Gen peds
25. You are called by a general practitioner to consult on a patient admitted to the hospital 4 days ago. The patient is a 7-month-old white boy with poor weight gain for the past 3 months, who has not gained weight in the hospital despite seemingly adequate nutrition. You take a detailed diet history from his foster mother, and the amounts of formula and baby food intake seem appropriate for age. Physical examination reveals an active, alert infant with a strong suck reflex who appears wasted. You note generalized lymphadenopathy with hepatomegaly. In addition, you find a severe case of oral candidiasis that apparently has been resistant to treatment. Which of the following is the most appropriate next step in the evaluation or treatment of this child?
*a. Increase caloric intake because this is probably a case of underfeeding.* b. Order human immunodeficiency virus (HIV) polymerase chain reaction (PCR). testing because this is likely the presentation of congenitally acquired HIV. c. Draw blood cultures because this could be sepsis. d. Perform a sweat chloride test because this is probably cystic fibrosis. e. Send stool for fecal fat because this is probably a malabsorption syndrome.
17. You are called to the ER to see one of your patients. The father of this 14-year-old mildly retarded child says that he found the child about 20 minutes ago in the neighbor's garden shed with an unknown substance in his mouth. The child first had a headache, but then became agitated and confused; while you are talking to the father in the ER the child begins to have a seizure and dysrhythmia on the cardiac monitor. The blood gas demonstrates a severe metabolic acidosis. Which of the following agents is most likely the culprit?
*a. Organophosphate* b. Chlorophenothane (DDT) c. Sodium cyanide d. Warfarin e. Paraquat
40. As part of your anticipatory guidance to new parents of a healthy newborn, you suggest putting the child in which of the following positions for sleep?
*a. Supine position* b. Prone position c. Seated position d. Trendelenburg position e. A hammock
24. 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?
a. 2 months b. 4 months c. 6 months d. 9 months e. 1 year
30. You find a discrete, whitish polyp that extends through the tympanic membrane in a child with a history of recurrent otitis media. This most likely represents which of the following?
a. A cholesteatoma b. Tympanosclerosis c. Acute otitis media with perforation and drainage d. Dislocation of the malleus from its insertion in the tympanic membrane e. Excessive cerumen production
11. A previously healthy 5-year-old boy has a 1-day history of low-grade fever, colicky abdominal pain, and a rash. He is well-appearing and alert. His vital signs, other than a temperature of 38°C (100.5°F) are completely normal. A diffuse, erythematous, maculopapular, and petechial rash is present on his buttocks and lower extremities, as shown in the photograph. He has no localized abdominal tenderness or rebound; bowel sounds are active. Laboratory data demonstrate Urinalysis: 30 red blood cells (RBCs) per high-powered field, 2+ protein Stool: Guaiac positive Platelet count: 135,000/μL These findings are most consistent with which of the following?
a. Anaphylactoid purpura b. Meningococcemia c. Child abuse d. Leukemia e. Hemophilia B
8. A mother calls you on the telephone and says that your 4-year-old son bit the hand of her 2-year-old son 48 hours previously. The area around the injury has become red, indurated, and swollen, and he has a temperature of 39.4°C (103°F). Which of the following is the most appropriate response?
a. Arrange for a plastic surgery consultation at the next available appointment. b. Admit the child to the hospital immediately for surgical debridement and antibiotic treatment. c. Prescribe penicillin over the telephone and have the mother apply warm soaks for 15 minutes four times a day. d. Suggest purchase of bacitracin ointment to apply to the lesion three times a day. e. See the patient in the ER to suture the laceration.
71. Over the past several weeks, a 2-year-old girl has exhibited developmental regression, abnormal sleep patterns, anorexia, irritability, and decreased activity. These symptoms have progressed to acute encephalopathy with vomiting, ataxia, and variable consciousness. The family recently moved, and they are in the process of restoring the interior of their home.
a. Atropine and pralidoxime (2-PAM) b. N-acetylcysteine (Mucomyst) c. Dimercaptosuccinic acid (DMSA, succimer) d. Naloxone (Narcan) e. Sodium bicarbonate
13. A 6-year-old boy is often teased at school because he has stooled in his underwear almost daily for the last 3 months. He was toilet trained at 2 years of age without difficulty, but over the last 2 years he had developed ongoing constipation. His family is frustrated because they cannot believe him when he says "I didn't know I had to go." He is otherwise normal; school is going well, and his home life is stable. His only finding on examination is significant for stool in the rectal vault. The plain radiograph of his abdomen is shown. Initial management of this problem should include which of the following?
a. Barium enema and rectal biopsy b. Family counseling c. Time-out when he stools in his underwear d. Clear fecal impaction and short-term stool softener use e. Daily enemas for 4 weeks
38. As a city public health officer, you have been charged with the task of screening high-risk children for lead poisoning. Which of the following is the best screen for this purpose?
a. Careful physical examination of each infant and child b. Erythrocyte protoporphyrin levels (EP, FEP, or ZPP) c. CBC and blood smear d. Blood lead level e. Environmental history
27. 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?
a. Child is currently on amoxicillin for an otitis media b. Positive family history of adverse reactions to DTaP vaccine c. A past history of infantile spasms d. Child is currently febrile to 39°C (102.2°F) *e. Prolonged seizures 6 days after the last DTaP vaccine*
19. A 2-year-old child (A) presents with a 4-day history of a rash limited to the feet and ankles. The papular rash is both pruritic and erythematous. The 3-month-old sibling of this patient (B) has similar lesions also involving the head and neck. The most appropriate treatment for this condition includes which of the following?
a. Coal-tar soap *b. Permethrin* c. Hydrocortisone cream d. Emollients e. Topical antifungal cream
26. A 5-year-old boy presents with the severe rash shown in the photographs. The rash is pruritic, and it is especially intense in the flexural areas. The mother reports that the symptoms began in infancy (when it also involved the face) and that her 6-month-old child has similar symptoms. Which of the following is the most appropriate treatment of this condition?
a. Coal-tar soaps and shampoo b. Topical antifungal cream c. Ultraviolet light therapy d. Moisturizers and topical steroids e. Topical antibiotics
20. An 8-hour-old infant develops increased respiratory distress, hypothermia, and hypotension. A complete blood count (CBC) demonstrates a white blood cell (WBC) count of 2500/μL with 80% bands. The chest radiograph is shown below. Which of the following is the most likely diagnosis?
a. Congenital syphilis b. Diaphragmatic hernia c. Group B streptococcal pneumonia d. Transient tachypnea of the newborn?? e. Chlamydial pneumonia
9. The adolescent shown presents with a 14-day history of multiple oval lesions over her back. The rash began with a single lesion over the lower abdomen (A); the other lesions developed over the next days (B). These lesions are slightly pruritic. Which of the following is the most likely diagnosis?
a. Contact dermatitis b. Pityriasis rosea c. Seborrheic dermatitis d. Lichen planus e. Psoriasis
37. 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?
a. Deferoxamine b. Pediatric intensive care unit (PICU) support and trial of naloxone c. N-acetylcysteine (Mucomyst) d. Atropine e. Dimercaptosuccinic acid (DMSA, succimer)
76. A 14-year-old male presents after taking a "happy pill" that his friend gave him. He is alert and oriented, but complains of a muscle spasm in his neck, making his head lean on his right shoulder. You also notice he is arching his back in an unusual manner.
a. Deferoxamine mesylate b. Diphenhydramine (Benadryl) c. Acetazolamide and sodium bicarbonate d. Ethanol e. Dimercaprol (BAL)
35. 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?
a. Tetanus toxoid b. Adult tetanus and diphtheria toxoid (Td) c. Diphtheria toxoid, whole cell pertussis, and tetanus toxoid (DPT) booster d. Tetanus toxoid and tetanus immune globulin e. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap)
31. 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?
a. Dextrose 5% in 1/4 normal saline (D5 1/4 NS) b. Dextrose 5% in 1/2 normal saline (D5 1/2 NS) c. Normal saline d. Whole blood e. Dextrose 10% in water (D10W)
5. A previously healthy 4-year-old child pictured below presents to the emergency room (ER) with a 2-day history of a brightly erythematous rash and temperature of 40°C (104°F). The exquisitely tender, generalized rash is worse in the flexural and perioral areas. The child is admitted and over the next day develops crusting and fissuring around the eyes, mouth, and nose. The desquamation of skin shown in the photograph occurs with gentle traction. Which of the following is the most likely diagnosis?
a. Epidermolysis bullosa b. Staphylococcal scalded skin syndrome c. Erythema multiforme d. Drug eruption e. Scarlet fever
34. 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?
a. Examination of joint fluid b. X-ray of the knee c. Erythrocyte sedimentation rate (ESR) d. CBC and differential e. Blood culture
29. A 2-year-old boy has been vomiting intermittently for 3 weeks and has been irritable, listless, and anorectic. His use of language has regressed to speaking single words. In your evaluation of this patient, which of the following is the most reasonable diagnosis to consider?
a. Expanding epidural hematoma b. Herpes simplex virus (HSV) encephalitis c. Tuberculous meningitis d. Food allergy e. Bacterial meningitis
16. 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?
a. Fasting plasma glucose of 135 mg/dL b. Random plasma glucose of 170 mg/dL c. Two-hour glucose during glucose tolerance test of 165 mg/dL d. Acanthosis nigricans on the neck e. Symptoms alone are enough to make the diagnosis
54. A 6-year-old returns from playing all day in the snow with several erythematous, ulcerative lesions on his fingertips; he complains the lesions are painful and itchy.
a. Frostnip b. Frostbite c. Chilblain d. Cold panniculitis e. Hypothermia f. Trench foot
93. A 6-month-old child has a loud systolic murmur at the left lower sternal border
a. Glomerulonephritis b. Severe anemia c. Heart block d. Ventricular septal defect (VSD) e. Arteriovenous malformation f. Coarctation of the aorta
23. You are seeing a 2-year-old child, brought by his father for a well-child examination. In providing age-appropriate anticipatory guidance, you should tell him which of the following?
a. He should set his water heater to 71°C (160°F) to ensure the sterility of dishes and clothes, thereby decreasing the risk of infections. b. Milk should be switched from whole to skim or low fat. c. Continue rear facing car seats. d. Purchase a bed alarm to assist with the child's nocturnal enuresis. e. Teach the child to swim so that the parents have the ability to allow the child to be alone in pools.
18. The mother of a 3-day-old infant brings her child to your office for an early follow-up visit. The mom notes that the child has been eating well, has had no temperature instability, and stools and urinates well. She notes that over the previous 3 days the child has had a progressive "rash" on the face as pictured here. Which of the following is the most likely diagnosis?
a. Herpes b. Neonatal acne? *c. Milia* d. Seborrheic dermatitis e. Eczema
6. A mother brings to your office an article from the Internet suggesting that infants in day care have a statistically higher incidence of upper respiratory infections (p < 0.05) as compared to children not in day care. You explain to her that this means which of the following?
a. Infants in day care are 5% more likely to have an upper respiratory tract infection than infants not in day care. b. A critical threshold for medical significance has been reached. c. Infants in day care will have an upper respiratory infection 5% of the time. d. The odds are less than 1 in 20 that the differences in upper respiratory infection rates observed were only a chance variation. e. The study suggests that day cares are not safe for children
36. 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 immunized 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. Copious irrigation d. Primary rabies vaccination for the child e. Destruction of the dog and examination of brain tissue for rabies
4. A 4-year-old girl is noticed by her grandmother to have a limp and a somewhat swollen left knee. The parents report that the patient occasionally complains of pain in that knee. An ophthalmologic examination reveals findings as depicted in the photograph. Which of the following conditions is most likely to be associated with these findings?
a. Juvenile rheumatoid arthritis b. Slipped capital femoral epiphysis c. Henoch-Schönlein purpura d. Legg-Calvé-Perthes disease e. Osgood-Schlatter disease
49. A 3-year-old boy awakens every night around 2:00 AM screaming incoherently. His parents note that he is agitated, seems awake but unresponsive, and goes back to sleep within a few minutes. He has no memory of the episodes in the morning.
a. Night terrors b. Nightmares c. Learned behavior d. Obstructive sleep apnea e. Somniloquy
32. During the examination of a 2-month-old infant, you note that the infant's umbilical cord is still firmly attached. This finding prompts you to suspect which of the following?
a. Occult omphalocele *b. Leukocyte adhesion deficiency* c. IgG subclass deficiency d. Umbilical granuloma e. Persistent urachus (urachal cyst)
14. A 2-year-old child presents to the office with a paternal complaint of "bowlegs." The girl has always had bowlegs; her previous pediatrician told the family she would grow out of it. Now, however, it seems to be worsening. Her weight is greater than 95% for age, and she has significant bowing out of her legs and internal tibial torsion; otherwise, her examination is normal. A radiograph of her lower leg is shown. Which of the following is the most likely diagnosis?
a. Osgood-Schlatter disease b. Physiologic genu varum c. Slipped capital femoral epiphysis d. Legg-Calvé-Perthes disease e. Blount disease
21. A 16-year-old arrives to your office soon after beginning basketball season. He states that he has had progressive pain in his knees. A physical examination reveals, in addition to tenderness, a swollen and prominent tibial tubercle. Radiographs of the area are unremarkable. Which of the following is the most likely diagnosis?
a. Osgood-Schlatter disease b. Popliteal cyst c. Slipped capital femoral epiphysis d. Legg-Calvé-Perthes disease e. Gonococcal arthritis
22. You are performing a well-child examination on the 1-year-old child shown in the picture. For this particular problem, which of the following is the most appropriate next step in management?
a. Patch the eye with the greater refractive error b. Patch the eye that deviates c. Defer patching or ophthalmologic examination until the child is older and better able to cooperate d. Reassure the mother that he will outgrow it *e. Refer immediately to ophthalmology*
39. 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?
a. Provide oral rehydration solutions b. Administer acetaminophen rectally c. Order to rest on the bench until symptoms resolve *d. Initiate whole body cold water immersion* e. Tell him to go take a shower and rest until the next day's practice
33. You are seeing an established patient, a 4-year-old girl brought in by her mother for vaginal itching and irritation. She is toilet trained and has not complained of frequency or urgency, nor has she noted any blood in her urine. Her mother noted she has been afebrile and has not complained of abdominal pain. Mom denies the risk of inappropriate contact; the girl also denies anyone "touching her there." Your physical examination of the perineum is significant for the lack of foul odor or discharge. You do note some erythema of the vulvar area but no evidence of trauma. Which of the following is the most appropriate course of action?
a. Refer to pediatric gynecology for removal under anesthesia of a suspected foreign body in the vagina. b. Counsel mother to stop giving the girl bubble baths, have the girl wear only cotton underwear, and improve hygiene. *c. Refer to social services for suspected physical or sexual abuse.* d. Swab for gonorrhea and plate on chocolate agar, and send urine for Chlamydia. e. Treat with an antifungal cream for suspected yeast infection.
7. A patient comes to your office for a hospital follow-up. You had sent him to the hospital 3 weeks earlier for persistent fevers but no other symptoms; he was diagnosed with endocarditis and is currently being treated appropriately. Advice to this family should now include which of the following?
a. Restrict the child from all strenuous activities. b. Give the child a no-salt-added diet. c. Provide the child with antibiotic prophylaxis for dental procedures. d. Test all family members in the home with repeated blood cultures. e. Avoid allowing the child to get upset or agitated
12. A 4-month-old baby boy arrives to the ER cold and stiff. The parents report that he had been healthy and that they put him to bed as usual for the night at the regular time. When they next saw him, in the morning, he was dead. Physical examination is uninformative. A film from a routine skeletal survey is shown below. Which of the following is the most likely diagnosis?
a. Scurvy b. Congenital syphilis c. Sudden infant death syndrome (SIDS) d. Osteogenesis imperfecta e. Abuse
43. 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.
a. Sebaceous nevus b. Salmon patch c. Neonatal acne d. Pustular melanosis e. Erythema toxicum f. Seborrheic dermatitis g. Milia
44. An adolescent boy complains of a splotchy red rash on the nape of his neck, discovered when he had his head shaved for football season. The rash seems to become more prominent with exercise or emotion. His mother notes that he has had the rash since infancy, but that it became invisible as hair grew. He had a similar rash on his eyelids that resolved in the newborn period.
a. Sebaceous nevus b. Salmon patch c. Neonatal acne d. Pustular melanosis e. Erythema toxicum f. Seborrheic dermatitis g. Milia
15. A very concerned mother brings a 2-year-old child to your office because of two episodes of a brief, shrill cry followed by a prolonged expiration and apnea. You have been following this child in your practice since birth and know the child to be a product of a normal pregnancy and delivery, to be growing and developing normally, and to have no chronic medical problems. The first episode occurred immediately after the mother refused to give the child some juice; the child became cyanotic, unconscious, and had generalized clonic jerks. A few moments later the child awakened and had no residual effects. The most recent episode (identical in nature) occurred at the grocery store when the child's father refused to purchase a toy for her. Your physical examination reveals a delightful child without unexpected physical examination findings. Which of the following is the most likely diagnosis?
a. Seizure disorder b. Drug ingestion c. Hyperactivity with attention deficit d. Pervasive development disorder e. Breath-holding spell
10. A chubby 6-month-old baby boy is brought to the clinic by his father. His father is concerned that his penis is too small (see photograph). The child is at the 95% for weight and the 50% for length; he has been developing normally and has had no medical problems. Which of the following is the most appropriate first step in management of this child?
a. Surgical consultation b. Evaluation of penile length after retracting the skin and fat lateral to the penile shaft c. Ultrasound for uterus and ovaries d. Weight loss e. Serum testosterone levels
42. A 5-month-old child with poor growth presents to the ER with generalized tonic-clonic seizure activity of about 30-minute duration that stops upon the administration of lorazepam. Which of the following historical bits of information gathered from the mother is most likely to lead to the correct diagnosis in this patient?
a. The child has had congestion without fever for the past 3 days b. The child is developmentally normal, as are his siblings c. The mother has been diluting the infant's formula to make it last longer d. The mother reports there are two dogs and one cat at home. e. The mother previously worked as an attorney in an energy-trading firm
28. A mother arrives to the clinic with her three children (ages 2 months, 18 months, and 36 months). The 18-month-old has an intensely pruritic scalp, especially in the occipital region, with 0.5-mm lesions noted at the base of hair shafts, as shown in the picture. Which of the following therapies should be avoided in this situation?
a. Treatment of all household contacts with 1% lindane (Kwell) b. Use of 1:1 vinegar-water rinse for hair for nit removal c. Washing of all clothing and bedding in very hot water d. Replacement of all commonly used brushes e. Advice to the mother that treatment will again be necessary in 7 to 10 days
63. A newborn infant is noted to have microcephaly with sloping forehead, cutis aplasia on the scalp, microphthalmia, and cleft lip and palate. His echocardiogram demonstrates a complex heart lesion including atrial septal defect (ASD), ventricular septal defect (VSD), and dextrocardia.
a. Trisomy 13 b. Cri du chat syndrome c. Angelman syndrome d. VATER e. Cornelia de Lange syndrome
41. 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?
a. Trisomy 21 b. Trisomy 18 c. Trisomy 13 d. Fragile X syndrome e. Williams syndrome