Med Bullets Peds

A 1-day-old ex-39-week newborn female is experiencing bilious vomiting. Her Apgar scores were 8 and 10, at 1 and 5 minutes respectively, following birth. She otherwise appears well. There is no significant abdominal distension. An abdominal radiograph is presented in Image A. A nasogastric tube is placed. Which of the following is the most appropriate next course of action?

A new born infant with bilious vomiting and the classic "double-bubble" sign on abdominal radiograph is suffering from duodenal obstruction and needs immediate surgical evaluation.

Tay-Sachs disease

A normal spleen and accumulation of GM2 ganglioside are seen in Tay-Sachs disease, a deficiency of hexosaminidase A.

A two-year-old boy, born at term, is at the pediatrician's office for a well-child visit. He can jump but cannot ride a tricycle; he can build a tower of 6 cubes but cannot copy a circle; he can follow a two-step command but does not play cooperatively. He has approximately a 50 word vocabulary. He can remove his clothes but cannot brush his teeth. What is the correct conclusion from this child's developmental milestones?

A two-year-old should a several hundred word vocabulary, and in this case, this boy most likely is delayed in language development. According to standard developmental milestones, a stranger should understand 50% of the child's speech, and the child using 2-3 word sentences.

A 19-month-old boy with no past medical history presents to his pediatrician with a fever and a rash. His mother states that he has had several days of cough, runny nose, red eyes, and fatigue. She thought that he felt feverish but didn't have a thermometer. She became concerned last night when a reddish, blotchy rash appeared on his face and he felt very hot. He goes to a day care run by his church, has no sick contacts at home, and has not received any vaccinations due to religious objections. On exam, he has a temperature of 104 F, erythematous conjunctivae, and a rash as seen in Figure A. Which of the following could shorten the duration of this patients illness?

A young, unvaccinated child with cough, coryza, and conjunctivitis (the three Cs), high fever, and an erythematous maculopapular rash that originated on the head and spread down the body most likely has measles. Vitamin A has has been shown to reduce mortality in children less than 2 years of age with measles.

An ex-30-week very low birth weight female infant is now 5 days old and receiving routine care in the neonatal ICU. She was delivered prematurely because of intrauterine growth restriction. Her vital signs are within normal limits. She is on nasal CPAP (FiO2 21%) and is tolerating her feed advance. Her physical exam is unremarkable. Which test should she have in the next couple of days?

All premature infants are at risk of intraventricular hemorrhage (IVH). As the condition is often asymptomatic, screening for IVH via cranial (transfontanel) ultrasound should occur by day 7 of life. IVH is most commonly found in premature (< 34 weeks) infants and in low birth weight infants

A 4-week-old female infant presents with an episode of bright red blood coming from her rectum. The episode took place about an hour ago; the mother is a pediatric nurse and seems gravely concerned about intussusception. On physical examination, the infant appears healthy and happy. The blood pressure is 90/60 mm Hg, pulse is 100/minute, respirations are 20/minute, and temperature is 98° Fahrenheit (37° Celsius). Heart and breath sounds are normal. The abdominal examination is soft and non-tender; the guaiac test is positive. There is no bruising evident on the infant.

Anal inspection and dietary history are likely to be the most critical factors in making an appropriate diagnosis Explanation Anorectal fissures and allergic colitis are the 2 most common causes of hematochezia presenting at this age; therefore, anal inspection and dietary history are the most critical factors in making an appropriate diagnosis in this case.

Fabry's disease

Angiokeratomas are seen in Fabry's disease, an X-linked recessive deficiency of alpha-galactosidase A (also known as ceramide trihexosidase). (Note: Do not confuse Fabry's disease with Farber's disease (a deficiency of ceramidase) that presents at age 1 with granulomatous nodules on joints and vocal cords.)

Annular pancreas

Annular pancreas presents with bilious vomiting and abdominal distension.

Antiendomysial antibody testing

Antiendomysial antibody testing is the most reliable test for celiac disease, although results are technician-dependent. The gold standard for diagnosis remains a small intestinal biopsy; it reveals blunting of the small intestinal villi while consuming gluten-containing foods, as well as the response to a gluten-free diet.

Apert syndrome

Apert syndrome occurs due to a mutation in the FGF receptor with the resulting characteristic facial appearance of mid facial hypoplasia and craniosynostosis.

lipid screening in childhood

At present, the recommendation is for universal lipid screening between ages 9 and 11 years and again between ages 17 and 21 years. Targeted screening is also recommended beginning at age 2 years for children with certain risk factors.

Duodenal atresia

Duodenal atresia presents with bilious vomiting and is associated with Down syndrome.

A 10-year-old boy with severe cerebral palsy and moderate kyphosis lives in a long-term facility; he has been experiencing more problems with reflux since a viral upper respiratory infection a few months ago. He was tolerating ad lib oral feedings, but now refluxes with most feedings (coughing and gagging). The staff is concerned about his nutritional status. Question What evaluation would be the most useful to access this patient's overall nutritional status?

Correct answer: Monitoring skinfold thickness and arm circumference Explanation The correct response is monitoring skinfold thickness and arm circumference. Children with cerebral palsy and other neurologic disorders are likely to have feeding dysfunction causing inefficient feeding through spillage, as well as aspiration.

A 4-day-old infant is seen for a routine newborn check; he has yellow skin from his face down to his chest. He is a full-term baby, had a normal vaginal delivery, weighed 3.180 kg at birth, and was 3.100 kg at discharge. He is breastfeeding well and stooling and voiding regularly. He is well-hydrated and active. Laboratory results reveal an indirect bilirubin of 12.2 mg/dL and a direct bilirubin of 1.0 mg/dL. Question What is the physiologic mechanism behind this jaundice?

Correct answer: An elevation of indirect bilirubin due to increased bilirubin production Explanation The correct response is an elevation of indirect bilirubin due to increased bilirubin production. Unconjugated indirect bilirubin enters the liver and is excreted from the hepatic cells in a water-soluble form (conjugated and direct) into the biliary system. The direct bilirubin leaves the body in the form of stool. The most common cause of indirect hyperbilirubinemia is physiologic jaundice, which peaks at 2-4 days of life.

previously well 17-year-old Caucasian boy presents to the emergency department with a 3-week history of epistaxis from both nares, which has been occurring approximately every other day. There is no history of melena, hematemesis, hemoptysis, or hematuria. He has noted what he considers to be a normal amount of bruising after lacrosse competitions. He has been feeling more tired than usual, but attributes this to a heavy practice and school examination schedule. There has been no fever or trauma to the nose. On examination, vital signs are normal. Scattered petechiae are noted on the arms and legs. Dried blood is present in the nasal vestibule bilaterally. A spleen tip is palpable.

Correct answer: CBC and coagulation studies Explanation The presence of epistaxis, petechiae, and a palpable spleen should suggest a coagulopathy, for which CBC and coagulation studies would be the best first steps to assess the cellular and noncellular components of the clotting system. While allergic rhinitis is a common cause of epistaxis, the presence of petechiae suggests a systemic problem.

A 4-year-old girl is evaluated in the emergency department after her mother discovered that she had swallowed approximately 15 of her grandfather's 25 mg amitriptyline tablets 8 hours ago. There is no reason to suspect any co-ingestions. Prior history is normal. Weight is 19.5 kg. Temperature is 101.9°F; pulse is 140, and she has a blood pressure of 82/52. The patient is drowsy, but she can be aroused verbally. Her oral mucosa is dry. Her pupils are dilated and sluggishly reactive. EKG shows only sinus tachycardia. Question What mechanism best accounts for her mydriasis, xerostomia, and depressed level of consciousness?

Correct answer: Anticholinergic effect Explanation The correct response is an anticholinergic effect Toxicity is due to CA's anticholinergic effects, alpha-adrenergic blockade, norepinephrine and serotonin reuptake inhibition, and blockage of myocardial fast sodium channels with membrane stabilization. Major toxicity includes CNS depression (anticholinergic effect), mydriasis (anticholinergic effect), seizures (norepinephrine and serotonin reuptake inhibition), hypotension (alpha-adrenergic blockade), tachycardia (anticholinergic effect) and cardiac conduction defects (fast sodium channel blockade).

A 4 ½-year-old boy presented for follow-up of a respiratory illness that began 3 days ago with rhinorrhea and non-productive cough. Since then, he has had occasional labored breathing. He has been slightly less active than usual but has been eating and drinking well. His mother thought he felt warm but did not take his temperature. Past history was unremarkable. Vital signs were normal, with temperature 100.2°F and respiratory rate 16 and unlabored. Oxygen saturation was 97% on room air. The lungs were clear except for scattered expiratory wheezes. Question What outcome is most likely?

Correct answer: He will recover uneventfully within several days. Explanation The patient will likely recover uneventfully within several days. The clinical decision as to whether a child has pneumonia can be perplexing, especially in a non-toxic appearing child, since there is no set of pathognomonic signs and symptoms. However, the most useful predictive factors are fever, tachypnea, and desaturation. The absence of all 3 makes pneumonia unlikely, while the presence of 2 out of 3 makes pneumonia probable.

A 5-year-old boy presents with a 2-week history of pruritic, cutaneous lesions on his face and arms. He has a history of similar episodes in the past, especially in the winter months; they resolved spontaneously. He has no other significant medical or surgical history; family history is positive for asthma in his mother. On examination, pruritic lesions are seen on his cheeks and anterior cubital fossa. Question What immunoglobulin level is characteristically high in this patient?

Correct answer: IgE Explanation The correct response is serum IgE. The patient is suffering from atopic dermatitis. He has a typical history of atopic dermatitis (i.e., pruritic, cutaneous lesions and a positive family history of asthma). Serum IgE levels are high in atopic dermatitis.

A 1-week-old female infant was born to a 16-year-old single mother; the infant presents with a 2-day history of bilateral conjunctival edema, hyperemia, and watery to mucopurulent discharge. Otherwise, she has been eating fairly well; there has been no fever, vomiting, diarrhea, or any respiratory symptoms. Her mother had sporadic prenatal care, and the infant was born by normal spontaneous vaginal delivery. She received routine topical prophylaxis with erythromycin. Her vital signs and exam appear normal, with the exception of both eyes (as previously described). Question What is the most likely diagnosis?

Correct answer: Neonatal chlamydial conjunctivitis Explanation The correct response is neonatal chlamydial conjunctivitis. The most frequently identified cause of infectious neonatal conjunctivitis is due to Chlamydia trachomatis, which is transmitted perinatally from infected mothers (especially adolescents).

A 12-year-old boy presents for reevaluation of a 2-month history of mild to moderate intermittent left knee pain and mild left hip pain. Symptoms have increased in intensity and frequency over the past 2 weeks, along with new onset of left hip stiffness and limping. There is no history of trauma or systemic symptoms. Vital signs were normal, but BMI was 32 kg/m2. Gait was antalgic with the left foot externally rotated. There was pain on passive range of motion of the left hip but not the left knee. Internal rotation of the left hip was limited. External rotation of the left hip with the knee flexed produced external rotation of the left lower leg.

Correct answer: Obtain radiographs of the left hip and knee Explanation You should obtain radiographs of the left hip and knee. The presentation is highly suggestive of a left slipped capital femoral epiphysis (SCFE), which usually appears in overweight teenage boys. It presents with hip and/or knee pain, hip stiffness, altered gait, and decreased range of motion. Radiography will show that the epiphysis of the femoral head is displaced posteriorly and inferiorly in relation to the neck of the femur, with an increase in the angle of the femoral head to the shaft. At this age, it is common for hip pathology to present with referred pain to the knee. A complaint of knee pain at this age warrants a thorough evaluation of the ipsilateral hip.

A 6-year-old girl presents with a 2-day history of a small, tender, superficial abscess on her left upper eyelid at the lid margin. She denies discharge, fever, or trauma. There is mild pain on palpation, and she has a normal ophthalmic exam. What treatment should be given?

Correct answer: Warm compresses Explanation This description is of a hordeolum, which is also called a stye. The usual causative agent is Staphylococcus aureus. Treatment involves warm compresses and frequently a topical ophthalmic antibiotic. Occasionally, surgical incision and drainage are required. There is no need for a systemic antibiotic for a minor infection, and the causative agent does not appear to be allergic or viral. A stye can be confused with a chalazion, which is a granulomatous inflammation of a meibomian gland characterized by a nontender nodule. The lesion tends to be chronic, and it shows no sign of acute inflammation.

A 2-year-old girl with no past medical history presents to her pediatrician for an annual well child check. She is doing well and her parents have no concerns. On physical exam, the pediatrician notes a physical exam finding that leads him to recommend an echocardiogram, which reveals a small ventricular septal defect. When questioned by the child's parent about further management, the physician recommends watchful waiting. Which of the following is the most likely exam finding detected by the child's physician?

For a patient with a small ventricular septal defect (VSD), a common exam finding is a pansystolic, harsh, vibratory murmur loudest at the LLSB. Incorrect Answers Answer 1: Widened pulse pressure is characteristic of conditions that cause shunting directly from the aorta (e.g. PDA, Aortic regurgitation). Answer 3: A crescendo-decrescendo murmur which radiates to the neck and axilla is characteristic of aortic stenosis. Answer 4: A high-pitched blowing murmur which radiates to the axilla is characteristic of mitral regurgitation. Answer5: A continuous machine-like murmur heard throughout the precordium is characteristic of a patent ductus arteriosus.

An 8-year-old male presents to a geneticist for further workup of a series of developmental delays, learning disabilities, and dysmorphic features. His past medical history is significant for delays in motor development, including sitting without support at 10 months and walking at 20 months. Academically, he is currently struggling with math in school. On exam, he displays a long, thin, face, a large jaw, and protruding ears. Given this patient's likely diagnosis, what physical finding is he likely to demonstrate following puberty?

Given the patient's characteristic physical features of a long face, protruding ears, male sex, and learning disability, he likely has Fragile X syndrome. Following puberty, these individuals characteristically have macroorchidism.

A 7-year-old boy presents to an urgent care center for a rash that began approximately 2 days ago. According to his mother, it began as a pink rash on his face and has subsequently spread to his trunk. Approximately 5 days before the rash appeared, he developed a fever of 38.2°C and rhinitis. On exam, the patient has numerous pink macules scattered on his face and trunk. Lastly, he has noticeable posterior cervical lymphadenopathy. What is the most likely diagnosis? Topic Review Topic QID: 4246 1. Scarlet fever 2. Measles 3. Rubella 4. Contact dermatitis 5. Parvovirus B19 infection

Given the prodromal symptoms of fever and cold like symptoms, as well as the characteristic erythematous rash, this patient most likely has rubella. Rubella is caused by the rubella virus, a togavirus that is transmitted via respiratory droplets following a incubation period of 14 to 21 days. Prior to the appearance of the rash, patients typically experience the prodrome of malaise, mild conjunctivitis, low grade fever, adenopathy and cold symptoms. The rash begins on the face as pink macules. After one day the rash typically spreads to the trunk and extremities

A 32-year-old woman brings her 5-year-old son to the pediatrician for evaluation of developmental delay. She states that he has difficulty climbing the stairs, but walks without assistance. He feeds himself with his hands and uses a "sippy-cup", but will not use utensils. He speaks in two-word sentences and names objects. Chart review reveals an uncomplicated birth history and achievement of developmental milestones up to the age of 6 months. On exam, he is a fair-skinned boy and underweight for his tall height, but in no acute distress. Ophthalmic exam is performed and shown in figure A. Which of the following interventions is most likely to improve long-term survival in this patient?

In a fair-skinned child with a Marfanoid habitus and mental retardation or developmental delay, suspect homocystinuria. If the disease is due to a decreased affinity of cystathionine beta synthase for vitamin B6, high-dose vitamin B6 can improve long-term survival.

A 37-year-old-woman delivers a male infant with Down syndrome at 38 weeks. His Apgar scores at one and five minutes are both 8, with scores of 1 for acrocyanosis and irregular breathing. He passes meconium several hours later. Between 24 and 48 hours after birth, the infant has multiple episodes of vomiting despite lack of feedings and does not have additional bowel movements. Vomitus is bilious and nonbloody. On physical exam, the infant is crying, he appears jaundiced, and his abdomen is distended. An abdominal radiograph is performed, which is shown in Figure A. Which is the first step in management of this patient?

The clinical presentation and radiograph are consistent with duodenal atresia. Nasogastric or orogastric tube placement is the first step in management prior to surgical intervention. Duodenal atresia is the congenital failure of the duodenal lumen to recanalize during fetal development. The condition is often seen in infants with Down syndrome and is associated with a number of congenital anomalies including biliary atresia, as well as cardiac and renal malformations.

You are working in the newborn nursery when a nurse approaches you with a concern about one of her patients. The patient is a 1-day-old full-term child who has not been feeding or sleeping well and has diarrhea. When you examine the child, you note an irritable sweaty baby with a high pitched cry, sneezing, and mottled skin. During your examination, he has a seizure. Which of the following would you expect to find documented in the patient's chart? Topic Review Topic QID: 5458 1. Maternal smoking during pregnancy 2. In utero exposure to amphetamines 3. In utero exposure to marijuana 4. In utero exposure to cocaine 5. In utero exposure to heroin

In utero exposure to heroin This newborn has signs of neonatal abstinence syndrome (NAS), which is a constellation of symptoms of withdrawal in children exposed to certain drugs during pregnancy. Opioid withdrawal is the most commonly implicated cause of NAS and can result in seizures. Neonatal abstinence syndrome (NAS) refers to acute symptoms of withdrawal in a neonate after the reduction of intra-partum (or post-partum) drug exposure. Commonly implicated drugs include: opioids (prescription or illicit), cocaine, methamphetamine, barbituates, and benzodiazepines. Symptoms typically start within the first few days of life and typically include symptoms of hyperarousal (e.g. tremors, increased wakefulness etc), gastrointestinal symptoms (vomiting, diarrhea, poor feeding, poor weight gain) and signs of autonomic dysregulation (e.g. fever, diaphoresis, piloerection).

Gaucher's disease

Macrophages with a "tissue paper" appearance are characteristic of Gaucher's disease, a deficiency of beta-glucosidase.

Necrotizing enterocolitis

Necrotizing enterocolitis is injury to the bowel wall secondary to asphyxia in the perinatal period. It presents 3-10 days after birth. Intramural air on abdominal radiograph is pathognomonic.

Potter's syndrome

Potter's syndrome is a constellation of findings in the neonate secondary to oligohydramnios, including pulmonary hypoplasia, bilateral renal agenesis, and clubbed feet.

Recombinant vaccines

Recombinant vaccines include HBV and HPV.

A one-day-old cyanotic infant with a grade 4/6 systolic murmur heard at the left, lower sternal border (LLSB) has the EKG shown. What is the most likely diagnosis?

The EKG shown demonstrates some typical findings noted in infants with tricuspid valve atresia (TVA): tall P-waves (due to right atrial enlargement), left-axis deviation (due to hypertrophy of the left ventricle), and small/absent R-waves in precordial leads V1-V3 (due to a hypoplastic right ventricle). In individuals with TVA, there is vital right-to-left flow of the entire systemic venous return across the foramen ovale because there is no direct communication between the right atrium and right ventricle. As a result, the left ventricle, which receives all the systemic venous return, becomes the dominant ventricle.

A 5-year-old boy is brought to the pediatrician for complaints of "left thigh pain." The pain has been persistent over the past week. He denies any trauma to the area. On physical exam he is noted to have overlying swelling at the mid-thigh. A biochemical profile is notable for hypercalcemia. A radiograph of the left thigh is remarkable for a lytic bone lesion. An electron micrograph of the responsible cells is shown in Figure A. These cells are most similar to what other cell type?

The boy in this vignette most likely has Langerhans cell histiocytosis (LCH), as evidenced by a solitary, painful, lytic long bone lesion with overlying swelling and hypercalcemia. Langerhans cells are, like macrophages, from the monocytic lineage.

Patau Sydrome (Trisomy 13)

The characteristic deformity in Patau Sydrome (Trisomy 13) included midline microcephaly, holoprosencephaly, cleft palate, cutis aplasia.

Pfeiffer syndrome

The characteristic deformity in Pfeiffer syndrome is an abnormally shaped calvarium (skullcap) secondary to craniosynostosis. This occurs due to a mutation in the FGF receptor.

A 17-day-old boy is brought in by his mother for constipation. This is her first child and she is concerned that he has not had a bowel movement for over 10 days and is not sure if this is normal. On physical examination, you discover that the boy is in the 8th percentile for weight. You also find a distended abdomen and an absence of stool in the rectal vault on rectal exam. A contrast enema reveals a transition zone between an area of normal colonic caliber a constricted area. If this child's condition involves the entire colon, what is the treatment of choice? Topic Review Topic QID: 6352 1. Watchful waiting 2. Daily stool softeners and laxatives 3. Colectomy 4. Ileostomy 5. Ileostomy with appendectomy

The child in this vignette most likely suffers from Hirschsprung disease. When the entire colon is is involved, the treatment of choice is a diverting ileostomy with appendectomy for pathologic confirmation of absent neurons in the myenteric plexus. Embryologically the enteric neurons arise from neural crest cells and must travel from the caudal hindbrain to the gut. In Hirschsprung disease, these ganglion cells fail to migrate to the bowel, especially the colon. Important risk factors for the disease include Down syndrome, Chagas disease, Waardenburg's syndrome, and MEN 2.

Which of the following is the most common cause of jaundice appearing on day 2 or 3 of life? Physiologic jaundice Hemolytic disease of the newborn Biliary atresia Hepatitis

The correct answer is A. Jaundice is a common condition among newborns and requires medical attention.

Which of the following should be the first step in evaluating a child with speech delay? Hearing evaluation Referral to a speech therapist Psychology referral Anticipatory guidance

The correct answer is A. Obviously, an evaluation of a child's hearing is paramount in determining the reasons for speech delay. Frequently, speech delay is a result of partial or full deafness. Referral to a speech therapist or psychologist without ascertaining the pathologic causes (if any) is premature. Anticipatory guidance is also premature in the absence of an accurate diagnosis.

Which of the following is the most likely cause of bacterial sepsis in a neonate? Group B Streptococcus Streptococcus pneumoniae Haemophilus influenzae Neisseria meningitidis

The correct answer is A. Septic shock is the most common cause of shock seen by internists in the United States. At present, Streptococcus agalactiae (Group B Streptococcus) is the most likely cause of bacterial sepsis in a neonate. This has changed from a few years ago, when Haemophilus influenzae was the most common cause. The widespread vaccination of children with the HiB vaccine has dramatically reduced this number. Streptococcus pneumoniae and Neisseria sp. are common, but not the most common.

A 1-year-old child adopted from Russia comes to you for the first time. The adoptive parents are unable to provide the child's immunization records. Which of the following would be the most appropriate management of this child? Give as many (age-appropriate) vaccines as possible on the first visit. Defer vaccination until records are available. Defer vaccination if the child has symptoms of an upper respiratory tract infection. Send serum for antibody titers to assess immune status before giving any vaccines.

The correct answer is A. As many age-appropriate vaccines should be given on the first visit as possible. Those vaccines that follow schedules should then be followed as per recommendations. The other choices present a problem in that the child will still not be protected against the various illnesses vaccinations are supposed to prevent. The catch-up immunization schedule is shown in the following figure.

Which of the following is the most common cause of failure to thrive in an infant? Nutritional deprivation Cystic fibrosis Cerebral palsy Inflammatory bowel disease

The correct answer is A. The most common cause of failure to thrive is nutritional deprivation. Without adequate nutrition, humans have difficulty surviving. In fact, in cases of failure to thrive clinicians are urged to examine all the contributing factors, including possible child maltreatment. Cystic fibrosis is the most common chronic lung disease of young adults.

Which of the following is the proper sequence of events for emergency management of an infant with septic shock? Provide antibiotics, fluids, and oxygen and consider endotracheal intubation. Give oxygen, consider endotracheal intubation, obtain venous access for IV fluid support, obtain a blood culture, and provide antibiotics. Obtain a blood culture, a urine culture, and a spinal fluid sample; give antibiotics; and provide IV fluids. Obtain a CT scan of the head and a chest x-ray, supply oxygen, and give furosemide.

The correct answer is B. Elements of all the choices would be correct in the resuscitation of an infant in septic shock. However, the clinician is advised to recall the ABCs of resuscitation—airway, breathing, and circulation. Septic shock patients are typically hypoxemic and require supportive oxygen therapy (usually 100%). To support the airway, endotracheal intubation must be considered. Venous access for IV fluids and necessary medication administration is paramount.

Which of the following is the most appropriate treatment for bronchitis in children? ampicillin Supportive care erythromycin corticosteroids

The correct answer is B. In children, acute bronchitis usually lasts 1 to 2 weeks and is self-limited. Treatment is usually limited to supportive care such as a vaporizer or humidifier or supportive medications for cough or fever. Antibiotics are not indicated due to the probable viral and self-limited nature of the disease.

Which of the following are significant sources of ongoing pertussis transmission? Young infants who are unimmunized Adolescents and young adults Elderly patients Contaminated surfaces in the rooms of infected patients

The correct answer is B. According to the Centers for Disease Control (CDC), the rate of endemic pertussis in this age group is extraordinarily high (some states report 150 to 200 cases per 1,000), and as such represent a significant source of transmission.

Which of the following would be the most reliable laboratory indicator of urinary tract infection? Urine dipstick for leukocyte esterase and nitrites Urine culture Urine gram stain Microscopic urinalysis

The correct answer is B. Culture and sensitivity is the most reliable indicator of a urinary tract infection (UTI). The other tests are primary tests that will point the clinician toward a diagnosis, but not confirm it.

An 8-year-old boy presents with fever and sore throat for 3 days that has become much worse over the last 24 hours and is most severe on the left side. On examination, he is febrile, ill appearing, and drooling, but is not in respiratory distress. Which of the following is the most likely diagnosis? Croup (viral laryngotracheobronchitis) Peritonsillar abscess Epiglottitis Bacterial tracheitis

The correct answer is B. Patients with peritonsillar abscess typically present with severe sore throat pain, trismus, odynophagia, and medial deviation of the soft palate, along with a muffled voice (the "hot potato" voice). Following treatment, peritonsillar cellulitis either resolves or develops into a peritonsillar abscess. Existence of an abscess is confirmed by needle aspiration. The literature supports treatments ranging from needle aspiration, incision and drainage, to tonsillectomy. Complications, such as extension into adjacent structures, are possible if it is left untreated or treated improperly. The term croup does not refer to a single illness, but rather a group of conditions involving inflammation of the upper airway that leads to a cough that sounds like a bark, particularly when a child is crying.

An 18-month-old child with sickle-cell disease (hemoglobin S) presents with 3 days of a runny nose and a temperature of 101.5°F. Which of the following is the best management approach for this patient? Treat with cold and cough preparation and follow-up in the morning. Perform appropriate cultures and begin empiric intravenous antibiotics in the hospital. Prescribe amoxicillin and follow-up first thing in the morning. Prescribe around-the-clock acetaminophen and ibuprofen (alternating) to manage the fever.

The correct answer is B. Sickle-cell disease is an autosomal recessive disorder in which abnormal hemoglobin leads to chronic hemolytic anemia, resulting in several clinical problems. Acute painful episodes may be due to vasoocclusion and can be provoked by infection, dehydration, and hypoxia. If a patient presents with fever, such as in this question, the clinician must assume infection and admit the patient for diagnostic cultures and appropriate antimicrobial treatment. Due to the range of infections that may be present, blind treatment with amoxicillin would be inappropriate. Supportive treatment, as described in answers A and D, is ill-advised in this situation.

A 3-year-old child presents with a 3- to 4-week history of poorly localized pain in the upper and lower extremities and back along with a low-grade temperature (maximum of 101°F). Physical examination reveals a temperature of 100.4°F; a pulse of 150 beats per minute, regular; and a respiration of 30 breaths per minute. The child appears tired and pale, and further examination reveals lymphadenopathy and hepatosplenomegaly. Which of the following would be the most appropriate initial evaluation in this patient? A bone scan to evaluate for osteomyelitis A complete blood count and bone marrow aspirate to rule out leukemia A CT of the abdomen to evaluate the hepatosplenomegaly Liver-associated enzymes to assess for hepatitis

The correct answer is B. The child's symptoms are worrisome and point strongly to leukemia (most commonly ALL) as a potential cause. Most of the symptoms of acute leukemia are due to replacement of normal bone marrow elements by malignant cells. The infection is usually due to neutropenia. Patients generally appear pale and have purpura and petechiae. Fever is common, and patients typically present with enlargement of the liver, spleen, and lymph nodes. The complete blood count will ascertain the presence of neutropenia, and the bone marrow analysis will confirm the diagnosis. A CT of the abdomen will only indicate whether hepatosplenomegaly is present; it will not determine the cause.

A febrile 2-year-old child with respiratory distress and diffuse crackles/rales most likely has which of the following? Tuberculosis Viral pneumonia Bacterial pneumonia Mycoplasma pneumonia

The correct answer is B. Viruses are the most common cause of pneumonia in children. Diffuse crackles rather than discrete or specific lobar rales tilt the diagnosis in the direction of a viral origin. Bacterial pneumonia typically is discrete or well rounded, affecting one or more lobes. Mycoplasma pneumonia is a subset of bacterial pneumonia and presents much the same way, albeit usually with less respiratory distress. Tuberculosis is common among the homeless, immunocompromised individuals, and individuals from foreign countries where the disease is prevalent. This condition presents with classic signs of pneumonia, including tachypnea, nasal flaring, grunting, dullness to percussion, egophony, decreased breath sounds, and crackles. However, a febrile 2-year-old child presenting as described in the question most likely has viral pneumonia.

Which of the following is the most common predisposing condition in children with a first urinary tract infection (UTI)? Close contact with another child with a UTI Poor perineal hygiene Structurally abnormal kidneys demonstrated on ultrasound Vesicoureteral reflux demonstrated on cystourethrogram

The correct answer is D. Abnormalities such as a vesicoureteral reflux and hydronephrosis are common, with vesicoureteral reflux being the most common congenital abnormality. Close contact with another infected child is extremely unlikely to cause a urinary tract infection (UTI). Poor perineal hygiene may lead to a UTI if bacteria are transmitted when wiping after voiding; however, this is also unlikely.

Which of the following is considered to be the most ominous finding in a patient with severe asthma? Persistent cough despite albuterol and steroid therapy A respiratory rate of 30 breaths per minute Both inspiratory and expiratory wheezing Altered mental status

The correct answer is D. All of the choices may indicate serious complications; indeed, inspiratory and expiratory wheezing may be indicative of status asthmaticus. However, altered mental status indicates significant hypoxia and impending catastrophe.

Which of the following developmental milestones would you expect to see in a healthy 7-month-old infant? Feeds self Follows one step verbal commands Rolls from back to stomach Uses pincer grasp

The correct answer is C. A 6- to 8-month-old child is expected to roll from back to stomach. The other answers are developmental milestones expected to occur later in the child's life.

Which of the following is an absolute contraindication to administering the DtaP vaccine? A child with an ear infection and fever of 101°F who otherwise appears to be well A history of inconsolable crying for 2 hours after a DtaP on a previous visit Allergic reaction to the vaccine on a previous dose A history of a cousin who had a bad reaction to the same vaccine

The correct answer is C. An allergic reaction to any vaccination is an absolute contraindication for continuation of the series for obvious reasons. Other contraindications for administration of the DtaP vaccine include Guillian-Barré syndrome or other neurologic disorders. A reaction in a second-degree relative is not a contraindication, nor is a history of crying. In a child with a fever who otherwise appears well, the clinician should use his or her best judgment. The practitioner should consider carefully the benefits and risks of this vaccine in these circumstances. If the risks are believed to outweigh the benefits, withhold the vaccination; if the benefits are believed to outweigh the risks (e.g., during an outbreak or foreign travel), give the vaccine.

Which of the following is the most likely cause of chronic cough in a 10-year-old child? Tuberculosis Whooping cough Asthma Foreign-body obstruction

The correct answer is C. Cough is the most common reason patients seek medical attention for respiratory complaints. Acute coughs can mean a host of various conditions, but chronic cough in children is most likely the result of undiagnosed asthma. The second most common cause of cough in children is nasal and/or sinus disease or other upper respiratory conditions. A foreign body can cause recurrent unilateral pneumonia or acute respiratory distress. Tuberculosis, which presents with cough, is not the most likely cause.

A previously well, afebrile 18-month-old child who presents with an abrupt onset of respiratory distress is most likely to have which of the following? Croup Epiglottitis Foreign-body aspiration Bacterial pneumonia

The correct answer is C. In healthy children, especially in this age group, an abrupt onset of respiratory distress is usually due to foreign-body aspiration.

Which of the following typically signifies a pathologic heart murmur in an infant? It has a vibratory quality. It is 2/6 in intensity. It is holosystolic. It is best heard in the back and both axillae.

The correct answer is C. In infants, pathologic murmurs include all diastolic murmurs; all holosystolic, late systolic, or continuous murmurs; loud murmurs >3/6; and those with associated cardiac abnormalities. The other parameters listed are not always or usually pathologic.

A 3-year-old child presents with a chief complaint of sore throat. She also has a fever of 102°F, a runny nose, a hacking cough, and hoarseness. Several family members have similar symptoms. Which of the following is the most likely etiologic agent for her symptoms? Group A Streptococcus Epstein-Barr virus Adenovirus Mycoplasma pneumoniae

The correct answer is C. Over 51 serotypes of adenoviruses produce a variety of clinical syndromes. Adenoviral infections are usually self-limited and are frequently found among infants, children, and military recruits. This child has symptoms of the common cold, which is primarily the manifestation with which most of us are familiar. This is characterized by rhinitis, malaise, and pharyngitis, with or without fever (seen frequently in non-Streptococcal exudative pharyngitis). The Epstein-Barr virus causes infectious mononucleosis; it frequently manifests as malaise, fever, pharyngitis, lymphadenopathy, and splenomegaly. Mycoplasma pneumoniae is usually seen in an older population, such as college students or others living in close quarters with many other people. Symptoms do not usually include rhinorrhea or hoarseness.

Which of the following physical examination findings is most helpful in differentiating Lyme disease from another bacterial infection of the knee? The size of the effusion is usually smaller in Lyme disease. Warmth of the joint is less frequent in Lyme disease. The degree of disability/limitation of range of motion is usually less in Lyme disease. Point tenderness is absent in Lyme disease.

The correct answer is C. Patients with bacterial effusions of the knee typically have larger effusions, which cause decreased ROM and more disability. The other statements are incorrect.

A 2-year-old child presents with a 2-day history of temperature of 101°F, runny nose, and "noisy breathing." Examination reveals an alert child in mild respiratory distress with stridor when agitated. He is able to drink without difficulty. Which of the following is the most likely cause of this illness? Epiglottitis caused by Haemophilus influenzae type B Bacterial tracheitis caused by Staphylococcus aureus Viral laryngotracheobronchitis (croup) caused by parainfluenza Peritonsillar abscess caused by Group A Streptococcus

The correct answer is C. The term croup does not refer to a single illness, but rather a group of conditions involving inflammation of the upper airway that leads to a cough that sounds like a bark, particularly when a child is crying. The caregiver might also describe noisy breathing. Similar symptoms may occasionally be caused by bacteria or an allergic reaction, although most cases of croup are caused by viruses, most commonly parainfluenza virus. Other cases may involve adenoviruses, influenza, respiratory syncytial viruses, and measles. Most children with viral croup are between the ages of 3 months and 5 years. Symptoms are most severe in children younger than 3 years of age. Croup may be accompanied by fast or difficult breathing and sometimes a grunting noise or wheezing while breathing.

An 18-month-old child presents with a fever of 104°F for 6 days without localizing signs or symptoms except for poorly described abdominal pain. Examination reveals mild left side abdominal tenderness, but no rebound. Which of the following would be the most appropriate component of further evaluation? Obtain a rectal swab for routine stool culture. Consult the surgical service to rule out appendicitis. Obtain a catheterized urinalysis and urine culture. Order an abdominal obstruction series.

The correct answer is C. Urinary tract infections (UTIs) are the most common nosocomial infection in the United States and are very common among nonhospitalized patients. Based on the choices provided in the question, a UTI is the most likely cause. The patient has mild left-sided tenderness without rebound, thus the absence of peritoneal signs tends to put appendicitis low on the differential list.

Which of the following organisms is the most common cause of community-acquired (vs. hospital-associated) urinary tract infections (UTIs) in the United States? Enterococcus faecalis Pseudomonas aeruginosa Escherichia coli Staphylococcus aureus

The correct answer is C. Urinary tract infections (UTIs) are the most common nosocomial infection in the United States. Escherichia coli is the most common pathogen in these cases.

The chest x-ray of a patient with bacterial pneumonia usually reveals which of the following? Diffuse bilateral patchy infiltrates Multiple lobes of one lung involved Single lobe total or partial consolidation Reticulonodular infiltrates

The correct answer is C. Viruses are the most common cause of pneumonia in children. Diffuse crackles rather than discrete or specific lobar rales tilt the diagnosis in the direction of a viral cause. Bacterial pneumonia typically is discrete or well rounded, affecting one or more lobes. This presents radiographically with partial or complete consolidation. Bacterial pneumonia can progress to multiple lobes; however, the most common radiographic presentation is typically in a single lobe. Diffuse patchy infiltrates can be present in several conditions, ranging from tuberculosis to other chronic lung diseases. Reticulonodular infiltrates are usually present in fibrotic lung diseases, including, but not limited to, asbestosis.

A 4-year-old child presents with complaints of fever, medial knee pain, and a limp. However, the physical examination reveals full range of motion of the knee, with no effusion or bony tenderness. Which of the following is the most likely diagnosis? Osteomyelitis of the distal femur or proximal tibia Bacterial arthritis of the knee Toxic synovitis or bacterial arthritis of the hip An occult fracture of the distal femur or proximal tibia

The correct answer is C. With any orthopedic presentation, the clinician should examine the joints proximal and distal to the area in question. When the examination is essentially unremarkable for the joint in question, then other areas should be examined. Usually, it is the proximal area that will have the problem. Toxic synovitis and bacterial arthritis are more likely in this patient due to the fever. When patients, especially overweight adolescents, present only with pain and a limp, the clinician should look for signs of aseptic necrosis. Osteomyelitis may present with fever, but typically physical findings are present to support such a diagnosis.

Which of the following statements is FALSE regarding idiopathic scoliosis? It is more commonly diagnosed in adolescent females Thoracic dextroscoliosis is the most common type In curvatures of 30° or more, rib cage deformity may be evident Curvatures > 40° require corrective bracing

The correct answer is D. Curvatures greater than 40° prove resistant to bracing and may require spinal fusion. Answers A, B, and C are all true statements.

Which of the following is the most common cause of cardiac arrest in children? Myocardial infarction Poisoning Trauma to the chest Respiratory failure

The correct answer is D. Far and away, respiratory failure secondary to foreign-body aspiration or organic causes is the primary cause of cardiac arrest in children.

Why should table (cow's) milk not be introduced into a child's diet until 12 months of age? Cow's milk contains too much fat for infants. Infants are frequently lactose intolerant. Cow's milk contains levels of vitamin D that are toxic to infants. Consumption of cow's milk can result in iron deficiency.

The correct answer is D. Infants who rely on a diet of cow's milk are at high risk of anemia during the first years of life, because cow's milk is low in iron (about 2.6 mg Fe per 1,000 kcal).

A 2 week-old child is brought to the pediatrician's office for their first well-child visit. The child was born overseas and did not receive the standard post-natal testing that is performed in the United States. While in the office, the mother states that she has noticed a musty odor in the child's diaper, and that the child has begun to develop a rash on his forearms. The pediatrician is immediately concerned that the child may be suffering from an accumulation of which of the following amino acids?

This child is suffering from Phenylketonuria (PKU), which presents with the classic symptoms of musty odor and eczema.

A 7-year-old child falls off his bike and scrapes his knee but gets up and resumes biking. Three days after the accident he presents to the emergency department with a 36-hour history of a temperature of 102°F, a swollen knee, and markedly decreased range of motion. Which of the following would be the most appropriate first step in the management of this patient? Apply an ACE compression wrap, keep the leg elevated, and give ibuprofen. Obtain a complete blood count and blood culture and begin cephalexin. Obtain a Lyme titer and begin amoxicillin. Aspirate joint fluid for gram stain and culture as well as cell count.

The correct answer is D. Judging from the patient's history, this patient likely has cellulitis and a bacterial effusion in the knee. The essential diagnostic test is aspiration and culture. Aspiration of fat globules floating in the effusion may also reveal an occult fracture. An ACE wrap and elevation with ibuprofen for pain without knowing the culture of the effusion is inappropriate and could prove dangerous to the child. The history does not support obtaining a Lyme titer. A complete blood count should be obtained. The aspirate will probably contain Staphylococcus species, but a confirmatory aspirate would make the prescribing of the cephalosporin more appropriate.

Which of the following would help differentiate sinusitis from an uncomplicated cold in children? Sinus transillumination Fever for 1 day Mucoid rhinorrhea Runny nose for longer than 10 days

The correct answer is D. The common cold is usually self-limited, frequently lasting less than a week. Symptoms that last for more than 1 week (and less than 4 weeks) are hallmarks of diagnosis. Diminished sinus transillumination (less transillumination in fluid versus air) may be due to a transient adenovirus or allergic response. The same holds true for fever or mucoid rhinorrhea.

Which of the following findings in a child should raise concern about coarctation of the aorta? Pulsus paradoxus Widened pulse pressure A 2/6 murmur at the left sternal border O2 saturation (pulse oximetry) markedly higher in the upper extremity than the lower extremity

The correct answer is D. The usual presentation of coarctation of the aorta is systemic hypertension. Patients present with an associated bicuspid aortic valve and absent or weak femoral pulses. Systolic pressures are also higher in the upper extremities compared to the lower extremities, which would lead to higher pulse oximetry in the upper versus the lower extremities. Cardiac catheterization can provide definitive gradient information across the lesion. A pulsus paradoxus and a widened pulse pressure are present in aortic aneurysms. A II/VI murmur can be caused by several conditions and is nonspecific in this case.

A 2-week-old infant presents to the emergency department with a 12-hour history of listlessness and poor feeding with no other localizing symptoms; specifically, she has had no upper respiratory symptoms or vomiting or diarrhea. On physical examination, she has a temperature of 103°F rectally, a heart rate of 200 beats per minute, and a respiratory rate of 60 breaths per minute. She has decreased tone and poor perfusion. The physical examination is otherwise unrevealing. Which of the following is the most likely underlying reason for this child's symptoms? Severe dehydration with hypovolemic shock Heart failure with cardiogenic shock Child abuse Sepsis

The correct answer is D. This child is clearly septic, as demonstrated by her vital signs (including the very high fever). Nothing in the patient's presentation (especially the physical examination) indicate dehydration with hypovolemia. Although a 2-week-old infant may have heart failure secondary to a congenital disorder, the physical examination does not bear this out. No clear signs or symptoms of child maltreatment are present.

Which of the following cerebrospinal (CSF) findings would be most suggestive of viral (aseptic) meningitis? WBC of 1,400 with 90% polys, 3 RBC, protein 210, glucose 20 WBC of 6 with 10% polys, 90% lymphocytes, RBC 42,000, protein 100, glucose 60 WBC of 2 with 10% polys, 90% lymphocytes, 10 RBC, protein 23, glucose 74 WBC of 390 with 30% polys, 70% lymphocytes, 20 RBC, protein 76, glucose 80

The correct answer is D. Viral (aseptic) meningitis usually produces a spinal fluid that is clear to cloudy with normal glucose and increased protein. The opening pressure can be normal to increased with a predominance of lymphocytes.

A 23-year-old female with HIV gives birth to a baby girl. During the latter months of her pregnancy she experienced only mild symptoms including intermittent malaise, fatigue, and occasional myalgias. The infant presents with the pathologic findings seen on imaging (Figures A and B). Which of the following maternal exposures is most likely responsible for the infant's disease?

The infant in the question stem most likely suffers from congenital toxoplasmosis as a result of maternal exposure to cat feces.

A 4-month-old male is brought to the pediatrician by her mother because of a marked change in the baby's behavior. The doctor notes that last month the patient was well-appearing and active but has since slowly deteriorated and become hypotonic, withdrawn, and inconsolable. An extensive workup reveals a deficiency of sphingomyelinase. Which of the following is characteristic of this patient's disease?

The patient has Niemann-Pick disease, a lysosomal storage disease characterized by a deficiency of sphingomyelinase. Splenomegaly is typical of Niemann-Pick disease. Niemann-Pick results from a deficiency in the lysosomal enzyme sphingomyelinase, whereby sphingomyelin accumulates in reticuloendothelial and parenchymal cells. The disease presents with failure to thrive and neurologic symptoms from demyelination including hypotonia. Niemann-Pick type A is fatal in infancy while type B is a non-neuronopathic form seen in adults. Inheritance is autosomal recessive. Both Tay-Sachs disease and Niemann-Pick are well-known for its "cherry-red" macular spots seen on ophthalmologic exam, however Tay-Sach does not present with hepatosplenomegaly or cervical lymphadenopathy.

A worried mother brings her 5-day-old, full-term infant to the Emergency department because he has developed a rash. Yesterday she noted that his skin looked slightly blotchy, but today he has several "yellow bumps." On exam, the infant is afebrile and has numerous 1-2 mm yellow papules overlying erythematous macules on his chest, neck, and face (See Figure A). What is the next best course of action?

This child likely has erythema toxicum neonatorum, which is a benign skin finding in newborns. Observation is appropriate, as it resolves within hours to days of first appearing.

A 12-year-old girl with no known allergies is brought in by her father for complaints of a sore throat. She states that she has not had a cough. On physical exam her temperature is 100.9 F, she has anterior cervical lymphadenopathy, and her oral exam is shown in Figure A. Which of the following is the most appropriate next step to prevent future complications? Topic 1. Throat culture 2. Oral penicillin prescription 3. Oral clindamycin prescription 4. Oral azithromycin prescription 5. Reassurance

The patient in this vignette most likely has bacterial pharyngitis, as evidenced by the history and physical exam. The best next step is penicillin administration. Group A Streptococcal (GAS) pharyngitis must be treated promptly to avoid the development of rheumatic fever. Confirmation by culture is not required in patients who present with the classic presentation of bacterial pharyngitis (fever, absence of cough, exudates, painful lymphadenopathy, and fever). In patients without penicillin allergy, the first line treatment is a 10-day course of oral amoxicillin or penicillin V. In penicillin-allergic patients whose reaction is less severe than anaphylaxis, a 10-day course of a first-generation cephalosporin is used. In those with prior anaphylactic reactions to a penicillin, treatment with 10 days of clindamycin or clarithromycin, or 5 days of azithromycin, is recommended.

A 3-year-old male is brought to the emergency department by his mother shortly after the two immigrated from Nepal. You immediately notice a confluent erythematous rash on the child's face and body. Through an interpreter, you learn that the patient developed a low grade fever 1 week ago, after having previously been well. The rash, which first appeared 2 days ago, began on the patient's face, and has since spread to his trunk and extremities. Vital signs are T 103.5F, BP 100/70, RR 20, HR 80, SpO2 98%. Which of the following is a possible sequela of this patient's disease?

The patient presented in the question stem has measles (rubeola) infection. Subacute sclerosing panencephalitis (SSPE) is a rare complication of measles. Measles is caused by the rubeola virus, a paramyxovirus. It presents with a prodrome of cough, coryza, and conjunctivitis with photophobia, followed by the appearance of red spots with blue-white centers on the buccal mucosa known as Koplik spots. Following the disappearance of Koplik spots, a characteristic rash appears (head/face to trunk to extremities). Subacute sclerosing panencephalitis is a rare, fatal, progressive, neurodegenerative disease that occurs 7-10 years following measles infection.

A 3-month-old male is brought to the emergency room by his mother for 2 days of difficulty breathing. He was born at 35 weeks gestation but has otherwise been healthy. Vital signs are T 38 C, HR 100/60, HR 140, RR 60 O2 90%. On exam, expiratory wheezing and intercostal retractions are noted. Oral mucosa is noted to be dry. You decide to initiate supportive care and admit the patient. Which of the following is the most helpful in confirming the diagnosis? Topic Review Topic QID: 2585 1. Chest radiograph 2. Serologies 3. Blood culture 4. Rapid antigen test of nasal aspirate 5. Gram stain of nasopharyngeal swab

The patient's presentation is consistent with respiratory syncytial virus (RSV) bronchiolitis. Screening for RSV antigen in nasal and pulmonary secretions can confirm the diagnosis. Bronchiolitis in children under two years of age is most commonly caused by RSV and is seen most often in the fall and winter months. Inflammation of the smaller airways of the lower respiratory tract results in low-grade fever, tachypnea, expiratory wheezing, and intercostal retractions. In patients who demonstrate severe bronchiolitis, as evidenced by persistently increased respiratory effort or who appear clinically ill, hospitalization is required for close monitoring in addition to supportive care.

A mother brings her 6-month-old male infant to your office. She reports that her son has been breathing faster than usual for the past 2 days, and she has noted occasional wheezing. She states that prior to the difficulty breathing, she noticed some clear nasal discharge for several days. The infant was born full-term, with no complications, and no significant medical history. Vital signs are T 38 C, BP 100/60 mmHg, HR 120 bpm, RR 40 rpm, SpO2 95%. Physical exam reveals expiratory wheezing and crackles, and intercostal retractions are noted. Which of the following is the most appropriate next step in management? Topic Review Topic QID: 2584 1. Oral amoxicillin 2. Intubation 3. Non-invasive supportive care 4. Inhaled fluticasone 5. CT scan of the chest

The patient's presentation is most consistent with respiratory syncytial virus (RSV) bronchiolitis. Treatment involves supportive care with consideration for a trial of bronchodilators. Bronchiolitis in children under two years of age is most commonly caused by RSV and is seen most often in the fall and winter months. Inflammation of the smaller airways of the lower respiratory tract results in low-grade fever, tachypnea, expiratory wheezing, and intercostal retractions. Treatment involves supportive care and, if clinically indicated, a one-time trial of bronchodilators. Failure to provide appropriate support may result in worsening of disease and subsequent respiratory failure.

A 17-year-old male presents to his physician complaining of 9 days of fatigue, subjective fever, and sore throat. He is sexually active but states that he uses condoms. His exam reveals a temperature is 102 F, mobile posterior cervical lymphadenopathy, and splenomegaly. His throat looks like Figure A. What is the most appropriate next step in diagnosis?

The subacute presentation of fatigue, fever, exudative pharyngitis, and posterior cervical lymphadenopathy in an adolescent patient make mononculeosis the most likely diagnosis. The heterophile antibody test, colloquially known as the monospot test, is the correct next step.

A 13-year-old female with no past medical history presents to her pediatrician's office with a chief complaint of "too much hair," which appeared in the last few months and for which she is getting bullied at school. On physical exam, she has a deep voice, is in the 40th percentile for weight and the 30th percentile for height. She has scattered dark hair and acne on her chin, jaw, and chest. She is a Tanner III and has not yet experienced menarche. She otherwise appears well. Her family history is significant for a couple cousins born with ambiguous genitalia and Ashkenazic Jewish heritage. What is her most likely diagnosis? Topic Review Topic QID: 5402 1. 21-hydroxylase deficiency 2. Polycystic ovarian syndrome 3. Hypothyroidism 4. Hyperprolactinemia 5. Androgen-secreting neoplasm

This adolescent female with a family history of classic congenital adrenal hyperplasia (CAH), virilization, hirsutism, acne, short stature, and possible late-onset of menses likely has nonclassic (aka late-onset) CAH, caused by a 21-hydroxylase deficiency. CAH is an autosomal recessive disorder that has several different forms. The most severe, classic form presents in newborn females with salt-wasting and ambiguous genitalia

A pediatrician is inspecting a newborn child after delivery and notices that the child has a prominent calcaneus on each foot, and a small head with a prominent back portion. Upon further examination the physician notices that the child has a heart murmur. The mother had an uneventful pregnancy, however she refused chromosomal testing during her pregnancy. A blood sample is taken and karyotyping is performed revealing an extra chromosome. Which is the most likely diagnosis?

This child most likely has the diagnosis of Edward Syndrome or Trisomy 18. Edward syndrome or Trisomy 18 is usually diagnosed at birth or in utero. The majority of diagnoses are made prenatally. Characteristic features of this syndrome include "rocker-bottom feet", atrial or ventricular septal defects, cleft lip/palate, microcephaly with a prominent occiput, underdeveloped thumbs, and hypertelorism (wide distance between the eyes).

A 4-month-old male infant with a history of eczema presents to the pediatrician with one day of a rash. His mother reports that he had been itching his eczema over the last few days and seemed more tired this morning. On exam, he is febrile to 102 F and irritable but his vitals are otherwise within normal limits. His face and trunk are covered with a monomorphic vesicular rash as shown in Figure A. He attends daycare but has no sick contacts. What is the most appropriate next step in treatment? Topic Review 1. Supportive care and isolation 2. Oral clindamycin 3. IV clindamycin 4. Oral acyclovir 5. IV acyclovir

This infant with a history of eczema, fever, irritability, malaise, and a disseminated monomorphic vesicular rash most likely has eczema herpeticum, for which the treatment is IV acyclovir. Eczema herpeticum is caused by herpes simplex virus (HSV) in the setting of an impaired skin barrier (such as eczema).

A 3-day-old male infant born at 39 3/7 weeks to a 29-year-old G2P1001 mother exhibits yellow discoloration of the skin notable from the forehead to the level of the umbilicus. Which of the following would be concerning and prompt further evaluation of this infant? 1. Total serum bilirubin level of 10 mg/dL at 72 hours of life 2. Conjugated serum bilirubin level of 1.6 mg/dL at 60 hours of life 3. Appearance of the infant's jaundice first occurring at 48 hours of life 4. Clinical persistence of the infant's jaundice through 1 week of age 5. Total serum bilirubin of 4 mg/dL at 48 hours followed by 11 mg/dL at 72 hours

This infant's clinical picture is consistent with a diagnosis of neonatal jaundice. A rising serum total bilirubin at a rate of greater than 5 mg/dL/24hr is indicative of pathologic jaundice and warrants further investigation.

The newborn of a mother with poor prenatal care develops perioral cyanosis and tachypnea shortly after birth. Physical exam reveals right-sided heart sounds and a wide body habitus. The chest radiograph is shown in Image A. An orogastric tube is immediately placed and the patient is intubated. What is the most likely diagnosis?

This infant's presentation is consistent with congenital diaphragmatic hernia. Congenital diaphragmatic hernia (CDH) occurs when a congenital defect in the diaphragm allows the herniation of abdominal viscera into the chest. Compression of the lungs and shift of the mediastinum occurs, resulting in the cyanosis and right-sided heart sounds observed on physical exam. Morgagni hernia is a congenital diaphragmatic hernia that occurs secondary to potential anterior medial defects in the diaphragm.

A 30-year-old patient presents to a new physician after he was relocated because of his work. Upon review of his new patient information form, it is discovered that he has a past medical history of non-classical congenital adrenal hyperplasia. Which of the following was the most likely presentation in this patient? 1. Ambiguous genitalia at birth 2. Hypertension 3. Skin hypopigmentation 4. Precocious puberty 5. Puberty delay

This male with non-classical congenital adrenal hyperplasia (CAH) would most likely present with precocious puberty as a result of excess testosterone production. CAH is an autosomal recessive disorder that has several different forms. The classic form is the most severe and presents in newborn females with salt-wasting and ambiguous genitalia. Milder, nonclassic forms can present anytime from childhood to adulthood with the signs and symptoms of hypertestosteronism, including virilization, hirsutism, acne, short stature, and possibly late-onset of menses. 21-hydroxylase deficiency causes most forms of the disorder. Incorrect answers: Answer 1: An ambiguous genitalia may be seen in female patients with 21-hydroxylase deficiency, but is not usually seen in males. Answer 2: Hypertension is seen in patients with 11-hydroxylase deficiency; patients with 21-hydroxylase deficiency are hypotensive. Answer 3: Patients with both 21 and 11-hydroxylase deficiencies are usually hyperpigmented as a result of excess ACTH production. Answer 5: Patients with 17-hydroxylase deficiency have a puberty delay.

A pregnant mother presented to the obstetrician for her 20 week check-up. On ultrasound, a cleft lip was visualized, along with a mass protruding from the umbilicus. At the time of delivery, the physician notes that the shape of the child's feet is also abnormal. What is the most likely etiology for this patient's condition?

This patient most likely has Patau syndrome (trisomy 13), which is most commonly caused by meiotic nondisjunction. The most common physical presentations include an omphalocele, rocker-bottom feet, holoprosencephaly, and cleft lip and palate.

A 3-year-old male is brought to the emergency department by his mother. He has a confluent erythematous maculopapular rash on his face and body (Figure A). He developed a low grade fever 1 week ago, after having previously been well. The rash, which first appeared 2 days ago, began on the patient's face and has since spread to his trunk and extremities excluding his palms and soles. The patient was also experiencing cough, red injection of his conjunctiva, and white lesions on his buccal mucosa earlier in the course of this illness. His temperature is 103.5 deg F (39.7 deg C), blood pressure is 100/70 mmHg, respirations are 20/min, pulse is 80/min, SpO2 98%. His mother states that she is vaccinated against childhood infections but that her children are all non-immunized. Which of the following is a potential complication of this disease?

This patient most likely has measles with the classic presentation including cough, coryza (rhinitis), conjunctivitis, and buccal lesions (Koplik spots) followed by maculopapular rash that spreads cranial-caudally but excludes the palms and soles. Subacute sclerosing panencephalitis is a potential complication of certain strains of measles with the M protein, can lead to progressive neurologic complications, and is fatal.

A 17-year-old male presents to a geneticist for further evaluation. In addition to struggling academically, his pediatrician noticed he is tall for his age and has small testes and gynecomastia (see Figure A). Upon further work-up, what genetic finding will this patient most likely have? 1. 46, XXY 2. 47, XXY 3. 21-hydroxylase deficiency 4. 46, XY, androgen insensitivity syndrome 5. 45, X

This patient's clinical findings are most consistent with Klinefelter syndrome. This is a genetic disorder in which patients have an extra X-chromosome and a karyotype of 47, XXY. Further workup reveals a 47, XXY karyotype and typically, azospermia.

A 3-day-old male develops bilateral purulent eye discharge. He also exhibits a runny-nose as well as eyelid edema and redness. A photograph of the infant can be seen in Figure A. Which of the following could have been given as standard prophylaxis to prevent the development of this infant's condition?

This patient's presentation of bilateral eye discharge on day 3 of life is consistent with gonococcal ophthalmia neonatorum. Topical 0.5% erythromycin applied immediately after birth is effective prevention against development of neonatal gonococcal conjunctivitis. There are 3 common types of neonatal conjunctivitis encountered on USMLE exams: chemical, gonococcal, and chlamydial. They may be easily differentiated based on the time of presentation. Chemical conjunctivitis often occurs within the first 24 hours of life and is typically secondary to the use of certain prophylactic topical ointments applied to newborns to prevent gonococcal conjunctivitis. Gonococcal conjunctivitis occurs 3-5 days after birth and chlamydial conjunctivitis occurs 5-10 days after birth. Incorrect Answers: Answer 1: IV acyclovir is used to treat neonatal herpetic conjunctivitis, which may present with vesicles on the skin surrounding the eyes or other evidence of systemic involvement. Answer 2: IV ceftriaxone is a recommended regimen for the treatment of, not prophylaxis against, neonatal gonococcal conjunctivitis. Answer 3: PO erythromycin may be used to treat chlamydial conjunctivitis; however, it is not recommended for prophylaxis of gonococcal ophthalmia. Answer 5: Artifical tear drops may be useful in the prevention and/or treatment of chemical conjunctivitis, which most commonly manifests within the first 24 hours after birth.

A 7-year-old male is brought to his pediatrician's office by his mother complaining of a sore throat for 3 days. He denies cough. The patient has a history of otitis media and is allergic to penicillin (he develops a rash). Vital signs are temperature is 102.5 deg F (39.2 deg C), pulse is 80/min, blood pressure is 124/82 mmHg, respiratory rate is 18/min, SaO2 is 99% on room air. Physical examination of the patient's throat is shown in Figure A. Which of the following is the most appropriate treatment? Topic Review Topic FIGURES: A QID: 6197 1. Penicillin 2. Amoxicillin 3. Clindamycin 4. Erythromycin 5. Metronidazole

This pediatric patient has Group A Streptococcus (S. pyogenes) (GAS) pharyngitis and a non-anaphylaxis allergy to penicillin. Reasonable alternative treatments of GAS pharyngitis for patients with penicillin allergies include erythromycin or first-generation cephalosporins, such as cefalexin.

A 7-day-old girl is brought to the general pediatrics clinic by her mother. She was the product of a full-term uncomplicated pregnancy and was delivered via cesarean for breech presentation. The mother received regular prenatal care throughout the pregnancy. This morning, after changing the child's diaper, the mother noticed that the newborn had blood at the vaginal introitus. The mother has no other complaints, and the infant is eating and voiding appropriately. Vital signs are stable. Physical exam reveals moderate mammary enlargement and confirms the vaginal spotting. The remainder of the exam is unremarkable. What is the next step in management?

Vaginal spotting or bleeding is normal in female infants less than 3 months of age and will stop as soon as maternal estrogens are cleared from the baby's blood. The parents of this child only require reassurance.

A 12-year-old boy presents with fever and severe sore throat. Which of the following physical exam findings helps differentiate a peritonsillar abcess from epiglottitis? Topic Review Topic QID: 4432 1. Muffling of the voice 2. Dysphagia 3. Deviation of the uvula 4. Cervical lymphadenopathy 5. Fever

While epiglottitis and peritonsillar abscess share several similar presenting signs and symptoms, the key differentiating finding is a uvular deviation which is only found with a peritonsillar abscess. Peritonsillar abscesses occur primarily in young adults

The characteristic deformity in Down syndrome (Trisomy 21) includes

a flattened nose, small teeth, clinodactyly, short neck, epicanthal fold, strabismus, brush field spots, single transverse palmar crease.

This patient has scarlet fever, for which the treatment of choice is penicillin. However, given the patient's previous reaction to penicillin administration, he should be treated with

he should be treated with cephalexin (a first generation cephalosporin). Patients with severe penicillin allergies (i.e. anaphylaxis or respiratory symptoms) should be treated with erythromycin or clindamycin to avoid the 10% cross-reactivity that occurs between penicillin and cephalosporins.

A 2-year-old girl is brought to the ED 30 minutes after her mother witnessed her swallow a small disc-battery. The patient is irritable but otherwise is not gagging, reporting chest or throat pain, or vomiting. She is in no respiratory distress, and her vital signs are as follows: T 37, HR 105, BP 90/70, RR 24, O2 Sat 99% RA. A radiograph is obtained and is shown in Figure A. Which of the following is the most appropriate next step in the management of this patient? 1. No action is needed, wait for spontaneous passage of battery in the stool 2. Observe with serial radiographs; if has not passed pylorus in 24 hours, remove endoscopically 3. Use bougienage to advance battery into stomach 4. Use foley catheter for retrograde retrieval of battery 5. Immediate endoscopic removal of battery

his has ingested a disc-battery, with imaging demonstrating that the battery is currently lodged in the esophagus. Immediate endoscopic removal is warranted, as mucosal injury to the GI tract can often occur rapidly with these ingestions.

infantile colic, which should resolve by

infantile colic, which should resolve by around 4 months of age.

The MMR vaccine can be used to prevent this disease, and may be given to HIV-positive patients who have

who have a CD4 count greater than 200.