Clipp Case Questions

A 3-week-old infant is brought to the pediatrician for failure to thrive (despite adequate, even prolonged, feedings) and respiratory distress (particularly tachypnea). EKG shows high voltage QRS complexes in leads V1 and V2. What other features does this infant most likely have?

Left-to-right shunt Case 18

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 spiral fracture of the tibia Case 25

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?

Absence seizures Case 19

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?

Absent DTRs due to Botulism Case 9

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?

GERD Case 15

A 15-year-old female comes to the clinic with a chief complaint of feeling tired for one month. She has also been complaining of frequent nosebleeds while at school and bruising easily. When further history is elicited, you find out that menarche was at the age of 9 and her periods have always been heavy and irregular. Her mother and grandmother also have histories of heavy periods and easy bruising. You suspect a bleeding disorder and send off some labs including a CBC, INR, PT, PTT, and a von Willebrand panel to confirm your diagnosis. Your suspicion was correct for the most common type of bleeding disorder. How is this bleeding disorder most commonly inherited?

AD Case 5

George is a 7-year-old boy frequently in trouble at school for being disruptive and inappropriately talkative in class, not following directions set by his teacher, and not working well with classmates during group activities. His mother relates that at home George is always on the go, sleeping only 6 to 7 hours a night. He does not follow her rules all the time either, including not doing his homework, and sometimes putting himself in danger by doing things she tells him not to do, such as running away unaccompanied. Which of the following is the most likely diagnosis?

ADHD Case 4

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?

ALL Case 21

An 8-year-old obese male comes to the clinic with a chief complaint of right knee pain with the right foot medially rotated. On an exam the right knee is neither swollen nor erythematous but he is noted to have a limited ROM of the right hip. In addition, when he lifts his right leg, it externally rotates. The patient did not have a URI or any trauma preceding the onset of pain. The vital signs are normal at the time of the visit and he is well appearing and afebrile. What is/are the best next step(s) in management?

AP and lateral x-ray followed up by internal reduction of the femoral head Case 17

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?

ASD Case 18

Brian, a 5-year-old boy with swelling around both his eyes and an abdomen that looks "bigger than normal," is brought in by his mother to your preceptor's office. Mom explains that she noticed the puffy eyes and bigger belly starting the week before. It seemed to appear out of nowhere, and Brian has been completely healthy except he had a cold several days before these symptoms developed. When you ask Brian if he has noticed anything else weird, he says that his "pee-pee looks like Coca-cola," at which point his mom scowls and tells him to stop being silly. His blood pressure taken by the nurse right before entering the room is elevated. Based on the above information, which of the following does Brian likely have?

Acute glomerulonephritis Case 31

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?

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 Case 23

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?

Age-appropriate development Case 3

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?

Alcohol Case 1

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 diarrhea 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?

Alveolar consolidation in RLL Case 13

You are notified that a 10-day-old patient in your practice had a newborn hemoglobin screen positive for sickle cell disease. Pregnancy and delivery were uncomplicated. Mother is 19 years old and works as a nurses' assistant at a nursing home. When questioned, she says she remembers her grandmother died of chest pain and a lung infection. Which of the following should be ordered next for the baby?

Antibiotics Case 30

Devin is a 2-year-old African-American boy with sickle cell disease. Today his parents brought him to the ED because he was not feeling well. His mother reports that he has been very tired for the past week. Vitals show a temperature of 39°C, BP of 120/75 mmHg, RR of 24 bpm, and HR of 104 bpm. On physical examination he is ill appearing. His conjunctivae appear pale, and his sclerae are anicteric. Lungs are clear to auscultation. His abdominal exam is benign (non-tender, non-distended, with no organomegaly). His extremities are non-tender upon palpation. His nailbeds appear pale. Stat CBC reveals Hgb: 4.5 g/dL, Hct 15%, WBC 1800, and platelets 88,000. Mother is concerned as she has never seen him so ill before. What is the most likely cause of his new symptoms?

Aplastic anemia Case 30

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?

Appendicitis Case 16

Luanne is a 15-year-old female who presents 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, 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 pain like this 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. She is due to start her period next week. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mmHg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine 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?

Appendicitis Case 22

A 16-year-old homeless female presents with low-grade fever and abdominal pain. The patient reports recent unprotected sex. Abdominal examination reveals tenderness to palpation in the lower abdominal region, but no masses are appreciated. Pelvic examination reveals whitish cervical discharge and cervical motion tenderness. The discharge is sent for culture, and a pregnancy test is negative. What is the next best step in management?

Arrange for hospitalization Case 22

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?

Asymmetric breath sounds and wheezing Case 12

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?

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. Case 15

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?

BP and urinalysis Case 21

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?

Biliary Atresia Case 8

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?

Breast feeding jaundice Case 8

A 4-year-old male with a history of Down syndrome and no other medical problems is brought to his pediatrician's office by his mother for increasing fatigue, intermittent fever, and decreased appetite for one week. On exam you note conjunctival pallor and hepatosplenomegaly. What is the best next step in the management of this patient?

CBC + peripheral smear Case 29

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?

CF is caused by a mutation in CFTR, resulting in defective salt balance Case 26

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?

Cardiac Defects Case 1

Billy, a 7-year-old boy, presents to the clinic with complaints of headaches and episodes of feeling sweaty and flushed. He also reports that at times he feels as if his heart is racing. Billy was full term, had an uncomplicated birth, and has been otherwise healthy until now. On exam his BP is 120/80 mmHg and is the same in his upper and lower extremities. His weight and height are in the 50th percentile for his age. What is a likely cause of Billy's hypertension?

Catecholamine excess Case 4

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?

Cerebral Edema Case 16

An 18-month-old male comes to the clinic for a well-child check. His mother says he is a happy boy and endorses no complaints. She notes that he was born a few weeks early via emergency C-section and spent two months in the NICU. She says he is feeding well and gaining weight. When you ask about developmental milestones, you find out that that he pulls himself up to stand, but is not walking yet. He has several words and is interactive. There is no family history of disease during infancy. He is up to date on his immunizations. He is one of five children and his parents are currently experiencing difficult financial times. Exam reveals increased tone and hyperreflexia in his lower extremities. What is the most likely diagnosis of his developmental delay (if any)?

Cerebral Palsy Case 28

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?

Chest x-ray and tuberculin skin test Case 13

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 hemorrhages. What is the most likely diagnosis?

Closed head injury Case 25

Kenny is a 12 year-old male who comes to your clinic with a chief complaint of crampy abdominal pain. His mother tells you that sometimes he wakes up from sleep due to the pain. He also has diarrhea that sometimes has blood in it. When asked about stressors in his life, his mother sighs and tells you that she is recently divorced and had to move Kenny to a new school. On physical exam, he appears small for his age. Abdomen is soft, non-distended, but tender to palpation at the RUQ. On rectal exam, you note anal skin tags and an anal fistula. Skin exam shows red tender nodules on his shins. Labs show a microcytic anemia. What is the next best step in management?

Colonoscopy Case 27

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?

Congenital Hypothyroidism Case 9

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?

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 Case 9

An 8-year-old boy is brought to clinic by his parents because they are concerned that he has not been doing his homework. His teacher recently called the parents to say that their son seems distracted in class, constantly interrupts other children when they are speaking, and is very fidgety. When you speak with the boy, he tells you that he did not know about the homework assignments and that he tries hard to pay attention in class. What is the next best step in management?

Contact the teacher to find out more about his behavior. Find out more about the child's behavior at home Case 4

8-year-old Jenny presents complaining of intermittent, crampy abdominal pain that has persisted over the last three months. The pain is nonspecific, nonfocal, and not associated with any other systemic symptoms such as fever, chills, weight loss, nausea, vomiting or diarrhea. The pain also seems to occur more frequently during the week and not as often on weekends. The abdominal exam is normal. Jenny is given a diagnosis of functional abdominal pain and scheduled for a one-month follow-up. Six months later, she returns to the clinic complaining of more frequent, more severe abdominal pain that is waking her up at night. She also reports a week of diarrhea containing mucus and blood without associated fever or vomiting. Review of her growth chart demonstrates a slowing of weight gain and a drop in height velocity. What is the most likely diagnosis?

Crohn's Disease Case 27

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?

Croup Case 12

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?

DKA Case 16

A 10-year-old boy presents to his pediatrician with a history of hypopigmented non-pruritic "dots," mostly located on his face and neck. His mother complains that lesions get worse during the summer when her son plays outside. On exam, they are slightly scaly, hypopigmented lesions approximately 0.5 cm in diameter. What is the most likely etiology of his rash?

Decreased number of active melanocytes and decreased number and size of melanosomes Case 32

A 16-year-old female presents to clinic complaining of worsening fatigue. Family history is significant for hypothyroidism and heavy periods in the grandmother. Her exam reveals mild tachycardia and oozing around a recent piercing, but is otherwise normal. Labs reveal Hgb 8.5 g/dL, MCV 58, PT 12.5, PTT 44, and low von Willebrand factor activity. Which of the following is the most appropriate treatment for her underlying disorder?

Desmopressin Case 5

A 4-year-old patient with sickle cell disease presents for a well child evaluation. She has a history of three sickle cell vaso-occlusive crises in the past, including dactylitis and bone pain. She has been symptom-free for a few months and today she is feeling well. She is meeting her developmental milestones. She had an upper respiratory infection recently, but seems to be getting better now. She is up to date on her standard vaccinations up to 2 years including a full course (four doses) of Prevnar. What would you do for her today?

Dose of pneumococcal polysaccharide vaccine Case 30

When you are at your preceptor's office, you are told to see Amy, a 20-month-old female diagnosed with cerebral palsy (CP) at the last visit. Your preceptor knows that you just had your lecture on CP and tries to have you figure out which type of CP Amy has. She tells you that Amy was born at full term but had severe jaundice and required extensive treatment for hyperbilirubinemia, including an exchange transfusion. She now has slow and uncontrolled movements throughout her body. Her brain MRI shows some atrophy of the basal ganglia. What type of CP does Amy have?

Dyskinetic CP Case 28

John is a 17-year-old presenting today for a pre-participation physical exam. During the interview, he reports a low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a temperature of 101.3° F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His participation would be most likely affected by which of the following tests?

EBV serologies Case 6

A 16-year-old male presents to your office requesting clearance to play football. You begin by taking his medical history. He says that he feels very well, but admits that he recently experienced one episode of syncope that occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while playing basketball. Physical examination reveals no abnormalities. What is the next best step in management?

ECG and referral to cardiology Case 6

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 behavior, 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?

ED Immediately Case 23

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?

Echocardiogram to look for coronary artery aneurysm Case 11

You are called to the delivery of an infant boy experiencing fetal distress. After a vaginal delivery with vacuum assist, the infant cries spontaneously but remains acrocyanotic, despite supplemental oxygen delivered by mask. The neonate is hypotonic and moves his extremities only in response to noxious stimuli. Physical exam reveals an open mouth with a protruding tongue, upslanting palpebral fissures, low-set ears, and a transverse crease across both palms. You immediately recognize this syndrome, and your attending asks you what is the most common cardiac defect in these patients?

Endocardial cushion defects Case 29

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?

Enterovirus Case 11

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?

Erythematous and edematous feet Case 11

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 diarrhea, 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?

FTT due to inadequate caloric intake Case 26

A 15-month-old is able to stand on his own, walk backward, and throw objects underhand. He is unable to draw/scribble or grasp markers. He can say one syllable words "ma" and "da" but his words are unintelligible. He holds a sippy cup with help. He does come when called, plays with a ball and waves bye-bye by imitating his parents. Does this baby have developmental delay, and, if so, within which domains?

Fine motor and language delay Case 28

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?

Fingerstick glucose Case 16

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?

Foreign Body Aspiration Case 12

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?

Foreign body asipiration Case 12

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?

Fractionated bilirubin Case 8

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 screening. 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?

Fragile X syndrome Case 29

An 11-year-old male comes to the clinic with a chief complaint of abdominal pain for three months. The pain is not associated with eating. Sometimes he feels full and nauseated, along with the pain, but then it resolves on its own. He denies diarrhea, vomiting, and bloody stools. His mother is primarily concerned because his abdominal pains cause him to miss school quite often now. ROS is otherwise negative and the only pertinent issue is his pain. When you evaluate his growth curves, he is progressing at the 60th percentile for height and weight and you do not notice a change since birth. Through a social history you ascertain that he is quite intelligent and has recently been advanced to 7th grade from 5th grade. Vital signs are within normal limits for his age and physical exam (including rectal and genital) are unremarkable. Stool sample was sent in anticipation of today's visit and was negative for occult blood. What is the most likely cause for his abdominal pain?

Functional abdominal pain Case 27

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?

GBS sepsis / meningitis Case 23

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)?

Gastroesophageal reflux Case 25

A 16-year-old previously healthy male comes to the Pediatrics Urgent Care Clinic having "almost fainted" at soccer practice. He says that he had not eaten much earlier in the day and it was very hot and muggy outside. He felt light-headed and sick to his stomach. He denies losing consciousness and did not fall to the ground. He denies any chest pain. When you examine him, his eyes are sunken and he is tachycardic. What would be your next step in his management?

Give fluids and recheck his vital signs Case 6

A 2-year-old female is brought to the ED by her mother because of increasingly frequent abdominal pain. She has been experiencing this pain on and off for the past year, along with increasing abdominal distention, vomiting, and diarrhea. You chart her height and weight, and find that she is below the 5th percentile for both. IgA tissue transglutaminase (TTG) antibody returns positive. What is the best treatment for this patient?

Gluten Free Diet Case 27

A 3-year-old boy presents for a follow-up visit after being diagnosed with iron deficiency anemia. 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?

Gradually introduce new foods and slowly decrease his old favorites Case 3

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?

Greasy stool Case 26

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?

HSP = small vessel vasculitis Case 21

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?

Haemophilus influenzae Case 14

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 color and was still when she found him, but quickly regained his color. 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?

Head CT Case 25

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?

Heroin Case 1

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?

High TSH, Low T4 Case 9

A 3-year-old girl comes to the clinic with a limp and a slightly externally rotated right hip. Which of the following signs/symptoms would you expect in the history or exam if a diagnosis of transient synovitis were made?

History of a recent upper respiratory tract infection Case 17

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?

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?

Hyperammonemia and elevated urine orotic acid Case 9

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?

Hypoglycemia Case 7

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?

IV Ceftriaxone Case 10

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?

Inadequate caloric intake Case 26

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?

Infection with Bordetella pertussis in the paroxysmal stage Case 12

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?

Influenza, Hep B, IPV Case 2

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?

Intracranial hemorrhage Case 16

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 anemia with a hemoglobin of 10.0 g/dL. You note that her hemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anemia?

Iron deficiency Case 3

A 3-year-old female is at the pediatrician's office for continued right knee pain after a ground-level fall six weeks ago. The patient is UTD on all immunizations, has no significant PMH, and no recent illnesses. Mom reports the patient complains of pain mostly in the morning when going to daycare but doesn't seem to be bothered by it while playing outside in the afternoon. On exam the patient's vitals are all within normal limits. Her physical exam reveals a well-appearing toddler who walks stiffly and avoids bending her right knee. The knee has a mild effusion but no obvious erythema. There is pain with passive flexion and extension of the right knee. During the exam the girl tells you her left ankle also hurts, which mom had forgotten about but says started hurting the same time as the right knee. Her CBC is normal, while her ESR and CRP are mildly elevated. Which of the following is the most likely cause of this patient's condition?

JIA Case 17

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?

Kawasaki Disease Case 11

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?

LP Case 23

A 6-year-old female comes to the clinic with a chief complaint of worsening right knee pain over the past month. On exam, you note generalized lymphadenopathy and splenomegaly. She coughs intermittently throughout the visit, and her mother explains that she is just getting over a cold. You note absence of tenderness, erythema, effusion or warmth over the hip, knee, or ankle joints. Her vitals are unremarkable except for a low-grade fever (100.8 F). Reviewing her chart, you note that she has lost 5 lbs since her visit 2 months ago. She sits with her right leg externally rotated but appears to be in pain despite trying several different positions, refusing to bear weight on that side. What is the most likely diagnosis?

Leukemia Case 17

An 8-year-old boy presents with tea-colored urine, oliguria, joint pain, hypertension, and generalized edema. One month ago, he presented with fever and sore throat, headache, abdominal pain, strawberry tongue, papular sandpaper rash. At that time, he did not have runny nose, congestion or cough. He was treated with appropriate antibiotics for his symptoms and made a full recovery. Which of the following diagnostic findings supports his new symptoms?

Low C3 complement Case 31

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?

Low dose inhaled corticosteroids Case 13

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?

MRI Case 20

A 6-year-old male comes to the clinic with a chief complaint of scrotal swelling, recent weight gain, and decreased appetite. Vital signs are stable and there is no evidence of cardiac disease or jaundice. Further workup reveals proteinuria, hypoalbuminemia, and hyperlipidemia, consistent with nephrotic syndrome. Which of the following histological patterns is most likely to be seen on light microscopy?

Normal glomeruli with minimal increase in mesangial cells and matrix Case 31

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?

Maxillary Sinusitis Case 14

Jane is an 8-year-old girl who presents to your clinic for follow-up after being hospitalized for status asthmaticus. She has just completed a 10-day course of systemic steroids. Given her history of moderate persistent asthma, her outpatient regimen includes Advair, a combined steroid and bronchodilator. She was also diagnosed with ADHD one year ago and was started on Concerta, 18 gm PO once a day. Her BMI today is at the 83rd percentile for her age, and her blood pressure is at the 98th percentile for her age. What is the most likely cause of her stage I hypertension?

Medication Case 4

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?

Meningitis Case 19

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?

N-myc amplification is bad Case 2

Katie is a 5-year-old girl with 10-day history of swelling of her face, especially around the eyes. Her mother has also noticed that her pants have become too tight for her, and that she has gained nearly 5 pounds despite a decreased appetite. About a week prior to the start of the swelling, her mother recollects an episode of rhinorrhea, cough, and sore throat. Urinalysis shows no red blood cells or casts, but you have no other data from urinalysis due to a lab error. On exam, temperature is 98.8 F, heart rate is 95 bpm, blood pressure is 95/65 mmHg. Her face is diffusely swollen. Heart and lung exams are normal. Abdominal exam shows some abdominal fullness but no masses or organomegaly. Both feet appear slightly puffy. Which of the following is the most likely cause?

Nephrotic syndrome Case 31

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?

No immediate intervention is necessary Case 15

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?

Observation / symptomatic treatment (NSAIDs for joint pain, etc) Case 21

A 2-year-old female with normal birth and developmental history presents with increased agitation and decreased arousability. Her father suffers from chronic pain secondary to a back injury, and her mother found an open container of pills on the bed. Vitals reflect bradycardia, bradypnea, hypotension, and slight hypothermia. On physical exam, she exhibits somnolence, constricted pupils, hypoactive bowel sounds, and hyporeflexia. What substance was most likely ingested?

Opioids Case 24

A 3-year-old male presents to clinic with an annular, well-circumscribed, scaly plaque with a raised erythematous border and central hypopigmentation on the left thigh. The mother reports that the lesion is highly pruritic and that the patient has been exposed to other children with a similar rash at day care. Upon further examination, a similar lesion with boggy borders is also found on the posterior aspect of his scalp. Which of the following is the most appropriate treatment for this child's problem?

Oral griseifulvin Case 32

A 2-year-old male is brought into the ED by his mother because of vomiting and altered mental status. He has pinpoint pupils and seems to be drooling and sweating uncontrollably. His heart rate is 60 bpm, his respiratory rate is 45 bpm, and he seems to have difficulty breathing. Which ingestion is the most likely cause of his symptoms?

Organophosphate Case 24

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?

Otitis media with effusion Case 14

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?

PKU Case 8

A 16-year-old female presents with acute onset of diffuse abdominal pain with periodic sharpness in the right upper quadrant that radiates to her back. She has had some episodes of vomiting and has a fever. She is sexually active and has used alcohol in the past. Which of the following is most likely to present with right upper quadrant pain?

Pancreatitis Case 22

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?

Phenylalanine hydroxylase Case 1

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 120/70 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?

Place IV and start NS bolus Case 23

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?

Post infectious cerebellitis Case 20

A 16-year old female presents to the ED with abdominal pain. Upon questioning, the patient notes that the pain is pretty consistently in the RLQ without radiation. She denies dysuria, hematuria, or blood in the stool. She has a history of multiple sexual partners and inconsistent condom use. She does not use any other contraceptive measures. She believes her last menstrual period was 3 weeks ago, but she is unsure. She has no history of abdominal or pelvic surgeries. Her temperature is 100.8 F, heart rate is 85 bpm, respiratory rate is 12 bpm, and blood pressure is 110/70 mmHg. Her abdominal exam is notable for involuntary guarding, tenderness to palpation in the RLQ without rebound tenderness, and no CVA tenderness. Her pelvic exam is notable for cervical motion tenderness with some discharge. What is the best NEXT step in management?

Pregnancy Test Case 22

An 8-year-old healthy obese African American male with no past medical history is found to have a blood pressure of 125/90 mmHg on all four extremities on routine evaluation during an office visit for well-child care. Review of symptoms is negative. A physical exam and screening bloodwork are performed. Both are normal, with the exception of his blood pressure and obesity. What is the most likely diagnosis?

Primary HTN Case 4

A 17-year-old boy presents for a sports pre-participation physical. He reports that he occasionally gets short of breath and feels light-headed with exercise, and sometimes he experiences chest pain as well. He lost consciousness once last season during a playoff basketball game, but attributed it to feeling sick at the time. His grandfather died suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis?

Prolonged QT syndrome Case 6

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?

Pyloric Stenosis Case 15

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?

RA > foramen ovale > LA > LV > systemic circulation Case 18

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?

Rapid strep test with back-up culture if negative Case 11

A 4-year-old child is refusing to walk over the course of a week. Her mother recalls that she fell off her bike yesterday. On exam, she is afebrile, but has decreased ROM of her hip. You review her file and note that she is up-to-date on her immunizations and she was last seen three weeks ago for a self-limited episode of diarrhea that she developed while visiting family in rural Mexico. Aspiration of her affected hip joint reveals slight increase in inflammatory cells but normal chemistries and a negative gram stain. Culture is pending. Which of the following is the most likely diagnosis?

Reactive arthritis Case 17

Claire is a 16-year-old female who presents for birth control management. Her review of symptoms is unremarkable except for chest pain. When you ask her more questions, she reveals the pains are intermittent, on and off for the past couple months. It is not associated with exertion, sharp, and well localized at the left sternal border. It is very brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in. She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and physical exam are normal. Which is the next best step in management?

Reassurance Case 6

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?

Reassure the parents that the boy's development appears normal Case 2

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?

Renal Bladder U/S Case 10

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 tachypneic. 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?

Respiratory Distress Syndrome Case 7

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?

Respiratory Distress syndrome Case 7

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?

Rhinovirus Case 14

A 5-year-old African-American male with sickle cell disease presents to clinic with a chief complaint of severe chest pain for the past day. His mother notes that he has been breathing quickly and that she measured his temperature this morning to be 100.5 F. Patient describes pain as an 8/10 on the faces scale. Patient is tachypneic on exam and has an oxygen saturation of 97% on room air. Chest exam reveals normal lung sounds bilaterally, and he has some reproducible tenderness over his chest wall. A chest x-ray is performed and demonstrates clear lung fields and a cardiac silhouette that is within normal limits. What is the most likely cause of the chest pain?

Rib infarction Case 30

A 16-year-old obese Caucasian female with a history of irregular menses presents to the ED with severe abdominal pain and altered mental status. She uses intravenous drugs weekly. She has regular unprotected sexual intercourse with multiple male sexual partners. She has experienced fevers, nausea, vomiting, and right shoulder pain and reports no vaginal bleeding. She has not regularly seen a physician for years. Only bedside studies are performed. Vitals are T 38.0 C, BP 90/60 mmHg, P 120 bpm, R 20 bpm. Qualitative B-hCG is positive, and hemoglobin is 7 g/dL. On exam, she is in apparent distress and has difficulty answering questions. Auscultation of the chest is clear. The abdomen is somewhat rigid with tenderness in the right lower quadrant as well as guarding and rebound tenderness. On pelvic exam, there is cervical motion tenderness but no bleeding or masses noted. What is the most likely diagnosis?

Ruptured ectopic pregnancy Case 22

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?

Send samples for culture and begin parenteral antiobiotic treatment Case 10

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?

Sepsis secondary to prolonged rupture of membranes Case 7

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?

Shigella Case 19

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?

Short-acting beta agonist PRN with low-dose inhaled corticosteroid Case 13

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?

Simple Febrile Seizure Case 19

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?

Skeletal survey Case 25

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?

Small round blue cells with dense nuclei forming small rosettes

Johnny is brought to your office by his parents for his 18-month well child check. His family recently moved into town, and this is the first time you are seeing him. Per mom, he was born at 32 weeks, and the details of his neonatal course are not clear. Parents share that he is not walking and they are very concerned. Johnny has met his social and language developmental milestones. Physical exam reveals spasticity, exaggerated deep tendon reflexes, and clonus in both of his lower extremities. An MRI of the brain is ordered, and the radiologist reports findings of periventricular leukomalacia. What is the most likely diagnosis?

Spastic diplegia Case 28

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?

Sweat chloride test Case 26

A 2-year-old male presents to the ED with a 5-hour history of hyperactivity, fever, and sweating. His BP is 160/90 mmHg, HR 130 bpm, RR 30 bpm. On exam, he has dilated pupils, cool skin, and hyperreflexia. What is his most likely accidental medication ingestion?

Sympathomimetic Case 24

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?

TSH Case 9

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?

TTN Case 7

A 14-year-old girl presents to your office wondering why she has not had her period yet. Her mother states that she and the patient's grandmother reached menarche at 13 years of age. The patient is concerned she is behind her friends in terms of development. She is doing well in school and has not had developmental problems in the past. On physical examination, her breasts are elevated without a secondary mound, and curly, coarse pubic hair is present on the labia majora in a triangular shape but does not reach the mons pubis. What Tanner stage would you assign this patient?

Tanner Stage III Case 5

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?

Tension Headache Case 20

Frank is 16-year-old male brought in by his mother who complains that her son "looks much younger than his age." She states that until about four years ago, she did not notice much difference between Frank and his friends. However, in the past two years, Frank has become the shortest person in his class. Frank's mother is concerned that he has a "hormone problem" and wants to know how she can tell if he has begun puberty. What is usually the first sign of puberty in a male?

Testicular enlargement Case 5

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 anemic. Which of the following is most correct?

The most likely cause of anemia in the question is picky eating resulting in low iron intake, which would cause microcytic anemia. Case 3

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?

Urinary catheterization Case 10

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?

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. Case 15

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?

This is HSP. Would not see low platelets - this would be ITP Case 21

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?

This patient's murmur is caused by flow through the pulmonary outflow tract and should be evaluated (ASD) Case 18

A 3-year-old child is found to have a dry, pruritic rash on his face. Physical exam is notable for confluent areas of erythema and scaling. There are mild excoriations surrounding some areas and mild lichenification of the extensor surfaces of both elbows. What is the next best step in management of this child's problem?

Topical steroids and emollients Case 32

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?

Trial of prophylactic meds for migraines Case 20

You are working in the pediatric ED when a 3-year-old girl, Jenny, presents with altered mental status for the past six hours. Her mother reports that the babysitter called her at work today after Jenny started acting agitated and "looking very sick." The mother reports "she feels so warm, I think she has a fever and has become dehydrated." On exam, the patient is agitated and anxious with dilated pupils. Her skin is warm and dry. Vitals reveal tachycardia and hypotension. You suspect the child may have accidentally ingested one of her mother's medications. An overdose of which of the following medications could cause Jenny's symptoms?

Tricyclic Antidepressant Case 24

A 4-day-old male infant was born by vaginal delivery to a 35-year-old G1P1 who declined prenatal screening. The infant has mild hypotonia, epicanthal folds, upslanting palpebral fissures and a flat face. On physical exam, he is in no acute distress, has normal oxygen saturation and has a continuous murmur. Lymphocyte karyotyping showed a particular change in chromosome number. What genetic abnormality is most likely?

Trisomy 21 Case 29

You are on the nursery service when your team is called to evaluate a 1-day-old infant. The infant was born via NSVD at 40 weeks' gestation to a 38-year-old G1P1A0 mother who did not have access to prenatal care and did not receive prenatal testing. The infant weighed 7 lbs 12 oz at birth and had Apgar scores of 7 and 8. On exam the infant is sleeping comfortably. She is afebrile with normal vital signs but appears to have low tone on exam. You also notice her ears seem to be lower than her eyes and appreciate mild edema of the hands and feet. Additionally, you note a fluid-filled sac at the base of the neck that does not appear to interfere with breathing. A karyotype performed after birth reveals a chromosomal abnormality. Which of the following is the most likely cause of this patient's condition?

Turner syndrome Case 29

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?

UTI Case 10

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?

Urinalysis Case 31

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?

Wilm's Tumor Case 2

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 rhinorrhea. 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 rhinorrhea and erythematous mucous membranes, the remainder of his physical exam is unremarkable. What is the next best step in management?

Workup for source of fever Case 19

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?

Worse at night (persistent asthma) Case 13

A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in what order she should expect to see normal developmental changes in her daughter. Which of the following sequences is correct?

breast bud -> pubic hair -> growth spurt -> menarche Case 5