx is erythematous. No crackles or wheezing are heard. Mom reports that acetaminophen aids in bringing down the fever temporarily; however, the fever returns in a few hours. Mom is concerned for possible pneumonia since she was recently was given antibiotics for bronchitis. Her immunizations are up to date. Which of the following is most likely responsible for Rosy's symptoms? • A. Strep pneumoniae • B. Group A Strep • C. Rhinovirus • D. Haemophilus Influenzae type B • E. Pertussis
C. Rhinovirus
A 9-year-old male presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. He has struggled with these complaints over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him? • A. Oral antibiotics • B. Short-acting beta agonist PRN • C. Short-acting beta agonist PRN with low-dose inhaled corticosteroid • D. Short-acting beta agonist PRN with medium-dose inhaled corticosteroid • E. Long-acting beta agonist
C. Short acting bet agonist PRN with low dose inhaled corticosteroid
An 18-year-old mother with her 3-month-old son arrives at urgent care clinic with a chief complaint of "my baby stopped breathing!" She and her baby are rushed into a triage room, where her son is noted to be very lethargic with increased work of breathing. As vital signs are being obtained, the mother reports "my baby stopped breathing in the car coming here, and didn't start again until I reached over and jostled his car seat!" Mom then shared that "my boyfriend said he rolled off the couch last night. Could it be related?" Mom also stated that her son hasn't been as active as usual, and has been vomiting occasionally. Physical exam is notable for a respiratory rate of 70 bpm with intercostal retractions and crackles in the right lower lung fields posteriorly. You admit this patient with the diagnosis of pneumonia for empiric antibiotics and support, pending additional evaluation. CXR subsequently demonstrates a RLL infiltrate and faint, vertical lines on several posterior ribs bilaterally. What is the best next step in management? • A. Obtain a PTH level • B. Sweat chloride testing • C. Skeletal surgery (more x rays) • D. Anticipatory guidance about appropriate car seat usage • E. Head ultrasound
C. Skeletal survey (more x rays)
A 5-year-old boy is noted to have a grade II systolic murmur and a widely split S2 murmur on cardiac exam. His vital signs are stable and he has been asymptomatic. Which of the following statement is accurate regarding this patient's presentation and likely condition? • A. No further work-up for a presumed venous hum • B. Chest x-ray, ECG, and echocardiogram would be indicated as next steps to work up a presumed ventricular septal defect • C. This patients murmur is caused by flow through the pulmonary outflow tract and should be evaluated • D. The patient should be scheduled now for cardiac catheterization
C. This patients murmur is caused by flow through the pulmonary outflow tract and should be elevated
A previously healthy 4-year-old girl is brought to her pediatrician because her parents have noticed that she has been less active than usual for the past three weeks. Her father explains that it is difficult to get his daughter out of bed in the mornings and that she no longer plays outside with her older brother. Physical examination is notable for a temperature of 38.4 C, heart rate of 125 bpm, pallor, truncal bruising, and diffuse lymphadenopathy. The remainder of the exam, including a thorough neurologic assessment, is unremarkable. Which of the following is the most likely diagnosis? • A. Aseptic meningitis • B. Kawasaki disease • C. Non-accidental trauma • D. Acute lymphoblastic leukaemia • E. Mononucleosis
D. Acute lymphoblastic leukaemia
A 6-month-old infant arrives in the ED with a 12-hour history of poor feeding, emesis, and irritability. On exam, she is ill-appearing with T 39.2 C, P 160 bpm, R 40 bpm, BP 80/50 mmHg. CBC shows WBC 11.2, Hgb 13.5, Plt 250. Urinalysis shows > 100 WBC per hpf, positive leukocyte esterase, and positive nitrites. She has no history of prior urinary tract infection. Chest x-ray is negative. Urine and blood cultures are pending. After bringing her fever down, she was still uninterested in drinking, but her exam improved, and you were confident she did not have meningitis, so an LP was not performed. Which of the following is the best next step in management? • A. Oral ampicillin • B. Oral ampicillin + gentamicin • C. Intravenous ciprofloxacin • D. Intravenous ceftriaxone • E. Intravenous piperacillin + tazobactam
D. Intravenous ceftriaxone
A 3-week-old infant is brought to the pediatrician for failure to thrive (despite adequate, even prolonged, feedings) and respiratory distress (particularly tachypnoea). EKG shows high voltage QRS complexes in leads V1 and V2. What other features does this infant most likely have? • A. Cyanosis from a right-to-left shunt • B. Systolic murmur with a widely split second heart sound • C. Continuous murmur that is louder during systole • D. Left-to-right shunt
D. Left-to-right shunt
During the middle of dinner on your day off, you receive a call from one of your neighbors who remembers that you are a medical student. He is concerned about his 15-year-old daughter who had previously been in her usual state of health and has no significant past medical history. However, over the past 24 hours, his daughter suddenly spiked a fever of 103 F and has "not been herself," acting very lethargic and dazed at times. He also notes that she has been breathing heavily, not been able to eat or drink, and has not urinated over the past 12 hours. He wants your advice about whether she should be taken to the ED. Although you are fairly certain that the best course of action would be to take her to the ED, you contemplate the differential diagnosis of her presentation. Given the limited history, which of the following is highest on your differential? • A. Acute cystitis • B. Diabetic ketoacidosis • C. CNS tumor • D. Menigitis • E. Hypoglycemia
D. Meningitis
A 5-year-old girl comes into your office for a well-child visit. The mother says that child is overall very healthy, but she highlights *"occasional colds"* and recently more *frequent temper tantrums*. She does well in preschool, is toilet trained, and enjoys eating mostly pasta, bread, and milk. She lives with her mother and father in a home built in 1985. Lab studies were significant for a *mild anaemia* with a *haemoglobin of 10.0 g/dL*. You note that her haemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anaemia? • A. Chronic blood loss • B. Lead poisoning • C. Chronic illness • D. Iron deficiency • E. Haemoglobinopathy
E. Haemoglobinopathy
Adam is a 2-hour-old infant born at 32 weeks' gestational age via spontaneous vaginal delivery to a healthy mother with negative group B streptococcus status. There was no premature rupture of membranes and no meconium in the amniotic fluid. His Apgars were 8 at one minute and 9 at five minutes. Over the last two hours he has become *progressively tachypnoeic*. On physical examination he is *large for gestational age*. His vital signs are *respiratory rate 75*, temperature 36.5 C and heart rate is 130 beats per minute. His lung exam is remarkable for *intercostal and subcostal retractions, grunting, and equal breath sounds*. His heart exam reveals normal rhythm, normal S1 and S2, no murmurs, and normal peripheral pulses and capillary refill. Which of the following is the most likely cause of the patient's condition? • A. Transient tachypnoea of the newborn (TTN) • B. Pneumothorax • C. Congestive heart failure • E. Sepsis • D. Respiratory distress syndrome
D. Respiratory distress syndrome
The parents of 5-month-old Tiffany are concerned about Tiffany's decreasing oral intake over the past 4 days. They report that she has been sleeping more but seems to tire out when feeding; in fact, mom's breasts have become quite engorged and she needs to pump to relieve the pressure. In addition to the sleepiness and poor feeding they report that she has not had a bowel movement in 3 days. She has no fever or respiratory symptoms. You note a weak cry on your exam, and a floppy baby when you try to sit her up. What additional finding are you likely to find on your exam? • A. Vesicular rash on her scalp • B. Large tongue and umbilical hernia • C. III/VI systolic murmur • D. Absent deep tendon reflexes • E. Cataracts and hepatosplenomegaly
D. Absent deep tendon reflexes
A 6-year-old boy presents to the ED with three days of diffuse muscle aches and occasional chills. Today, he had a headache and abdominal pain. He reports that he does not feel hungry because he feels sick to his stomach. He denies recent cough, congestion, sore throat, joint pains, or sick contacts. His vitals are: T 101.3 F, BP 108/71 mmHg, P 110 bpm, R 28 bpm, O2 sat 100% on RA. On physical exam, you notice blanching, erythematous macules on his ankles and several petechiae on his wrists. Upon questioning, his mother says that the spots on his wrists previously looked like the spots on his ankles. His neck is supple and there is no hepatosplenomegaly or lymphadenopathy. He reports no sick contacts, but recently visited his cousins in North Carolina. What is the best next step in management? • A. Give acetaminophen, obtain a Monospot, write a note for activity restriction, and advise his mother to bring him back if he is unable to tolerate fluids • B. Perform skin scraping of macules and examine under microscope with KOH prep • C. Admit the patient, obtain CBC, blood and CSF cultures, and await culture results to guide antibiotic therapy • D. Admit the patient, obtain CBC, blood and CSF cultures, then give loading doses of doxycycline 2.2 mg/kg and ceftriaxone 100 mg/kg/day • E. Give acetaminophen and obtain CBC, UA, and BUN/Cr
D. Admit the patient, obtain CBC, blood and CSF cultures, then give loading doses of doxycycline 2.2 mg/kg and ceftriaxone 100 mg/kg/day
A 14-month-old female with no significant past medical history presents to clinic with fever to 39.2 C and irritability. According to mom, the patient was initially sick one week ago with a runny nose and cough, but these symptoms had resolved. She started pulling at her ear and becoming increasingly irritable last night, with her fever spiking around 2:00 a.m. this morning. Patient is up to date on immunizations, and has had several prior ear infections. She was most recently treated last month with amoxicillin. When you examine her ears, you observe a red, bulging tympanic membrane with limited mobility in her left ear. The exam of the right ear is normal. You are confident in your diagnosis of acute otitis media. What is your treatment plan? • A. Observation • B. Anthistamines and decongestants • C. High-dose amoxicillin • D. Amoxicillin/clavulanate (with high-dose amoxicillin component) • E. Tympanocentesis
D. Amoxicillin/clavulanate (with high-dose amoxicillin component)
Luanne is a 15-year-old female with three hours of abdominal pain and two episodes of non-bilious, non-bloody vomiting. She rates her pain at 8/10 and describes it as constant and located mainly in the middle of her belly, but somewhat present throughout her abdomen. It is worse with coughing and moving. She has never had this pain before, and has had no appetite since the pain started. She is sexually active with her boyfriend of three months, always uses condoms, and has not been tested for STIs. Her last menstrual period was two weeks ago. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mm Hg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spin and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Her WBC and CRP are within normal limits. Based on the information above, what is the most likely diagnosis? • A. Ovarian torsion • B. Pelvic inflammatory disease • C. Ectopic pregnancy • D. Appendicitis
D. Appendicitis
A concerned mother brings her 7-day-old son to your office after noticing yellowing of his skin for 2 days. She has also noticed he has not been gaining weight since she brought him home from the hospital 5 days ago. This is her first son and she has been trying to do everything perfectly, including breastfeeding him, since she was told that breast milk provides adequate nutrients and other healthy benefits, like antibodies and growth factors. However, upon further questioning, she is feeding him only 6 times a day for 10 minutes each time. She admits her breasts often feel full and are not relieved by nursing. He was born full term by spontaneous vaginal delivery but had a hard time sucking with breastfeeding. Upon exam, he looks dehydrated and appears to have jaundice of the face and chest. He has also lost > 10% of his birth weight. What could be the cause of his jaundice? • A. Breast-milk jaundice • B. Physiologic jaundice • C. Sepsis • D. Breastfeeding jaundice • E. Crigler-Najjar syndrome
D. Breastfeeding jaundice
A young couple presents to the ED with their 2-month-old son complaining of excessive sleepiness and difficulty arousing him after his nap. Per the parents, the PMH and prenatal course are unremarkable, except that the patient has always been very fussy and would often cry despite being held and cradled. He is cared for during the day by his babysitter. Today he had been in his usual state of fussiness when the babysitter arrived, and they returned to find him napping quietly in his cradle but could not arouse him from sleep when it came time for his feeds. He finally opened his eyes after several minutes of gentle nudging but seemed to quickly fall asleep again. On exam, patient is afebrile with poor tone and is only mildly responsive to painful stimuli. Eye exam shows dilated pupils and an ophthalmology consult reveals retinal haemorrhages. What is the most likely diagnosis? • A. Bacterial meningitis • B. Infant botulism • C. Intoxication • D. Closed head injury • E. Metabolic disorder
D. Closed head injury
Jade is a 2-week-old female who was born at home and received no newborn screenings for congenital disease. Her mother brought her to the pediatrician's office concerned that her daughter appeared to be jaundiced and was constipated, tired, and not feeding well most of the time. Physical exam was notable for enlarged fontanels, jaundice without bruising, hypotonia without tremor or clonus, and an umbilical hernia. There was no sign of virilization, no abnormal facies, and no history of vomiting. Review of systems was otherwise negative except as stated above. Which of the following is the most important next step in Jade's management? • A. Glucose and electrolyte supplementation • B. Glucocorticoid and mineralocorticoid supplementation • C. No treatment needed • D. Consult with paediatric endocrinooogy and start treatmetn with 10 to 15 mcg/kg/day of crushed levothyroxine in liquid and follow up every 12 months • E. Empiric antibiotics after collection of blood, urine, and CSF cultures.
D. Consult with pediatric endocrinologist and start treatment with 10 to 15 mcg/kg/day of crushed levothyroxine in liquid, and follow up every 12 months
A 3-year old girl comes to the clinic with a chief complaint of fever (104F) for over a week. Her mom reports that she has been fussy and inconsolable since she became febrile. She has a red tongue, with large papillae, conjunctivitis, a palmar rash, unilateral cervical adenopathy, as well as swollen feet. Given the most likely diagnosis, what is the most important follow-up for this patient over the next few weeks? • A. Ophthalmology follow-up to determine extent of eye damage and determine need for corticosteroids • B. Physical therapy follow-up to help prevent long-term joint deformities and ensure long-term functionality • C. Cardiology follow-up to rule out presence of rheumatic fever • D. Echocardiogram to look for coronary artery aneurysm • E. Neurology follow-up to evaluate partial paralysis of lower extremities
D. Echocardiogram to look for coronary artery aneurysm
A 12-month-old previously healthy girl presents with cough and mild subcostal retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest x-ray demonstrates unilateral air trapping. What is the most likely diagnosis? • A. Croup • B. Pneumonia • C. Acute bronchiolitis • D. Foreign body aspiration • E. Asthma
D. Foreign body aspiration
Casey's parents just learned that Casey's screening test for CF was abnormal. What other signs and symptoms might you expect this patient to develop? • A. Bloody stools • B. Precordial thrill • C. Reflux • D. Greasy stool • E. Diaphoresis during feeds
D. Greasy stools
A 6-week-old infant girl whose family recently immigrated from Mexico is brought to clinic for "excessive sleepiness." The mother states the infant is not easily aroused for feedings and is not as active as she was previously. She is also concerned about her daughter's large "outtie" belly button. On exam, the patient is afebrile and jaundiced, with a puffy myxedematous face. The fontanels are large but flat. There is a large umbilical hernia. When asked about the results of a newborn screening exam, mom states that the screening was never performed. What would be an expected abnormal lab value(s) associated with her condition? • A. Low sodium, high potassium • B. Glucose < 40 mg/dL • C. High WBC with bandemia • D. High TSH, low T4
D. High TSH, low T4
A 5-day-old infant presents with a chief complaint of jaundice. As you obtain a careful history and physical examination, which of the following would NOT be a risk factor for jaundice in this infant? • A. Mediterranean origin • B. Prolonged labor with use of forceps during the delivery • C. Mother is type O+ and baby is type B • D. Phenylketonuria • E. Poor breastfeeding during first few days of life
D. Phenylketonuria
A 3-year-old girl presents to the ED with sudden onset difficulty walking. She does not have a fever, headache, nausea, or vision changes, but two weeks ago she had a runny nose, a fever, and a rash. Musculoskeletal exam reveal no abnormalities of lower extremities. Neuro exam reveals bilateral horizontal nystagmus, wide based stance and swaying, and bilateral overreaching on finger to nose test. An LP is performed which reveals a normal CSF. Which of the following is the most likely diagnosis? • A. Opsoclonus-myoclonus syndrome • B. Hydrocephalus • C. Infectious cerebellitis • D. Post infectious cerebellitius • E. Migraine headache
D. Post infectious cerebellitis
A 5-year-old male comes to the clinic with a chief complaint of four days of progressively worsening fever and that has been minimally responsive to acetaminophen. The patient complains of sore throat and decreased appetite. His sister had a positive rapid strep test and is now being treated with amoxicillin. Your concern is for Group A strep. What is the next best step in management? A. Start antibiotic treatment • B. Send blood cultures • C. Advise parents to give patient acetaminophen with return precautions • D. Rapid strep test with back-up culture if negative • E. Chest x-ray
D. Rapid strep test with back up culture if negative
A 10-day-old boy is brought to the ED by his mother because of "fever." Mom describes that the baby has been "sleepy" and feeding less vigorously than in the previous two days. She believes his urine output has also decreased. His birth history is notable for prolonged membrane rupture (about 32 hours), and maternal fever at the time of delivery. Prenatal and neonatal ultrasound revealed bilateral hydronephrosis. On exam, the infant is sleepy with a temperature of 38.5 C. A blood sample is sent for CBC, BMP, and culture. Attempts are made to obtain CSF and urine for analysis and culture, but only very small volumes of these fluids are obtained. Volume resuscitation is begun. Chest x-ray is performed with indeterminate results. What is the most appropriate next step? • A. Send samples for gram stains and begin parenteral empiric antibiotic treatment • B. Send the urine for urinalysis and the CSF for cell count, glucose and protein and begin parenteral antibiotic therapy • C. Admit for observation and continue supportive care • D. Send samples for culture and begin parenteral antibiotics treatment • E. Attempt to obtain larger samples. Antibiotics should not be started until all needed results are pending.
D. Send sample for culture and begin parental antibiotics treatment
On your first day rotating in the pediatric clinics, you are assigned to see a patient who is 9 weeks old and was brought into clinic by his worried mother. She states that her son has not gained weight since they left the hospital. His weight is < 5th percentile, and height and head circumference are at the 25th percentile. His mother says he drinks two ounces of milk every two to three hours, and suckling is strong without any spitting up during feeds. He poops more than 10 times a day, but it appears greasy and foul smelling. He had an unremarkable birth history and a normal newborn screen. Cardiac, pulmonary, abdominal, and neurologic exams are all normal. His mother mentions her cousin had trouble gaining weight and would get frequent "lung infections." Which of the following is the best next step in management? • A. Increase formula to a higher calorie mixture • B. Stool culture and Wright stain • C. Swallow study • D. Sweat chloride test • E. Echocardiogram
D. Sweat chloride test
A 6-month-old female is brought into the pediatrician's office for three days of high fever, fussiness, and decreased appetite. The patient has not had any upper respiratory tract symptoms, vomiting, diarrhea, or rash. On physical exam the patient is fussy, has a RR of 28 bpm and a pulse of 160 bpm. She is febrile to 102.8 F (rectal). The patient is alert and fully moving all extremities. Apart from her vital signs, no other significant exam findings are noted. A CBC demonstrates leukocytosis of 17.0 cells x 103 / μL with elevated bands. What diagnosis is most likely? • A. Measles • B. Bacterial meningitis • C. Acute otitis media • D. UTI • E. Roseola
D. UTI
A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would be characteristic of the cough that this patient would present with? • A. Does not awaken patient from sleep • B. Paroxysmal • C. Barking cough • D. Worse at night • E. Associated with crackles on exam
D. Worse at night
A 2-year-old girl is examined as an outpatient. While waiting for the pediatrician, her mother reads her a short book. When they are done, her mother asks her to take the book and return it to a bookshelf in the room. The child is *not able to hold a pencil and cannot write her name*. She can *kick and throw* a ball, but *cannot jump in place*. Which of the following best describes this child's development? • A. Delayed language • B. Delayed social skills • C. Advanced fine motor skills • D. Advanced gross motor skills • E. Age-appropriate development
E. Age-appropriate development
Question A 4-year-old girl with a history of type 1 diabetes mellitus was admitted to a local hospital for treatment of DKA. A few hours after the treatment, she develops grunting, irregular respirations, and has vomited twice. On exam, her left eye is pointing downward and out on straight gaze. Her diastolic blood pressure is 90 mmHg. What is a likely diagnosis? • A. Hypoglycemia • B. Hypokalemia • C. Hyponatremia • D. Pneumonia with possible sepsis • E. Cerebral oedema
E. Cerebral oedema
A 5-month-old male presents to urgent care with his mother who states that she witnessed her son stop breathing and turn blue for about 25 seconds. Upon physical stimulation by the mother, the patient began to breathe again. This is the first time she has ever witnessed this happening. The patient's birth and past medical history are unremarkable. Physical exam is unremarkable, vital signs are stable and normal, and lab studies are all within normal limits. Which of the following is LEAST likely to be on the differential diagnosis as a cause for this patient's ALTE (apparent life threatening event)? • A. Seizures • B. Arrhythmia • C. Infection • D. Gastroesophageal reflux • E. Congenital heart disease
E. Congenital heart disease
A 4-week-old female infant presents to clinic for a well child check. This infant had an uneventful delivery by NSVD at full term and subsequent normal neonatal screen. The nurse reports that her growth is a concern, with weight at 3.0 kg (< 3rd percentile) and weight for height at < 3rd percentile. Mom denies any drinking or drugs since before this pregnancy and says she has been breastfeeding every two to three hours and supplementing with appropriately mixed formula one to two times a day. She does report the baby seems to have issues latching and some possible gasping between suckles. There has been no diarrhoea, hematochezia, vomiting, or fevers. The vital signs and exam (apart from a thin infant) are normal. The mother's affect is flat, and she seems anxious when you ask her about her infant. What is the most likely diagnosis for this infant's failure to thrive? • A. Malabsorption • B. Gastroenteritis • C. Milk protein allergy • D. Congestive heart failure • E. Failure to thrive due to inadequate caloric intake
E. Failure to thrive due to inadequate caloric intake
Joe, a previously healthy 11-month-old male with 5-day history of a "cold," is brought to the ED by mom for one day of acute worsening cough and intermittent wheezing. Per mom, the cough was initially dry but has become more "phlegmy," making it difficult for Joe to breathe, particularly when he is feeding or more active. His immunizations are up to date, and he has no known allergies. His family history is significant for a 6-year old sister who was diagnosed with asthma four years ago. On exam, Joe is afebrile, mildly tachypneic with normal O2 saturation. He has prominent nasal flaring and mild subcostal retractions. He has clear rhinorrhea but no evidence of oropharyngeal erythema. Lung exam reveals decreased breath sounds and wheezes on the right. What is the most likely diagnosis? • A. RSV bronchiolitis • B. Epiglottitis • C. Viral URI • D. Asthma • E. Foreign body aspiration
E. Foreign body aspiration
Johnny is a 25-month-old male who presents to the ED with a 2-day history of vomiting and diarrhea. Dad relays a history of abrupt onset of vomiting that started yesterday around 1 pm. Johnny has had 6 episodes of emesis since yesterday and 3 episodes of diarrhea. The emesis is non-bilious and the diarrhea is described as watery with specks of blood throughout the diarrhea. There are no sick contacts in the home. Vital signs: T 37.1, P 102, R 20, BP 90/60. Physical examination is normal and Johnny has still been tolerating some PO feeds without instant vomiting. What is the most immediate intervention for this patient? • A. IV bolus with D5W • B. IV bolus with 0.9% saline • C. CT scan and surgical consult • D. random glucose test • E. no immediate intervention is necessary
E. No immediate intervention is necessary
An asymptomatic, healthy *9-month-old female* is found to have a *palpable RUQ mass* on exam. After further imaging and lab studies, the mass is diagnosed as a *neuroblastoma* that has involvement in the *bone marrow* as well. The mother is worried about the prognosis. Which of the following is true about the *prognosis* of neuroblastoma in this child? • A. Lymph node involvement is a poor prognostic factor • B. Prognosis of neuroblastoma is predictable • C. Children who are older than 12 months have a better prognosis than younger children • D. Favorable histology does not play a role in prognosis • E. Non-amplification of the n-myc gene is a favorable prognostic factor.
E. Non-amplification of the n-myc gene is a favourable prognostic factor
A 15-month-old boy presents to the ED in January with a 3-day history of diarrhea. His current weight is 11 kg. He was born at 39 weeks, without any perinatal complications. There is no significant history of travel, sick contacts, or recent changes in diet. The mother notes that he has had only 2 diaper changes over the last day. Physical exam is remarkable for an irritable but consolable infant with tachycardia and normal blood pressure. He is crying without tears and his mucous membranes are dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds. He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the following statements is true? • A. The patient is mildly dehydrated and should be managed with oral rehydration (Pedialyte). • B. The patient is moderately dehydrated and should be managed with oral rehydration (Gatorade). • C. The patient should be rehydrated with clear liquids and then transitioned to a lactose-free diet until his diarrhoea resolves. • D. The patient is moderately dehydrated and should be bolused with 220 ccs of D5 1⁄2 normal saline for emergency phase correction, to ensure hemodynamic stability. • E. The work-up for infectious diarrhea for this patient should include a Wright's stain for fecal WBCs, a stool Rotazyme, and a stool sample for culture and sensitivity.
E. The work up for infectious diarrhoea for this patient should include a Wrights stain for fecal WBCs, a stool Rotazyme and a stool sample for culture and sensitivity
A 2-year-old girl presents to the urgent care clinic with a 7-day history of high fever to 38.5 C, a maculopapular rash that began on the palms and soles of her feet, red eyes without discharge, and unilateral cervical adenopathy. What other symptom/sign might you discover on further history and exam? • A. Tonsillar exudates • B. Headache • C. Erythematous and oedematous feet • D. White spots on buccal mucosa • E. Dysuria
Erythematous and oedematous feet
A 3-year-old boy described by his mother as a picky eater comes in for a regularly scheduled well- child visit. His mother complains that he has had less energy than usual for the past few months. There is a high clinical suspicion he is anaemic. Which of the following is most correct? • A. The most cost-effective test to diagnose anaemia is a CBC. • B. Lead screening is never warranted since a 3-year-old is usually not mouthing objects. • C. The most likely cause of anaemia in the question is picky eating resulting in low iron intake, which woudl cause microcytic anaemia • D. The most common cause of anaemia in this situation is folate deficiency. • E. If anaemia is due to poor nutrition, restarting the bottle will help the child recover the most.
• C. The most likely cause of anaemia in the question is picky eating resulting in low iron intake, which woudl cause microcytic anaemia
A 1-month-old African-American male presents to your office for a check-up. The baby was born at term by NSVD to a 29-year-old G1P0 mother with no complications. Mother states the baby was feeding well until a week ago, when he developed increased sleepiness, prolonged feeding, and greater duration between feeds. His mother notes he stops to take breaks sometimes because he seems to be trying to catch his breath. He has 4 to 6 wet diapers per day and poopy diapers 3 or 4 times per day. Vital signs are: T: 37.6 C, RR: 68 bpm, P: 138 bpm, BP: 88/58 mmHg, and 02 saturation is 98%. The physical examination is notable for increased respiratory effort and retractions, and, upon cardiac examination, a murmur with a hyperactive precordium and no cyanosis. Abdominal exam reveals a liver edge palpable to 4 cm below the right costal margin. Which condition would be least likely to be the cause of the patient's symptoms? • A. Aortic stenosis • B. Coarctation of the aorta • C. Ventricular septal defect • D. Patent ductus arteriosus • E. Atrial septal defect
• E. Atrial septal defect
Alex is a 6-year-old boy who presents to the clinic with a chief complaint of acute onset of bruising. He is afebrile, and his mother reports that he recently had a URI. He was born at full-term and has never been hospitalized. He was circumcised at birth with no problems with bleeding. No one in his family has any chronic medical problems. There have been no serious childhood illnesses or deaths. No one has a history of easy bruising or bleeding. On exam you find that he has a purpuric rash on his buttocks and legs. His urinalysis reveals 15 to 20 RBCs/hpf. Which of the following additional findings would NOT be consistent with the likely diagnosis? • A. Elevated serum IgA • B. Blood in the stool • C. Colicky abdominal pain • D. Pain in his knees and ankles • E. Low platelets
• E. Low platelets