PA Easy Pediatrics

The American Academy of Pediatrics (AAP) recommends which of the following treatments for a two-year-old child with an acute otitis media who has a fever of 103.7˚F, had an ear infection two months ago, and in whom you suspect penicillin-resistant strep bacteria?

Amoxicillin-clavulanate 45 to 90 mg/kg, divided into BID dosing and administered for 10 days

A parent brings her child into the office with the concern of the way he stands. To the parent the child looks like they are knocking knees. If the child is indeed presenting this way, what would be the best description of this orthopedic abnormality?

Angulation of an extremity at a joint with the more distal part angled away from the midline.

A parent brings her child into the office with the concern of the way he stands. To the parent the child looks like they are "bowlegged." If the child is indeed bowlegged, what would be the best description of this orthopedic abnormality?

Angulation of an extremity at a joint with the more distal part angled toward the midline.

A mother presents with a 2-month-old infant with a concern of bald spots in the child's scalp. She states that there were ulcerated areas present at birth that healed within a few days. What is the most likely diagnosis? A Alopecia areata B Aplasia cutis congenita C Epidermolysis bullosa D Seborrheic dermatitis

Aplasia cutis congenita is a rare condition that is present at birth, and presents as asymptomatic ulcerations of the scalp. These ulcerations heal with scarring in a matter of weeks. The cause is believed to be incomplete neural tube closure or cessation of skin development of the embryo.

Azithromycin (B) is a macrolide antibiotic that

Azithromycin (B) is a macrolide antibiotic that binds to the 50S ribosomal subunit to inhibit protein synthesis. Beta lactam antibiotics (A) inhibit the transpeptidation reaction leading to cell wall destruction, Ciprofloxacin (C) inhibits DNA replication by binding to DNA gyrase and topoisomerase IV, tetracycline (E) binds to the 30S ribosomal subunit to inhibit protein synthesis, and sulfamethoxazole (D) inhibits dihydropteroate synthase and folate production.

What nerve is most commonly injured in a mid- or distal humeral shaft fracture? A Axillary B Median C Peroneal D Radial E Ulnar

Because of the radial nerves proximity to the humerus, mid and distal shaft fractures with significant displacement can cause a radial nerve injury.

A 2 year-old girl presents to the clinic due to fever, and right ear pain. Physical exam reveals a temperature of 103.1 F and an erythematous and immobile right tympanic membrane. The patient is subsequently prescribed amoxicllin. What is the mechanism of amoxicillin?

Beta lactam antibiotics inhibit the transpeptidation reaction leading to cell wall destruction (E).

chemosis

Chemosis is the swelling (or edema) of the conjunctiva. It is due to the oozing of exudate from abnormally permeable capillaries. In general, chemosis is a nonspecific sign of eye irritation.

Examination of a female newborn demonstrating cyanosis after feeding reveals a systolic ejection click that is heard best at the third left intercostal space, and a short grade III/VI systolic ejection murmur that is heard best at the second left intercostal space. Given this patient's physical exam findings, which of the following is the most likely finding on an echocardiogram? A Pulmonic stenosis B Aortic stenosis C Mitral regurgitation D Aortic regurgitation E Mitral stenosis

Choice A, pulmonic stenosis, is the most likely finding on echocardiogram, as severe pulmonic stenosis frequently presents with a newborn infant presenting with cyanosis after feeding, and a systolic ejection murmur heard best at the second left intercostal space. Congenital pulmonic stenosis occurs in 1 in 10 patients with congenital heart disease. Most patients demonstrate only mild to moderate pulmonary stenosis and are asymptomatic, but infants with critical stenosis require intervention with balloon valvuloplasty. Choice B, aortic stenosis, if critical, would present with pulmonary congestion and heart failure within the first few weeks of birth, with a lack of peripheral pulses and no murmur. Choice C, mitral regurgitation, would not present with a cyanotic infant; however, in more severe mitral regurgitation, failure to thrive, frequent respiratory infections, and heart failure can occur. It would also present with a holosystolic blowing murmur, heard best at the apex.

orbital blow out fracture

Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve.

An 11-year-old boy has a history of early growth failure and cherubic features. His height velocity chart is shown. What is the most likely cause of the sharp increase in the growth curve at age six? A Pituitary adenoma resection B Glucocorticoid replacement C Insulin therapy D Ensure supplementation E Recombinant human growth hormone

E The correct choice is E, recombinant human growth hormone. This patient had a classic presentation of growth hormone deficiency.

A 12 year old female found a tick on her leg after a camping trip. The tick was removed without incident. According to CDC recommendations, what is the appropriate testing for Lyme disease? A ELISA, if + or equivocal, follow up with Western Blot B Western Blot, if + or equivocal, follow up with ELISA C Cbc with diff and skin biopsy D Skin biopsy and gram stain

ELISA, if + or equivocal, follow up with Western Blot The CDC recommends first using ELISA to test for Lyme disease. If this is positive, then a Western Blot should be performed as confirmation

A 10-year-old male who plays soccer presents with annularly configured dermal papules that are skin colored and shiny, and are located on his shins. His mother states that the lesions started as nodules, and have since enlarged. There is no scale present and they are asymptomatic. No one else in his home has similar findings. What is the most likely diagnosis? A Atopic dermatitis B Contact dermatitis C Granuloma annulare D Tinea corporis

Granuloma annulare (GA) is a self-limited condition that may appear as solitary lesions or in a more generalized distribution. They begin as small, shiny skin colored dermal papules that enlarge over time with central clearing. There are no epidermal manifestations. GA commonly occurs over bony surfaces, such as the shins or dorsa of the hands. It is frequently misdiagnosed as tinea corporis; however, the absence of epidermal scaling helps rule out this diagnosis.

A 9-year-old girl is brought to the office by her mother who has noticed that the child's neck looks "odd." The girl states that it feels "like something is there," indicating the base of the neck, but that she has no difficulty swallowing. A thorough examination reveals only a firm, nontender, and diffusely enlarged thyroid with no thrills or bruits. All parameters on a thyroid function panel are within normal limits. Low levels of thyroid antibodies are present. What is this child's most likely diagnosis? A Chronic lymphocytic thyroiditis (Hashimoto thyroiditis) B Graves disease C Papillary carcinoma of the thyroid D Pituitary tumor E Subacute thyroiditis (deQuervain thyroiditis)

Hashimoto thyroiditis, the most common thyroid disorder in the United States, is an autoimmune disease. In children, girls 8-15 years of age are most commonly affected. Graves disease is most common in women ages 20-40. The thyroid enlargement is diffusely enlarged but may be asymmetric and may be accompanied by a bruit. In addition, the patient will have signs and symptoms of hyperthyroidism. Thyroid antibodies and hormones are elevated and TSH suppressed. Thyroid carcinoma is also more likely in women and papillary carcinomas are the post common. They present as a firm nodule in the gland, most often between 10 and 40 years after exposure to radiation. Thyroid-hormone-secreting pituitary tumors (rare) usually present with signs and symptoms of hyperthyroidism without enlargement of the gland and normal or high serum TSH levels. DeQuervain thyroiditis presents with signs and symptoms of hyperthyroidism and an enlarged tender gland.

A newborn male is diagnosed with Christmas factor deficiency. What is the likelihood that he inherited this disorder from his father? A 0% B 25% C 50% D 75% E 100%

Hemophilia B (or Christmas factor deficiency) is one of only two sex-linked pattern-bleeding disorders, and as such the disease occurs almost exclusively in males. Sons of carriers have a 50% chance of being affected and daughters of carriers have a 50% chance of being carriers themselves. The Correct Answer is: A

An Rh-negative, 5-year-old male child presents with acute onset of petechiae and purpura after an acute viral illness. In addition, he has episodes of epistaxis. Which of the following is a treatment option if his platelet count falls below 20,000/mm 3 , but he is not actively bleeding? A platelet transfusions B IV anti-D (WinRho SD) 50-70 mg/kg/dose C prednisone 2.4 mg/kg/24 hours × 2 weeks D splenectomy

In patients with idiopathic thrombocytopenic purpura, treatment options should be initiated when platelet counts fall below 20,000, regardless of whether there is active bleeding or not. Without active bleeding the treatment options include prednisone 2-4 mg/kg/24 hours for 2 weeks; IV immunoglobulin 1 g/kg/24 hours for 1 to 2 days, or IV anti-D 50-75 μg/kg/dose for Rh-positive patients. Splenectomy is indicated for life-threatening bleeding.

A 6-year-old female child presents with complaints of chronic hip pain so severe that she has not been able to walk to the school bus. Examination shows severe tenderness at the left hip with markedly decreased active and passive range of motion. Radiologic examination demonstrates joint effusion with widening. Which of the following is the most likely diagnosis? A osteochondritis dissecans B slipped capital femoral epiphysis C septic hip arthritis D Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is also known as avascular necrosis of the proximal femur. It typically occurs in children between 4 and 8 years old and persistent hip pain is the main symptom. On examination, the clinician notices a limp and/or limitation of motion of the affected hip. Radiologic examination demonstrates the necrosis with effusion and joint space widening with a negative aspirate. Treatment involves surgical hip replacement. Slipped capital femoral epiphysis (SCFE) is due to the displacement of the proximal femoral epiphysis owing to disruption of the growth plate. The head is normally displaced medially and posteriorly relative to the femoral neck. It typically occurs in adolescence, specifically obese males, and can also be associated with hypothyroidism. SCFE usually occurs after direct trauma to the hip or a fall. Patients complain of vague symptoms at first that progress into pain of the hip or of the knee. On examination, there is decreased internal rotation of the hip that can be confirmed by lateral X-ray of the hip.

Measles

Measles is one of the few exanthemas where the primary lesions are both macules and papules. These lesions may coalesce to become confluent. The pathognomonic lesion of measles is the Koplik spot, which is a blue-white papule with surrounding erythema appearing on the oral mucosa.

A 16-year-old male soccer player is complaining of pain to the right foot that has been getting progressively worse for the last 2 months. He states it hurts the most when he has all of his weight on his right foot as he plants to kick the ball. Most of the pain appears to be on weight bearing. You are concerned that this patient may be developing a stress fracture. Based on the patient's history and patient presentations, which bone is the most affected by stress fractures in the foot?

Of the metatarsals, the second metatarsal has the highest number of stress fractures. These weight bearing bones can be particularly vulnerable to stress fracture if the patient is involved in long distance running, especially if he/she is wearing improper footwear for that activity or footwear that has lost most of its shock absorbing abilities. Some young female athletes may be training so hard that they become amenorrheic which can contribute to osteopenia resulting in weaker bones. Older patients with osteoporosis will also have a higher risk of stress fracture. Initially stress fractures of the metatarsals may present with a small area of localized pain and the dorsal forefoot may demonstrate a fairly diffuse area of swelling. If the stress fracture is not treated early, some patients will experience an audible pop or crack as the incomplete stress fractures progresses to a complete break.

What age group is most at risk to develop osteoid osteoma? A Adolescents B Elderly C Middle-aged D Neonates E Toddlers

Osteoid osteoma is a benign bone forming tumor that usually develops during a patient's second decade of life. This type of tumor is much more common in boys than girls and typically affects the lower extremities (femur and tibia primarily) and spine more than other areas of the body. Patients typically present with gradually progressive bone pain that is worse at night and does not correlate with activity level. The tumor produces high levels of prostaglandins, so symptoms usually improve in 20-25 minutes if the patient takes a medication like ibuprofen, ASA or other NSAIDS that are prostaglandin inhibitors. A lack of improvement in symptoms with these medications should lead health care providers to consider a different diagnosis.

A 28-week-premature infant is noted to have increasing tachypnea and difficulty breathing, with diffusely decreased breath sounds on exam shortly after delivery. A chest x-ray reveals diffuse, bilateral atelectasis and air bronchograms. Which of the following is the most likely diagnosis? A Acute asthma exacerbation B Hyaline membrane disease C Meconium aspiration D Pleural effusion E Spontaneous pneumothorax

Premature infants, due to a lack of surfactant, develop marked atelectasis and decreased lung compliance, with acute respiratory distress. This is termed hyaline membrane disease and is the most common cause of respiratory distress in preterm infants

A 16-year-old girl is referred for a sports physical. Her blood pressure is 170/92 mm Hg. Urinalysis (UA) reveals 2+ protein. The girl's mother reports multiple episodes of urinary tract infections (UTIs) throughout childhood that were never investigated. The most likely diagnosis is A obstructive uropathy B orthostatic proteinuria C chronic reflux nephropathy D nephrotic syndrome E exercise-induced proteinuria

Retrograde flow of urine from the bladder damages the renal interstitium, causing inflammation and fibrosis. If untreated, irreversible damage to the kidneys will occur. Because this is a tubulointerstitial process, the urinalysis will be negative for protein in the early stages of damage. Most damage is done before age 5, but if undetected, glomerular damage will occur and protein will appear in the urine eventually. Hypertension develops as the GFR decreases.

Which of the following is the initial treatment step in an adolescent who presents to the emergency department with status epilepticus?

Status epilepticus is a medical emergency and is defined as seizure activity that lasts a minimum of 30 minutes. This results in hypoxia, acidosis, cerebral edema, and structural damage. In addition, fever, respiratory depression, hypotension, and death may occur. There are both convulsive and nonconvulsive types of status epilepticus. Because of its emergency status and potential complications, the clinician needs to initiate the ABCs (airway, breathing, circulation). Therefore, the first line of treatment is to establish and maintain an airway, oxygen is next, and then circulation, which encompasses pulse, blood pressure, and IV access. Once the IV is established, the orders should be for administering glucose-containing fluids and IV drug therapy with diazepam, lorazepam, or midazolam as well as administer phenytoin and phenobarbital. Arterial blood gases should be ordered and any abnormalities should be corrected approp

In a 4-year-old female child who presents with "toeing in," which of the following is the likely etiology? A femoral anteversion B genu valgum C genu varum D tibial torsion

The Correct Answer is: A "Toeing in" in children before the age of 2 is typically due to tibial torsion; however, any "toeing in" after the age of 2 to 3, is usually due to femoral anteversion. The femur has more internal rotation that results in the presentation. Genu varum is known as bowleg and genu valgum is known as knock-kneed.

This common malignancy is diagnosed in patients younger than 15 years of age, has an incidence peak during early childhood (2 to 4 years old), and is seen more prominently in industrialized nations. What is the name of this malignancy?

The Correct Answer is: A Acute Lymphoblastic Leukemia is the most common malignancy diagnosed in patients younger than age 15, and has a peak incidence of 2 to 4 years of age. It is seen more often in males, and the pattern affected suggests a leukemogenic contribution from factors associated with industrialization.

A 20-year-old male presents to the emergency department complaining of pain to the right shoulder region while playing basketball. He states that his arm was pulled back and rotated while he was moving forward, and then felt a popping sensation in the shoulder. Since then he has not been able to move the shoulder at all due to pain and immobility. It is suspected that he has a dislocation. Given this scenario, what would be the most likely type? What type of shoulder dislocation did he most likely experience?

The Correct Answer is: A All of the various types of dislocations mentioned above are possible, but anterior dislocations are by far the most common (>95%) and they are the most common of all joint dislocations.

A 3-year-old white male with low grade fever, lethargy, and fatigue for several weeks is seen on repeat visit. His mother states that nothing has helped. He has been trialed on a course of antibiotics without improvement. He has petechiae to his lower extremities and pallor throughout. What other physical finding is likely to be found in this patient? A Bone pain B Cranial nerve palsy C Epidural spinal cord compression D Painless enlargement of the scrotum E Subcutaneous nodules

The Correct Answer is: A All physical findings are possible in this patient, who has acute lymphoblastic leukemia (ALL). However, of those listed, bone pain is the most common.

A 5-year-old girl presents to the office with her mother, who states the child is experiencing excessive tearing, itching, and redness of her eyes. On physical exam you note marked injection with chemosis without discharge. The patient lacks adenopathy. Which of the following is the most likely diagnosis? A Allergic conjunctivitis B Bacterial conjunctivitis C Inclusion conjunctivitis D Keratoconjunctivitis E Viral conjunctivitis

The Correct Answer is: A Allergic conjunctivitis (A) is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis.

You suspect that a 5-year-old patient has allergic conjunctivitis. Which of the following symptoms or signs would best support this diagnosis? A Itching B Fever C Preauricular adenopathy D Profuse discharge E Sore throat

The Correct Answer is: A Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis (A). Fever (B) and sore throat (E) are more likely to occur in viral or bacterial conjunctivitis. Preauricular adneopathy (C) typically occurs in viral or chlamydial conjunctivitis.

A 10-year-old girl was recently diagnosed with type 1 diabetes. She appears to be adjusting well to her regimen of insulin and glucose monitoring, and follows a careful meal plan that she and her mother work on together. At a follow-up visit, she says that she will "die" if she can't participate on her summer swim team, but her mother is clearly concerned about her becoming hypoglycemic if she exercises that vigorously. In addition to reminding them that regular aerobic exercise is an important part of her overall well-being, which of the following is the most appropriate advice for them? A add an extra snack before exercising to the diet plan B ask the coach for a less-rigorous practice regimen C avoid dextrose-containing beverages during exercise D increase the amount of insulin on practice and competition days E try a less energy-intensive sport than swimming

The Correct Answer is: A Appropriate advice for children with type 1 diabetes is to have extra snacks before exercise. In addition, they should drink dextrose-containing fluids (C) during exercise and decrease insulin (D), while monitoring glucose before, during, and after exercise.

A 9-year-old child, who was diagnosed with a viral upper respiratory infection 2 weeks ago, returns to the clinic with a complaint of a 2-day history of drooping of one side of her mouth. She is afebrile with a blood pressure of 110/60 mm Hg. Her physical examination reveals an inability to completely close her left eye, inability to wrinkle her forehead, and the drooping of her mouth on the left side. Her smile is asymmetric. The remainder of her examination is otherwise normal. Which of the following is the MOST likely diagnosis? A Bell's palsy B botulism C brainstem glioma D Guillain-Barré syndrome

The Correct Answer is: A Bell's palsy is the acquired peripheral facial weakness (cranial nerve VII) of sudden onset and unknown etiology. It often follows a viral illness with notable improvement within 2 weeks and near complete recovery within 2 months.

A 5-year-old male child in the clinic is being evaluated for a firm, painful lump that is slightly reddened and approximately 3 cm in diameter, in his right axilla. His mother tells you the lump has been there for a couple of days. The boy does not look acutely ill. The mother informs you that they got a new kitten and puppy about a month ago but otherwise nothing else is new at home. Which of the following is the most likely etiology for his rash? A Bartonella henselae B parvovirus C Hodgkin disease D Osgood-Schlatter disease

The Correct Answer is: A Cat scratch disease (CSD) is caused by the gram-negative bacillus, Bartonella henselae. Regional lymphadenopathy will usually develop in about 1 to 7 weeks after the cutaneous lesions and will affect the nodes draining the site of the scratch or bite. Because Hodgkin disease involves the lymph nodes, it should be considered as a differential diagnosis when evaluating a child for CSD. However, it typically presents as a cervical lymphadenopathy.

A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following is the most appropriate management for this patient? A Cataract surgery within the next 6 weeks B Cataract surgery within the next year C Observation every 3 months D Observation every 6 months E Observation every year

The Correct Answer is: A Congenital cataracts that are large and affect visual acuity (e.g., central) must be surgically corrected within the first two months of life (A) to avoid the development of deprivation amblyopia.

A 4-year-old female is brought in by her parents due to an increased nightly cough and low grade temperature. The x-ray shown reveals a classic finding for which of the following diagnoses?

The Correct Answer is: A Croup, also known as laryngotracheobronchitis, is associated with upper tracheal narrowing and edema, which is visible on an anteroposterior soft tissue neck x-ray. This is termed the "steeple sign."

At 12 hours of age, a physical examination is performed on a neonate who has intrauterine growth retardation. He is noted to have microcephaly, jaundice, and hepatosplenomegaly. Which of the following is the MOST likely congenital viral infection in this neonate? A cytomegalovirus B herpes simplex virus C rubella D syphilis

The Correct Answer is: A Cytomegalovirus (CMV) is one of the congenital neonatal TORCH infections (toxoplasmosis, other [syphilis, varicella-zoster, and parvovirus in this list], rubella, cytomegalovirus, and herpes simplex/hepatitis/HIV). CMV is the most common congenital infection. The disease-specific manifestations for CMV include microcephaly with periventricular calcifications, neonatal jaundice with direct hyperbilirubinemia, and hepatosplenomegaly. Other associated manifestations include intrauterine growth retardation, thrombocytopenia, and purpura. Disease-specific manifestations of syphilis include mucocutaneous lesions (snuffles), periostitis, osteochondritis, and hemolytic anemia. Often, these babies are stillborn.

A father brings his son to the family practice clinic for a concern for coarctation of the aorta. The father was recently diagnosed with this disease, and he is concerned that his 5-year-old son may have it as well. What is the cardinal physical finding in coarctation of the aorta? A Decreased or absent femoral pulses B Systolic machinery-type murmur C Holosystolic murmur at the lower left sternal border D Thrill in the carotid arteries E Cyanosis at birth

The Correct Answer is: A Decreased or absent femoral pulses is the correct answer.

Which of the following is the most common etiologic agent of bacterial meningitis in the pediatric population of the United States? A Streptococcus pneumoniae B Haemophilus influenzae type B C Listeria monocytogenes D Neisseria meningitides

The Correct Answer is: A Despite the increase in vaccination of infants in the United States, Streptococcus pneumoniae remains the most common etiologic agent for bacterial meningitis in the pediatric population. Haemophilus influenzae type B is the second most common, but has gone down significantly due to the widespread vaccination of children

Patients in which of the following age groups are least likely to experience a dislocation or sprain when a significant stress is placed on their joints? A 5-10 years old B 15-20 years old C 35-40 years old D 55-60 years old E 75-80 years old

The Correct Answer is: A Dislocations and ligamentous injuries are uncommon in prepubertal children as the ligaments and joints are quite strong as compared to the adjoining growth plates. Excessive force applied to a child's joint is more likely to cause a fracture through the growth plate than a dislocation or sprain.

A 5-year-old child presents for her kindergarten checkup. The clinician notes that over the past couple of years, her height decreased from the 50th percentile to the 5th percentile. On examination, the clinician also notes truncal adiposity. Her CBC and lead levels were normal. Which of the following is the most likely diagnosis? A growth hormone deficiency B Cushing disease C congenital hypothyroidism D congenital adrenal hyperplasia

The Correct Answer is: A Growth hormone (GH) deficiency is defined as a decreased growth velocity, delay in skeletal maturation, absence of other explanations for poor growth (lack of intake), and laboratory tests demonstrating decreased GH secretion

A 12 year-old African-American male with a history of sickle cell disease presents to the clinic for routine follow up. A peripheral smear is performed. Which of the following best describes the cause of the abnormality pictured in the patient's peripheral smear?

The Correct Answer is: A Howell-Jolly bodies are noted in the peripheral smear and result from the lack of removal of nuclear material due to an absent or non-functioning spleen. Failure of nuclear maturation (B) produces macrocytosis, intravascular hemolysis (C) leads to the creation of schizocytes, lead intoxication (D) and thalassemia cause basophilic stippling, and uremia (E) is associated with Burr cells.

A patient presents with hyperleukocytosis (WBC 100,000). The bone marrow is consistent with T-cell ALL. The uric acid is less than 7.0 mg/dl. Prior to starting chemotherapy, what is the best therapy to initiate on this patient? A Allopurinol and IV fluids B Aluminum hydroxide and calcium carbonate C Glucocorticoids and vincristine D Leukapheresis and cranial irradiation E Sevelamer and mercaptopurine

The Correct Answer is: A Hyperuricemia is often a finding in patients with hyperleukocytosis. The optimal treatment is to start IV fluids, due to numbers of circulating white cells and allopurinol, to treat hyperuricemi

Which physical exam finding differentiates acne rosacea from acne vulgaris? A The absence of comedones B The absence of telangiectasias C The presence of erythema D The presence of inflammatory papules

The Correct Answer is: A The characteristic lesions of acne rosacea are small papules, papulopustules, and telangiectasias with flushing. There are no comedones present in acne rosacea.

An 8-year-old male with a history of atopic dermatitis presents with a localized rash, consisting of vesicles and eroded lesions. He has a low-grade fever, but no other symptoms. What is the appropriate treatment? A Oral acyclovir for 5 to 10 days B Oral keflex for 7 to 10 days C Topical aclometasone ointment for 10 to 14 days D Topical mupirocin ointment for 7 to 10 days

The Correct Answer is: A The classic lesion of eczema herpeticum is described as a "punched out" lesion, which refers to vesicles that have become eroded. Mild cases of eczema herpeticum can be treated on an outpatient basis with oral acyclovir. More severe cases must be treated on an inpatient basis with IV acyclovir and oral antibiotics if superinfected. (Kane et al., 2002, Fig. 23-4, pg. 550-552)

These lesions are visible on a 14-year-old female's forehead. What medication is this disorder best treated with?

The Correct Answer is: A The lesions are comedones (open and closed). Optimal treatment should be with topical retinoids such as tretinoin and adapalene, as these are comedolytic. Topical erythromycin is indicated in inflammatory acne, not comedonal acne as pictured. Benzoyl peroxide only has mild comedolytic activity and erythromycin has none. This combination medication would be more appropriate for inflammatory acne. Doxycycline has no comedolytic activity.

A 2-month-old female presents for a well child check. The mother has no concerns and feels that the child is doing well. On exam, there is no evidence of cyanosis and the peripheral pulses are normal and equal. However, there is a fixed and widely split S2, a right ventricular heave, and a systolic ejection murmur present. The murmur is heard best at the left sternal border second intercostal space. What is the most likely diagnosis?

The Correct Answer is: A The patient in this scenario is exhibiting the classic signs of an atrial septal defect

A 1 day-old boy develops progressing abdominal distension, bilious vomiting and failure to pass a meconium stool. Abdominal radiographs show dilated loops of small bowel. Which of the following is the most likely diagnosis in this patient? A Cystic Fibrosis B Hypothyroidism C Imperforate anus D Intussusception E Pyloric Stenosis

The Correct Answer is: A The patient presents with a meconium ileus consistent with a diagnosis of cystic fibrosis (A). Pyloric stenosis (E) typically presents between 3 and 6 months of age, while intussusception (D) presents later (6 to 24 months). Imperforate anus (C) presents at birth, but infants typically lack acute abdominal distention and bilious vomit. Other common causes of intestinal obstruction in a newborn include meconium plug syndrome, Hirschsprung Disease, Intestinal Atresia, and Midgut Volvulus.

A two-year-old male presents with a nodule on the side of his index finger. His mother states that he has had this nodule on one prior occurrence during infancy, and it resolved on its own. What is the most likely diagnosis? A Digital fibroma B Juvenile xanthogranuloma C Molluscum contagiosum D Verruca vulgaris

The Correct Answer is: A This child has a recurrent digital fibroma. It is a smooth, firm, pink nodule that occurs on the fingers and toes up through early childhood. Surgical excision is recommended so that the function of the digit is not impaired.

A 2-week-old male infant presents for a routine checkup. The mother complains that he nurses every hour, but vomits (nonbilious) after every time he eats. He has only had three bowel movements since he has been home. On examination, the infant has not gained any weight since leaving the hospital, and the clinician notes gastric peristaltic waves. Which of the following is the treatment of choice for this patient? A pyloromyotomy B metoclopramide C laparotomy D omeprazole

The Correct Answer is: A This infant is presenting with signs and symptoms of pyloric stenosis. Infants typically have vomiting (projectile at times) after every feeding and it normally starts between the age of 2 and 4 weeks.

A 3-year-old male on laboratory examination has a hemoglobin of 6 (9.5 to 15.0), platelet count of 43,000 (150,000 to 450,000), and Leukocyte count of 9.6 (4.5 to 11.0). Blasts are noted in peripheral smear and on marrow examination. What other laboratory examination is essential in this child? A Cerebrospinal fluid examination B Coagulopathy studies C MRI of the chest D Skeletal roentgenography E Urinalysis

The Correct Answer is: A This patient has acute lymphoblastic Leukemia (ALL). Examination of the CSF is essential to rule in/out CNS leukemia. A chest x-ray is adequate to determine if there is enlargement of the thymus or mediastinal nodes. An MRI would not be indicated at this point. Severe bleeds is uncommon and bleeding times are not typically effected. Skeletal roentgenography is not necessary for management of this patient, even if abnormalities are detected.

A 9-year-old male presents with an acute onset of petechiae, ecchymoses, and gingival bleeding. He has pallor, fatigue, and bony pain. A pancytopenia is noted on CBC. Ebstein-Barr is negative. Lymphoblasts are noted on smear. Vitals reveal a temperature of 100.8F, HR 74, and RR 20. A few shoddy cervical nodes are noted. What is the most likely diagnosis? A Acute lymphoblastic leukemia B Aplastic anemia C Infectious lymphocytosis D Infectious mononucleosis E Lymphoma

The Correct Answer is: A This patient has acute lymphoblastic leukemia (ALL). While all the diseases would be in the differential, only ALL fits all the findings. Infectious mononucleosis is excluded with a negative EBV. Infectious lymphocytosis would not have a pancytopenia or increased blasts on smear. Aplastic anemia would have a pancytopenia but not bony pain. Lymphoma typically does not have a pancytopenia associated with the disease.

An 8-year-old male with a history of atopic dermatitis presents with a widespread rash consisting of vesicles and eroded lesions. What is the causative organism? A Herpes simplex virus B Human papilloma virus C Staphylococcus aureus D Varicella zoster virus

The Correct Answer is: A This patient has eczema herpeticum. This is caused by the herpes simplex virus. Transmission can occur innocuously via the parent. Atopic dermatitis is a risk factor for eczema herpeticum, secondary to the impaired barrier function of the skin. This impaired barrier function allows the virus to spread rapidly.

A 1-year-old boy is brought to the emergency department by his parents, who state that the child refuses to walk or crawl and begins crying when they stand him. Swelling to his right knee is noted; it is also warm to the touch and pain response is noted. His parents state that it seemed to start a couple of days ago and has gotten worse. They don't recall a trauma, but state that he seems to bruise easily. The child's mother states that she also bruises easily. Vitals are as follows: Temp: 38.0°C, HR: 70, RR: 15. What laboratory finding would you expect? A Prolonged aPTT (activated partial thromboplastin time) B Prolonged bleeding time C Prolonged PT (prothrombin time) D Prolonged thrombin clotting time E Thrombocytopenia

The Correct Answer is: A This patient has hemophilia A. Patients with severe hemophilia A have a prolonged aPTT; all of the other tests should be within the normal range.

A 4 year old male presents with a fever for 5 days. His highest temperature was 39.4C. His mother brings him to the ED because she noticed this morning that his palms and soles were red. Now, there is blotchy erythema on the trunk with bulbar conjunctivitis and diffuse erythema on the tongue and prominent papillae. CBC shows leukocytosis. What is the appropriate management of this patient? A Hospitalization and IvIg B Hospitalization ad IV antibiotics C Outpatient antibiotics x 10 days D Outpatient symptomatic treatment

The Correct Answer is: A This patient is exhibiting classic signs and symptoms of Kawasaki Disease. Complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, myocardial ischemia or infarction, and stroke. Recommended treatment is hospitalization to monitor for complications and administration of IvIg with aspirin.

A 15-year-old obese male presents with annularly configured lesions in a generalized distribution. They are asymptomatic. What can these lesions be associated with? A Diabetes mellitus B Hyperlipidemia C Hypertension D Systemic lupus erythematosus

The Correct Answer is: A This patient presents with a generalized form of granuloma annulare (GA). Generalized GA can be associated with diabetes mellitus.

A 15 year old male presents with lesions on his palms, dorsum of his hands and lower arm. They began as red macules that developed a central vesicle over a few days. The lesions are pruritic with no other symptoms. What is the most common etiology? A Herpes simplex infection B Insect bites C Psoriasis vulgaris D Atopic dermatitis

The Correct Answer is: A This patient presents with the classic iris or target lesion of erythema multiforme (EM). The most common cause of recurrent EM is herpes simplex outbreak which usually precedes EM by a few days

A 16-year-old boy is seen for a sports physical prior to starting football. On auscultation, a grade II/IV holosystolic murmur is appreciated at the apex. Which of the following maneuvers would be the most appropriate to choose to increase the intensity of the murmur for better identification?

The Correct Answer is: A Utilizing isometric hand grip exercises, the murmur increases in intensity and may be heard radiating to the axilla. Isometric hand grip exercises increase the intensity of the murmur of mitral regurgitation by increasing arterial and left ventricular pressure, which increases the flow across the mitral valve, thereby increasing the murmur's intensity. Choice B is best used when listening to the murmur of mitral stenosis.

What type of fracture is not related to an acute bony trauma? A Greenstick B Stress C Oblique D Comminuted E Spiral

The Correct Answer is: B A stress or fatigue fracture is caused by small, repetitive forces that usually involve the metatarsal shafts, the distal tibia, and the femoral neck (though many other bones may be affected). These fractures may not be seen on initial radiographs. A greenstick fracture is an incomplete traumatic fracture with angular deformity seen in children. An oblique fracture is a traumatic fracture with an angulated fracture line. A comminuted fracture is a traumatic fracture in which there are more than two fracture segments. A spiral fracture is a traumatic fracture that has a multiplanar and complex fracture line usually caused by an excessive rotational force on a bone.

A 4-month-old, full-term infant female presents to the clinic for a well-child visit. The mother states the baby is nursing well and her growth chart progression is within normal limits. Which of the following supplements is most important for this infant to receive? A Fluoride B Iron C Omega-3 fatty acids D Protein E Vitamin K

The Correct Answer is: B Breastfed infants require additional dietary iron, either through supplements or through consumption of iron rich foods (i.e., fortified cerea

A 12-year-old boy presents to the clinic for follow-up regarding his recently diagnosed partial seizures. He reports no seizures or side effects since starting carbamazepine (Tegretol) 1 month ago. What study should be ordered to monitor this patient's treatment? A blood glucose B complete blood cell count C electroencephalogram D vitamin B12 E urinalysis

The Correct Answer is: B Carbamazepine is an anti-epileptic drug that potentially causes blood dyscrasias and requires CBC monitoring. Disorders of carbohydrate metabolism, vitamin B 12 deficiency, or renal toxicity are not commonly reported. EEG is used to help establish a diagnosis of a seizure disorder.

At a 2-month-old well-child checkup, a female infant is noted to have the following physical findings: widely open anterior and posterior fontanels, large protruding tongue, coarse facial features, low-set hair line, and an umbilical hernia. In the newborn period, there was a prolongation of physiologic icterus. The results of the newborn screening test are abnormal. Which of the following is the MOST likely diagnosis? A congenital adrenal hyperplasia B congenital hypothyroidism C Crigler-Najjar syndrome D galactosemia

The Correct Answer is: B Congenital hypothyroidism is one of the most common disorders tested for in newborn screening tests, revealing an elevated TSH (thyroid stimulating hormone) and a decreased T 4 (thyroxine). Symptoms suggestive of congenital hypothyroidism in the neonate include hypotonia, coarse facial features, hirsute forehead, large fontanels (anterior and posterior), widely open sutures, umbilical hernia, protruding/large tongue, hoarse cry, distended abdomen, and prolonged jaundice. Signs of congenital hypothyroidism include lethargy or hypoactivity, poor feeding, constipation, mottling, and hypothermia.

Cystic fibrosis has an autosomal

The Correct Answer is: B Cystic fibrosis has an autosomal recessive (B) genetic inheritance pattern. In this case their children have a 25% chance of being affected, 50% chance of being a carrier, and 25% chance of lacking inheritance of the genetic trait.

A 10 year old male presents with bright red, well-demarcated petechiae and palpable purpura located on bilateral lower extremities. He also complains of abdominal pain and mild joint pain. His mother report the child had an upper respiratory infection about a week ago. Punch biopsy shows IgA immunoreactivity around post-capillary venules. What is the most likely diagnosis?

The Correct Answer is: B Henoch Schonlein purpura (HSP) is commonly described as palpable purpura. It is precipitated by an upper respiratory infection and can also be associated with abdominal pain and joint pain.

Two and a half weeks after a camping vacation in upstate New York, a 12-year-old boy develops a fever and generalized headache. He complains that any light hurts his eyes, that he aches all over, and that he "just can't get warm." On examination he has a diffuse erythematous macular rash that spares the palms and soles, mild cervical lymphadenopathy, and slight hepatomegaly. He does not remember a tick bite, but his mother reports warning signs about ticks in the restrooms of the campground. Of the following tick-borne diseases, which is most likely?

The Correct Answer is: B Human granulocytic ehrlichiosis is commonly found in the upper Midwest and Northeast and has this clinical presentation. The incubation period is 5-21 days. Babesiosis and Lyme are spread by the same tick vector as HGE so must be considered. The incubation period for Babesiosis is 1-3 weeks and it is most common in coastal New England, northern California, and Washington State and around the lakes of the upper Midwest. Symptoms are similar, but usually include dark urine. The incubation period and distribution of Lyme disease are similar to HGE, but the rash is more typically that of erythema chronicum migrans.

What is the most common joint dislocation in children? A Ankle B Elbow C Finger D Knee E Shoulder

The Correct Answer is: B In children the elbow is the most commonly dislocated joint and it is the third most common joint dislocation for adults. The shoulder and finger are dislocated more frequently than the elbow in adults

4-year-old is diagnosed with severe thrombocytopenia, causing spontaneous bleeding two weeks after having influenza. The child has no evidence of anemia, neutropenia, or anything else that raises a suspicion for an alternate diagnosis, and there are no atypical findings on the blood film. What is the most likely diagnosis? A Autoimmune hemolytic anemia B Immune thrombocytopenic purpura C Thalassemia D Thrombotic thrombocytopenic purpura E Von Willebrand's disease

The Correct Answer is: B In children with no other potential causes, the most likely diagnosis is immune thrombocytopenic purpura. The disease must be distinguished from acute lymphoblastic leukemia in this population prior to finalizing the diagnosis. Autoimmune hemolytic anemia would present with an anemia. Thalassemia is an inherited hematologic disorder, von Willebrand is a bleeding disorder typically with normal platelet counts, and thrombotic thrombocytopenic purpura typically has an associated anemia and a lack of bleeding.

A 4-month-old male presents for a well child check. He is healthy and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur that is heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely finding on ECG? A Left ventricular hypertrophy B Normal ECG C Right axis deviation D Supraventricular tachycardia E Sick sinus syndrome

The Correct Answer is: B In this scenario the patient most likely has a small left-to-right shunt of a ventricular septal defect, given the clinical exam findings. The ECG is most frequently normal in a patient with a small ventricular septal defect. If the patient had a large left-to-right shunt left ventricular hypertrophy would be a possibility. The other choices are not commonly seen on ECG when a ventricular septal defect is present.

A 13-year-old female is seen for the first time to establish care. She is known to carry the diagnosis of beta-thalassemia major and has been maintained on regular transfusions for her anemia. She is short for her age and has not achieved menarche. Her glucose level is elevated and she has developed signs of diabetes mellitus. These findings are consistent with which of the following? A End stage thalassemia B Inadequate iron chelation C Inadequately transfused anemia D Stage 3 thalassemia E Untreated thalassemia

The Correct Answer is: B Inadequate iron chelation in patients with thalassemia major results in the absence of a pubertal growth spurt and failure of menarche. These patients may also develop diabetes mellitus, as well as other endocrine disturbances.

A 1400-gram preterm infant has a symptomatic patent ductus arteriosus. What medication has the best chance of closing the patent ductus arteriosus in this patient?

The Correct Answer is: B Indomethacin is an NSAID and inhibits prostaglandin synthesis, allowing for closure of the patent ductus arteriosus in preterm infants.

A mother presents with her 6-year-old child who has a rash on his arm. The rash which is a discrete, red or flesh-colored, flat-topped, thickened area that is linear in nature with papules with scale has remained unchanged despite the use of topical steroids for one month. The lesion is asymptomatic. What is the most likely diagnosis? A Atopic dermatitis B Lichen striatus C Morphea D Verruca vulgaris

The Correct Answer is: B Lichen striatus is a benign rash consisting of linearly configured, shiny, and flat lesions that occur on any skin surface. This rash occurs suddenly and resolves on its own in several weeks. The etiology is unknown.

Which of the following leukotriene pathway inhibitors is indicated for use in this child? A Beclomethasone B Montelukast C Salmeterol D Zafirlukast E Zileuton

The Correct Answer is: B Montelukast (B) is indicated for use in children 1 year of age or older, zafirlukast (D) is indicated for children > 5 years of age, and zileuton (E) is indicated for children > 12 years of age.

A 1 day-old boy develops progressing abdominal distension, bilious vomiting and failure to pass a meconium stool. Abdominal radiographs show dilated loops of small bowel. Which of the following genetic mutations should the patient be evaluated for? A ΔF508 B G551D C Q1412X D R117H E W1282X

The Correct Answer is: B Mutations in CFTR protein function resulting from genotype G551D mutations are amenable to treatment with ivacaftor (B).

A 16-year-old girl presents to the clinic complaining of strong desires to sleep at inappropriate times. She is very concerned because she "felt paralyzed" while falling asleep on the couch last night. Which of the following is the best diagnostic test to confirm this patient's diagnosis? A CT of the head B multiple sleep latency test C Tensilon test D thyroid stimulating hormone E polysomnography

The Correct Answer is: B Narcolepsy is characterized by hypersomnolence, loss of muscle tone prior to sleep, hallucinations upon initiating or arising from sleep, and episodes of sleep paralysis. The diagnostic test that is used in conjunction with clinical history to establish the diagnosis is the multiple sleep latency test.

A 6-week-old male with sickle cell disease presents to the pediatric office for his well-child visit. When should this child begin taking daily prophylactic penicillin? A Now B 2 months C 6 months D 12 months E 5 years

The Correct Answer is: B Patients with sickle cell disease develop functional asplenia as early as 3 months of age and should begin treatment with prophylactic penicillin at 2 months of age to prevent infection by encapsulated organisms (i.e., pneumococcus).

A 4-year-old boy presents to the outpatient clinic for a well child visit. Developmental assessment is normal. Upon visual acuity testing his vision is noted to be 20/30 right eye, 20/40 left eye, and 20/30 with both eyes. Which of the following is the most appropriate management of this child's vision? A Re-assess his vision in 3 months B Re-assess his vision in one year C Re-assess his vision prior to enrolling in kindergarten D Refer to an optometrist E Refer to a pediatric ophthalmologist

The Correct Answer is: B Pediatric ophthalmology referral criteria for 3- to 5-year-old children include visual acuity of less than 20/40 in either eye or greater than a two line difference between eyes, so referral to an optometrist (D) or pediatric ophthalmologist (E), which is preferred by the American Academy of Pediatrics, is not warranted and his vision can be re-assessed at his next well child visit in one year (B).

A 16-year-old boy presents to the office with complaints of a rash, low-grade fever, headache, and malaise. Symptoms began yesterday after he spent most of his free time in the past 4 days deer hunting in the woods around his house. He reports that he does check himself for ticks every night. He often finds them but has not noticed any this season that were latched on to his skin. On examination, his temperature is noted to be 99.9°F, his HEENT is unremarkable, and he has 1 to 2 mm red macules over wrists and ankles with remainder of skin clear. Heart, lungs, and abdomen unremarkable. The most likely diagnosis in this patient is A Lyme disease B Rocky Mountain spotted fever C ehrlichiosis D Q fever

The Correct Answer is: B Rocky Mountain spotted fever (RMSF) is a rickettsial infection caused by Ricketsia ricketsii. The organism is transmitted to humans through the bite of the dog tick and is more common among those who spend time outdoors in a wooded area. The illness begins with generalized symptoms of fever, headache, nausea, vomiting, malaise, and myalgias. The rash of RMSF begins as a macular rash and progresses to nonblanching petechiae. The rash begins over the wrists and ankles and progresses to the arms, legs, and trunk.

A 6-year-old female child presents with neck pain and fever for 2 days. Her remote history consists of 2 to 3 days of diarrhea and vomiting. She attends a local daycare where other kids had similar nausea/vomiting, but recovered. The LP was positive for gram-negative bacilli, decreased glucose, increased protein, and increased neutrophils. Which of the following is the most likely etiologic agent? A rotavirus B Salmonella species C Corynebacterium diphtheria D Clostridium botulinum

The Correct Answer is: B Salmonella species are gram-negative bacilli that are classified as Enterobacteriaceae, along with E Coli. While extremely uncommon as an etiology for meningitis, salmonella can cause lethal meningitis infections and must be watched.

A 14-month-old African American boy is diagnosed with sickle cell anemia. Neither parent has the disease. If you are counseling the parents of this child on the likelihood of another one of their children having sickle cell disease, what percentage would you tell them? A 0% B 25% C 50% D 75% E 100%

The Correct Answer is: B Sickle cell anemia is an autosomal recessive genetic disorder.

The Centers for Disease Control and Prevention recommend the first lead screening for children living in high risk areas in the United States at which age? A 6 months B 9 months C 15 months D 24 months

The Correct Answer is: B The CDC recommends that there are two age ranges for testing lead in children in the United States: 9 to 12 months and again at 24 months.

What is the peak incidence of age for a patient who presents with acute rheumatic heart disease?

The Correct Answer is: B The bulk of the cases of acute rheumatic fever are within the pediatric population. It is rare in younger children, as well as in adults over the age of 40.

A 3-year-old boy presents complaining of left ear pain since early this morning. The mother states he has had cold symptoms for 3 days and awoke crying, with left ear pain, and a temperature of 102.6˚ F. Which of the following physical exam findings most accurately establishes the anticipated diagnosis? A Fever greater than 101.5˚ F B Immobile or hypo-mobile tympanic membrane C Post-auricular adenopathy D Tenderness with palpation of the external ear E Tympanic membrane erythema

The Correct Answer is: B The diagnosis of acute otitis media is best established through the use of pneumatic otoscopy demonstrating decreased tympanic membrane mobility (B).

A 5-year-old male is being evaluated for an acute injury to the right ankle. On the x-ray of the ankle there is a distal tibia fracture that involves the separation of the epiphysis, as well as a small non-displaced chip fracture of the metaphysis of the tibia. Based on these findings, what type of Salter-Harris fracture does this child have? A I B II C III D IV E V

The Correct Answer is: B The growth plate is the most fragile part of the bone prior to bone maturation and thus is usually the first structure disrupted when force is applied. Statistically, Type II fractures are most common - those that involve both the growth plate and a chip fracture of the metaphysis.

The most common cause of nephrotic syndrome in children is A post-streptococcal glomerulonephritis B minimal change disease C diabetes mellitus D NSAIDs E polycystic kidney disease

The Correct Answer is: B The most common cause of nephrotic syndrome in children is minimal change disease.

Which of the following is the recommended treatment for a 4-year-old child with presumed bacterial meningitis? A cefotaxime or ceftriaxone plus ampicillin B cefotaxime or ceftriaxone plus vancomycin C gentamicin plus ampicillin D ampicillin plus chloramphenicol

The Correct Answer is: B The most common etiologic organisms for bacterial meningitis in children are S pneumoniae, N Meningitidis, and H influenzae. Because of an increase in resistant S pneumoniae, coverage with vancomycin and a third-generation cephalosporin such as cefotaxime or ceftriaxone is needed for best coverage.

The mother of a four-month-old brings her son in for evaluation of cyanosis. The mother noted the cyanosis in the last two days, and it is most evident when he is feeding or crying. He was previously healthy, with no medical problems. On physical examination, a grade III/VI systolic ejection murmur is present at the left sternal border in the third intercostal space, and radiates to the back. Which of the following diagnostic studies will best help you in establishing the diagnosis?

The Correct Answer is: B The most likely diagnosis, given the history and physical examination, is tetralogy of fallot. Echocardiography usually establishes the diagnosis by visualizing the large ventricular septal defect, the right ventricl infundibular stenosis, and the enlarged aorta

A 2-year-old boy presents to the clinic for his routine well child visit. On physical exam of his mouth and dentition you observe the following. Which of the following is the most likely diagnosis?

The Correct Answer is: B The patient is noted to have whitish discoloration at the gingiva margin consistent with the early demineralization of a dental carie (B

A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following should be ordered to confirm the suspected diagnosis? A Arterial blood gas B Inspiratory and forced expiratory chest x-rays C PA and lateral chest x-ray D Peak expiratory flow rate E Spirometry

The Correct Answer is: B The patient most likely has aspirated a foreign body. This is best evaluated through the demonstration of inspiratory localized hyperinflation and expiratory mediastinal shift (B) on chest x-ray.

An 8-year-old male with hair loss, pruritus, and posterior cervical lymphadenopathy has a + culture on dermatophyte test medium (DTM). Which of the following is the most appropriate treatment?

The Correct Answer is: B The positive DTM confirms the diagnosis of tinea capitis. The only approved treatment for tinea capitis is griseofulvin. In tinea capitis, the dermatophyte invades the hair shaft and topical treatment is not effective.

A six-month-old infant presents to the primary care provider with complaints of a spreading rash. The physical exam shows multiple yellow-brown macules and plaques that urticate when stroked. What would an appropriate treatment regimen include?

The Correct Answer is: B This condition is consistent with urticarial pigmentosa, and it will resolve over time. However, certain things such as NSAIDS, codeine, and scopolamine, as well as extreme temperatures, can cause such reactions as anaphylaxis.

A 12-year-old male presents with hyperkeratotic papules located on both hands. What is the causative organism? A Herpes simplex virus B Human papilloma virus C Parvovirus B19 D Varicella zoster virus

The Correct Answer is: B This patient has verruca vulgaris or the common wart. The causative organism is the human papillomavirus (HPV). They can affect patients of any age and can occur on any skin surface. There is a predilection for the hands and fingers.

An 8-year-old male child presents with brown, nonpruritic, annular lesions on the back of his hands and feet. Intradermal nodules are seen on the extensor surfaces of the elbows and knees that have been present for several months. At today's visit, the lesions are essentially unchanged since his last visit about a month ago. What is the best treatment for this suspected disorder? A excision and biopsy B no treatment C topical steroids D wet to dry dressings

The Correct Answer is: B This presentation is typical for granuloma annulare, which is a benign skin disorder, and treatment is not warranted. It is most commonly seen in children aged 6 to 10. The red to brown lesions are annular or circinate. These asymptomatic lesions are often confused with tinea corporis. The lesions will disappear on their own over a couple of years.

First-time parents present to the clinic with their 2-week old infant for a well-child visit. Which of the following strategies should be recommended to parents to help prevent sudden infant death syndrome (SIDS)? A Avoid pacifier use B Encourage tummy time while awake C Increase room temperature D Place infant on side for sleep E Use home monitors

The Correct Answer is: B Tummy time (B) helps infants develop strength to avoid situations that compromise breathing. Pacifiers (A) are recommended to help avoid bottle feedings as a sleep aid since they are associated with an increased risk of SIDS. Excess warmth (C) and prone or side (D) sleeping positions also increase the risk of SIDS. Home monitors (E) are not effective in the prevention of SIDS.

A 1-year-old female is having a 2-day history of fever (102 0 F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non-toxic appearing, has a rectal temperature of 100.2 0 F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x-ray has no specific findings. Based on these findings, what is the initial ancillary test to confirm the diagnosis? A Acid fast bath test B Viral nasal washings C Sputum culture and sensitivity D Blood cultures

The Correct Answer is: B Viral nasal washings are the best choice for determining RSV infection that causes bronchiolitis.

A 2-year-old child presents to the emergency department via ambulance due to a seizure lasting approximately 2 minutes with jerking and somnolence. En route in the ambulance her vital signs are: temperature 39°C rectal; pulse 120/min; respirations 32/min; blood pressure 110/64 mm Hg. Upon further questioning, her mother claimed she had a runny nose yesterday. On physical examination, she is sleepy but arousable with negative Kernig and Brudzinski signs. Which of the following seizures is the MOST likely diagnosis? A absence seizure B complex partial seizure C febrile seizure D simple partial seizure

The Correct Answer is: C A febrile seizure is a brief (less than 15 minutes), generalized, symmetric, tonic-clonic seizure associated with a febrile illness (temperature greater than 38.8°C) without any central nervous system infection or neurologic cause. An absence (petit mal) seizure is a brief (2 to 25 seconds) loss of consciousness that can occur multiple times per day. There is no loss of tone, and frequently the only observable behaviors are staring or minor movements such as lip smacking and semipurposeful movements of the hands.

What types of connective tissue are injured in a sprain? A Bones and muscles B Fascia and joint capsules C Ligaments and joint capsules D Muscles and tendons

The Correct Answer is: C A sprain involves injury to those tissues that give support to joints - ligaments and joint capsules. Injury to muscles, tendons, and fascia would all be classified as a strain. Injuries to bone would be classified as a fracture.

A 5-year-old girl presents to the office with her mother, who states the child is experiencing excessive tearing, itching, and redness of her eyes. On physical exam you note marked injection with chemosis without discharge. The patient lacks adenopathy. Which of the following is the most appropriate treatment? A Azithromycin 1 gram by mouth B Observation and reassurance C Olopatadine 0.1% ophthalmic solution twice daily D Sulfacetamide 10% ophthalmic solution three times a day for 5 days E Valacyclovir 500 mg by mouth twice daily for 10 days

The Correct Answer is: C Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis and is treated with antihistamines/mast cell stabilizers

A seven-week-old male infant is believed to have had a febrile seizure. The mother states that he has had rhinorrhea and fever x 2 days, and this afternoon he had a witnessed generalized tonic-clonic seizure for approximately two minutes. There is no history of seizures, trauma, new medications, or rash. A physical exam reveals an irritable infant with an elevated temperature of 102.4˚F, an erythematous bulging left tympanic membrane, and clear rhinorrhea with mucosal swelling. Which of the following is the most appropriate next management step for this infant? A Anticonvulsant medication B Electroencephalogram C Lumbar puncture D Skull x-rays E Watchful waiting

The Correct Answer is: C Although febrile seizures are common in the pediatric population, newborns and young infants with irritability, seizure activity, and fever should be evaluated for bacterial meningitis, according to the American Academy of Pediatrics. This requires a lumbar puncture.

What is a commonly shared feature of bipolar disorder and ADHD in pediatric patients? A disruptive B obsessed with ideas C behavior problems D impaired concentration E insomnia

The Correct Answer is: C Behavior problems are a commonly shared feature of pediatric ADHD and bipolar disease. Disruptive and impulsive behaviors are a shared feature of conduct disorder.

A 2-week-old male infant is being seen in the clinic for a profuse mucoid discharge from both eyes, with some associated tearing. On examination, you notice both eyes are hyperemic and the eyelids are red and swollen. Which of the following is the most likely cause of this patient's ophthalmia neonatorum (conjunctivitis in the newborn)? A allergic B gonococcal C chlamydial D viral

The Correct Answer is: C Chlamydial infections are the most common cause of conjunctivitis in newborns in developed countries. Other causes of ophthalmia neonatorum include reactions to silver nitrate prophylaxis, other bacterial infections such as gonococcal or staphylococcal, or viral organisms such as adenovirus or echovirus. Chlamydia trachomatis causes conjunctivitis and pneumonia in neonates.

A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following diagnostic studies should be performed as a result of this finding? A Fasting blood glucose B MRI of the eye and orbit C Rapid plasma reagin (RPR) D Serum cortisol level E Serum thyroid stimulating hormone level

The Correct Answer is: C Congenital cataracts may result from transmission of maternal infections such as herpes simplex virus, cytomegalovirus, toxoplasmosis, or syphilis and require further evaluation for potential systemic infection. A quantitative RPR (C) should be performed to assess for congenital syphilis.

While seeing a 12-week-old baby girl for her well-child checkup, it is noticed that she has tearing from her left eye. There is a small reddened area that is swollen and she cries when it is touched. The swollen area is just below the medial inferior eyelid. There is also constant tearing from this same eye. Her mother says it just started about 2 days ago and is getting worse. What is the most likely cause of this problem?

The Correct Answer is: C Dacryocystitis, whether acute or chronic, is usually secondary to bacterial infections. It presents as an acutely inflamed swelling and tender area over the lacrimal sac just medial and inferior to the inner canthus of the eye. Because the lacrimal sac is inflamed and blocked there is tearing and usually purulent discharge from the eye. Treatment consists of oral and topical antibiotics and warm compresses, and surgical drainage may also be indicated

Which of the following daily maintenance fluid requirements is the closest approximation for a 24-kg child who is refusing to eat? A 1,080 mL B 1,200 mL C 1,580 mL D 2,000 mL

The Correct Answer is: C Dehydration is a common pathophysiologic alteration in fluid balance in children. 100 mL/kg for the first 10 kg of body weight 50 mL/kg for the next 10 kg of body weight 20 mL/kg for the weights above 20 kg For this question, a 24-kg child would require: 100 mL/kg × 10 kg = 1,000 mL for the first 10 kg 50 mL/kg × 10 kg = 500 mL for the next 10 kg 20 mL/kg × 4 kg = 80 mL for the next 4 kg Total = 1,580 mL 24 kg

A 2-day-old infant presents with numerous red macules with central vesicles and pustules. The rash spares only the palms and soles. The infant has no fever and is nursing normally. What is the most likely diagnosis? A Acne neonatorum B Congenital herpes simplex C Erythema toxicum D Milia

The Correct Answer is: C Erythema toxicum is a benign rash seen in newborns. The cause of the rash is unknown and resolves spontaneously. The rash appears as erythematous macules, which may develop central vesicles within 24 to 48 hours. The palms and soles are spared.

A 20-month-old boy is brought into the emergency department by his parents. They state he has not been feeling well for 2 days and this morning noted he was "shaking all over" and was not responding to commands. This went on for less than 10 minutes and has never happened before. His current rectal temperature is 100.7°F. The seizures are characteristic of A absence seizures B Lennox-Gastaut syndrome C febrile seizures D infantile spasms

The Correct Answer is: C Febrile seizures can occur in children younger than 5 years when accompanied by a fever. They are characterized by a brief generalized motor seizure. Absence seizures are generalized seizures characterized by a loss of consciousness without motor involvement, typically seen in older children Lenox-Gastaut syndrome presents in childhood as well but is usually associated with developmental delay and seizures of akinetic and myoclonic nature (referred to as drop attacks) Infantile spasms occur without relation to systemic illness and are massive myoclonic events with bending at the waist.

A 7-year-old is diagnosed with an acute case of hematogenous osteomyelitis accompanied with fever and leukocytosis. Based on your knowledge of the disease, which bone is most likely to present with the infection? A Feet B Hands C Long bones D Pelvis E Vertebrae

The Correct Answer is: C Fortunately, hematogenous osteomyelitis is not common in children, but when it does occur it primarily is found in the long bones. The femur, tibia and humerus are the most typical locations for osteomyelitis in children. . The highly vascular metaphysis of long bones contribute to the potential for hematogenous spread of the implicated pathogen

An 11-month-old African-American male presents to the pediatric office with lethargy, jaundice and splenomegaly. A CBC reveals hemoglobin of 8.0 mg/dl and a hematocrit of 25%. Peripheral smear appearance is available below. Which of the following treatments will reduce hemolysis and increase hemoglobin levels for this patient?

The Correct Answer is: C Hydroxyurea directly reduces hemolysis and increases levels of fetal hemoglobin and reduces complications and transfusion frequency.

In a 6 year old non-bleeding child with a platelet count of 20,000, and a new diagnosis of immune thrombocytopenic purpura, what is the best clinical intervention? A Glucocorticoids B Immunization against pneumococcus C No therapy D Splenectomy E Weekly transfusions of platelets

The Correct Answer is: C In non-bleeding children with platelet counts of 20,000, no therapy is indicated. More than two-thirds of children diagnosed with ITP will resolve in less than six months, and more than 80% after one year. Immunization against pneumococcus is appropriate if a splenectomy is planned. Glucocorticoids are useful, but may be avoided as an initial intervention and avoidance of side effects. Splenectomy is used only after one year of diagnosis, and when the child is at least five years old. Transfusion of platelets is not needed in non-bleeding individuals.

A mother brings in her 20-month-old female child to the office because she noticed pubic hair growing. On examination, the clinician notices that the clitoris is enlarged; the rest is unremarkable. Which of the following is an expected laboratory finding on this patient? A increased aldosterone B increased estrogen C increased androstenedione D increased luteinizing hormone

The Correct Answer is: C Infant girls presenting with signs of precocious puberty need to be screened for congenital adrenal hyperplasia (CAH). CAH most commonly presents with pseudohermaphroditism in females—urogenital sinus, enlarged clitoris, or other signs of virilization

A 12-year-old female presents with a complaint of dry flaking skin that becomes fissured and painful. Her skin has always had dark plate-like scales. What is the most likely finding in the patient's history? A Her skin forms blisters with minimal contact B She was premature C There was a membrane present at birth D There were no symptoms present until the age of six

The Correct Answer is: C Lamellar ichthyosis is a condition in which a baby is born with a collodion membrane. Within a few weeks, this membrane is shed and replaced by large gray scales. These plate-like scales persist with no improvement over time. Painful fissures on the hands and feet are common.

A 6-year-old girl presents to the emergency department with abdominal distension of 1-day duration. She has not had a bowel movement or passed flatus in 72 hours. Examination reveals markedly diminished bowel sounds with tympany to percussion. She has also passed bloody mucus from her rectum. There is no evidence of hernia, and surgical history is negative. Which of the following is the most likely diagnosis?

The Correct Answer is: C Meckel diverticulum is prevalent in 2% of the population, has a 2:1 male:female predominance, and is usually located 2 ft from the ileocecal valve. The most common clinical presentations are bleeding, intestinal obstruction, and inflammation. Bright red or maroon bleeding is the most frequent complication in children younger than 2 years of age. Obstruction may develop secondary to a volvulus that occurs at the site of the diverticulum or from an intussusception with the diverticulum acting as the lead point.

A 6-year-old female presents with small erythematous papules grouped around the mouth. The mother reports that she tried to treat with over-the-counter hydrocortisone 1% cream. The condition has worsened. What is the best step in management of this condition?

The Correct Answer is: C Metronidazole 0.75% gel bid is a first line treatment for perioral dermatitis. Topical steroids, such as hydrocortisone valerate cream, will actually worsen perioral dermatitis and create a granulomatous condition. Oral antibiotics, like Keflex 500 mg bid, are frequently used to treat perioral dermatitis. However, Keflex is not indicated for perioral dermatitis. Clotrimazole is an antifungal cream that is not used in perioral dermatitis.

A 2-year-old male presents with a 10-day history of fever, cough, and decreased appetite and fluid intake. He is normally healthy. On examination, the child appears ill, has a temperature of 102.2 0 F, a pulse rate of 122, and a respiratory rate of 36. On auscultation of the lungs there are rhonchi heard on the right lung fields, as well as a small amount of wheeze. A chest x-ray is ordered, which reveals the presence of pneumatoceles. Based on these findings, what is the most likely pathogen causing this patient's infection? A Streptococcus pneumoniae B Hemophilus influenza C Staphylococcal aureus D Pseudomonas aeurginosa E Chlamydia pneumoniae

The Correct Answer is: C Pneumatoceles, pyopneumothorax, and empyemas are frequently encountered in pediatric Staphylococcal aureus pneumonias.

What is the most serious complication of the influenza B virus? A Multi-lobar pneumonia B Encephalitis C Reye's syndrome D Renal failure E Hepatitis

The Correct Answer is: C Reye's syndrome, while rare, is a very serious complication related to influenza B virus infections. There is a 30% mortality rate, which primarily affects the pediatric population. Hepatic failure and encephalopathy are events that occur in this fatal disease

A 1-year-old female is having a 2-day history of fever (102 0 F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non-toxic appearing, has a rectal temperature of 100.2 0 F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x-ray has no specific findings. What is the initial treatment of choice for this patient with these symptoms?

The Correct Answer is: C The choice for treatment of acute bronchiolitis is supportive care. Oxygen therapy is only reserved for those patients who are hypoxic, and antiviral medications have not proven to be effective in shortening or eradicating the infection.

Which of the following childhood exanthems is characterized by a 10-day incubation period followed by 3 days of fever, runny nose, and conjunctivitis giving way to a maculopapular rash starting on the head, progressing to the trunk, and accompanied by white spots on the buccal mucosa?

The Correct Answer is: C The description best fits that of measles. It has a 7- to 10-day incubation period followed by 3 days of coryza, fever, and conjunctival involvement. The prodrome dissipates as the characteristic rash develops first on the head and face and then the trunk. Koplick spots are the pathognomonic white spots that occur on the buccal mucosa in measles' infection. Herpes simplex infection can present as painful vesicles on the mouth and lips (HSV-1) or genitalia (HSV-2). It is preceded by fever and a tingling or burning sensation at the site where the vesicle will develop. Coxsackievirus causes hand, foot, and mouth disease with lesion distribution in those three areas. Rubella has a longer incubation period (2 to 2.5 weeks) and is less contagious than measles. It is sometimes asymptomatic or produces a milder course than measles.

A mother brings her 11-month-old son to you for a fever and rash. He had four days of fever worsening each day until last night when it measured 104.5°F taken orally before being given acetaminophen. When he awoke this morning, his fever was 100.4°F but he had developed a maculopapular rash to his trunk and extremities that blanches. Which of the following is the probable etiology?

The Correct Answer is: C The most prominent historical feature is the abrupt onset of fever, often reaching 40.6˚C, which lasts up to eight days (mean, four days) in an otherwise mildly ill child. The fever then ceases abruptly, and a characteristic rash may appear. Roseola occurs predominantly in children aged six months to three years, with 90% of cases occurring before the second year.

A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following is the most effective treatment option for the patient's suspected diagnosis? A Albuterol B Azithromycin C Bronchoscopy D Chest physiotherapy E Prednisone

The Correct Answer is: C The patient has most likely aspirated a foreign body. The most effective treatment is removal of the foreign body through bronchoscopy (C).

A 15-year-old male presents complaining of a sore throat, headache, and mild cough that started 8 days ago and has progressed to include a worsening cough and increasing fatigue. His chest x-ray reveals bilateral hilar infiltrates and a CBC is normal. Which of the following diagnostic tests will most likely confirm the suspected diagnosis? A Acid-fast bacilli smear and culture B Blood culture C PCR testing of sputum D Sputum culture E Sputum gram stain

The Correct Answer is: C The patient most likely has atypical pneumonia secondary to mycoplasma pneumoniae which is best confirmed by PCR testing of sputum (C),

A 15-year-old male presents to the outpatient clinic complaining of a sore throat and fever that developed over the last week after feeling fatigued for two to three weeks. The patient appears non-toxic with a temperature of 39.0˚ Celsius. Physical exam reveals pharyngeal and tonsillar erythema with exudates and tonsillar hypertrophy, posterior cervical adenopathy, and splenomegaly. Which of the following laboratory tests is most likely to confirm the expected diagnosis? A HIV antibody testing B Liver function tests C Monospot D Rapid strep test E Rapid plasmin reagin (RPR)

The Correct Answer is: C The patient presentation is consistent with infectious mononucleosis (IM) and can be confirmed through a monospot test (C). The time course of the symptoms and presence of posterior cervical adenopathy makes IM more likely than strep pharyngitis (D).

A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What imaging study is the best initial test to obtain in this patient? A Abdominal plain film B Barium enema C Barium upper GI series D CT scan of the abdomen E Upper GI endoscopy

The Correct Answer is: C The suspected diagnosis is pyloric stenosis. An upper GI series with barium is the best test to obtain in this instance. A barium enema is a good choice in suspected intussusception cases. An upper GI endoscopy is best used when a gastric or duodenal ulcer is suspected. An abdominal plain film or CT could be ordered, but aren't the best initial tests to obtain in this patient's presentation.

12-year-old female presents with linearly distributed light brown papules on her arm. They are asymptomatic and have been present for several years. The mother states that they appear to grow as the child grows. What treatment is necessary?

The Correct Answer is: C This condition is consistent with a linear epidermal nevus. They can appear at any age, but are usually present at or shortly after birth. The pigmented papules are arranged linearly and can occur on any skin surface. They are not symptomatic and will grow with the child. There is no treatment necessary.

A 6-year-old male presents with multiple lesions on his shins. The lesions are annular dermal plaques with a central depression. There are no epidermal changes. He states the lesions are asymptomatic. The child has no other medical problems and is a normal active child. What is the most likely diagnosis?

The Correct Answer is: C This is the classic distribution of granuloma annulare. These lesions commonly occur over bony surfaces and are thought to be secondary to minor trauma (such as playing soccer, normal play activities, or insect bites). The lesions will spontaneously resolve and no treatment is indicated. The distribution in this patient is similar to that of classic necrobiosis lipoidica; however, the dermal changes are classic for granuloma annulare. Necrobiosis lipoidica starts as brown-red plaques that evolve to become waxy appearing. They are commonly misdiagnosed as tinea corporis; however, there are no epidermal changes such as scaling. The lesions are completely dermal. Atopic dermatitis in a 6-year-old child is most commonly distributed on the flexural surfaces and consists of red scaling plaques that are pruritic.

Echocardiography shows a localized narrowing of the aortic arch, just distal to the origin of the left subclavian artery. What is the best definitive treatment for this patient?

The Correct Answer is: C This patient has coarctation of the aorta. Balloon angioplasty of the abnormality is the correct answer, and is a corrective repair.

A mother presents with a four-month-old male infant complaining of a dry, itchy rash that never seems to completely resolve. There are days when it appears to improve. She currently uses baby wash and baby lotion to care for his skin. She recently discontinued the lotion because he screams when it is applied. Which of the following is this condition exacerbated by?

The Correct Answer is: C This patient has the classic presentation of infantile atopic dermatitis. There are numerous factors that can irritate this condition including frequent (more than once a day) or long baths, soap based cleansers, cold dry environments, illness, stress, itchy clothing, and allergies.

A two-week-old female is being evaluated, and on examination she is noted to have bounding pulses with a widened pulse pressure. There is a murmur present at the second left intercostal space, and it is described as a rough machinery murmur. Cyanosis is not present. What is the most likely diagnosis in this patient? A Atrial septal defect B Coarctation of the aorta C Patent ductus arteriosis D Tetralogy of fallot E Ventricular septal defect

The Correct Answer is: C This patient is exhibiting signs of a patent ductus arteriosus. Atrial septal defects may not have a murmur associated with them early in the infant's life, but may develop four to six weeks after birth and present as a nonspecific systolic murmur.

An 8-year-old male presents with hair loss and scalp pruritus with scaling. The mother states it has been present for approximately two weeks. On physical exam, posterior cervical lymphadenopathy is found to be present. What would be the best diagnostic test to perform at this stage?

The Correct Answer is: C This presentation is classic for tinea capitis. Tinea capitis is extremely common in school aged children. It presents with a scaling, pruritic scalp and lymphadenopathy. There is often hair loss that is described as black dot alopecia. The diagnosis is confirmed by culture of dermatophyte test media (DTM).

A 14-year-old female patient presents to your family practice clinic having received a 1% total body surface area first and second degree burn to the left forearm. Of the following, what would you recommend for your patient? A Deroof any blisters, apply bacitracin topically, and prescribe pain medication, with follow-up in 48 hours, B Deroof any blisters, apply silver sulfadiazine topically, and prescribe pain medication, with follow-up in 48 hours. C Leave any blisters intact, apply bacitracin topically, and prescribe pain medication, with follow-up in 48 hours. D Leave any blisters intact, apply silver sulfadiazine topically, and prescribe pain medication, with follow-up in 48 hours, E Refer to the emergency department immediately,

The Correct Answer is: C Unless a critical surface (face, genitalia or hands) is involved, first and second degree burns may be treated in the outpatient setting. Blisters may be left intact as a physiologic dressing, and deroofed after they rupture. The patient requires tetanus prophylaxis and a topical antibiotic cream, usually either silver sulfadiazine or, preferably, bacitracin. Sulfadiazine may permanently stain skin, so use it cautiously in potentially exposed skin areas for cosmetic reasons.

Which of the following is the most common congenital heart malformation?

The Correct Answer is: C Ventricular septal defect, a hole between the two ventricles, can be cyanotic or acyanotic based on the size of the defect, and accounts for 30% of cases of congenital heart disease.

A 12 year old male presents with lesions on the palmar surface. They have been present for less than a week. Prior to the lesion appearing there was a small lesion that was assumed to be a bug bite. The lesion bleeds profusely with minimal provocation. What is the most likely diagnosis? A Glomus tumor B Hemangioma C Spider Angioma D Pyogenic granuloma

The Correct Answer is: D A pyogenic granuloma (PG) occurs at the site of minor trauma such as a bug bite or scratch. The PG grows rapidly forming a popular lesion with a collarette of scale. It will bleed profusely with minimal provocation. The only effective treatment is shave excision with curetting and ablation of the blood vessels that form the base of the PG.

A 4-year-old male has been experiencing a significant cough for the last 12 to 14 days, and initial episodes of coughing are characterized as frequent outbursts of 5 to 10 spastic coughs in a row. The patient does not report any fever, but does note that the coughing is worse at night. On examination, the patient is alert, awake, and oriented. His temperature is 97.7 0 F, pulse rate is 89, respiratory rate is 25, and blood pressure is 110/56. The HEENT is unremarkable, and lung sounds are clear to auscultation. You suspect that the patient may have an acute case of pertussis. Based on the history and physical exam findings, which is the test of choice for confirming a diagnosis of pertussis? A Complete blood count (CBC) B Throat culture C Chest x-ray D Nasopharyngeal culture E Sputum gram stain and culture

The Correct Answer is: D A special medium culture plate (such as a Bordet-Gengou agar) is required for the nasopharyngeal swab for the diagnosis of pertussis. Throat culture, chest x-rays, and complete blood counts are helpful in ruling out other disease patterns.

Which of the following indicates a poor prognosis for someone diagnosed with schizophrenia? A acute onset B co-morbid mood disorder C obvious precipitating event D younger age at diagnosis

The Correct Answer is: D A younger age of onset/diagnosis along with an insidious onset

An 8-year-old girl is rushed to the emergency department by her parents because she has become delirious. The child was diagnosed with influenza three days prior. Her parents say that she had begun vomiting yesterday, almost nonstop, and has not been able to hold down fluids. They also note that she has been breathing rapidly. Your exam reveals a tachypneic, disoriented female with hyperreflexia, a positive babinski reflex, and liver enlargement. CSF analysis reveals a normal protein and cell count. What is the most likely diagnosis? A Bacterial meningitis B Guillain Barre syndrome C Measles encephalitis D Reye's syndrome E Viral meningitis

The Correct Answer is: D Although rare, Reye's syndrome is associated with viral infections, salicylate use during illness, and metabolic disorders. Illness is associated with liver fat deposition and degeneration, intractable vomiting, and mental status changes, which may progress to seizures, delirium, and coma. Cerebral edema contributes to these changes and other neurologic findings.

An avulsion fracture at the base of the fifth metatarsal is commonly called which of the following?

The Correct Answer is: D An avulsion fracture at the base of the fifth metatarsal, usually secondary to plantar flexion and inversion is called a Jones fracture. Also called a ballet or dancer's fracture, it is the most common metatarsal fracture. The fracture occurs at the proximal diaphysis. A Bennett fracture is an oblique fracture of the first metacarpal near the carpometacarpal joint. A boxer's fracture is a fracture of the fifth metacarpal. This is the most common fracture of the hand. A chauffer's fracture is an oblique fracture through the base of the radial styloid in the forearm. A Lisfranc fracture is actually a fracture and dislocation involving the tarsometatarsal joints

An 8-month-old male presents to the clinic due to irritability, fatigue and parental concerns about developmental delays. He is fifth percentile for weight and 33rd percentile for height. An office based hemoglobin level is 8.4 mg/dL. The infant is prescribed iron supplementation, to begin today. Which of the following tests should be performed in 5-7 days to confirm response and adherence to iron supplementation? A Ferritin B Hemoglobin C Hematocrit D Reticulocyte count E Serum iron

The Correct Answer is: D An elevated reticulocyte count 1 week after initiation of iron supplementation confirms the presence of IDA and efficacy of therapy. The hemoglobin (B), hematocrit (C), serum iron (E) and ferritin (A) will improve subsequently to the increase in the reticulocyte count. After one month of iron supplementation the patient's hemoglobin should increase by 1-2 mg/dL and the hematocrit should increase by 3-6%.

A 9-year-old male child presents with a painful rash of his upper extremity. His mom states it started 4 days ago and seems like it is spreading. Physical examination demonstrates a vesicular rash across the right upper arm and chest but does not cross the midline. Which of the following prescriptions would be most appropriate for this patient at today's visit? A hydration B nonsteroidal anti-inflammatory drugs (NSAIDs) C Varicella-Zoster immunoglobulin (VZIG) D oral acyclovir

The Correct Answer is: D As this patient is presenting with signs and symptoms of herpes zoster within the appropriate time frame for antiviral treatment, the treatment for this patient would be oral acyclovir

Children with Cushing syndrome

The Correct Answer is: D Children with Cushing syndrome typically have short stature, while those who are obese due to exogenous factors have normal or tall stature.

An 8-month-old male presents to the clinic due to irritability, fatigue and parental concerns about developmental delays. He is fifth percentile for weight and 33rd percentile for height. An office based hemoglobin level is 8.4 mg/dL. Which of the following is the most likely diagnosis? A Alpha thalassemia minor B Beta thalassemia minor C Folate deficiency D Iron deficiency anemia E Sideroblastic anemia

The Correct Answer is: D Infants with poor nutrition are at greatest risk of iron deficiency anemia between the ages of 6 and 24 months.

A 2-year-old baby girl is brought to the ED with a history of abdominal pain and diarrhea. Mother states that the child was playing normally and then "doubled over" with what appears to be abdominal pain. The abdomen appears slightly distended and is tender to palpation. While in the ED the child has a bloody, diarrheal bowel movement. Which of the following is the most likely diagnosis? A pyloric stenosis B mesenteric ischemia C Crohn disease D intussusception E Hirschsprung disease

The Correct Answer is: D Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. The patient develops paroxysms of pain followed by bloody bowel movements

A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What laboratory finding is most consistent with the suspected diagnosis? A Decreased hematocrit B Elevated amylase C Hyperkalemia D Hypochloremic alkalosis E Hyponatremia

The Correct Answer is: D Laboratory findings that are consistent with the suspected diagnosis of pyloric stenosis include hypochloremic alkalosis with potassium depletion. An elevated hemoglobin and hematocrit can also be present, and are due to dehydration. Changes in amylase or serum sodium are not present in cases of pyloric stenosis.

An 8-month-old male presents to the clinic due to irritability, fatigue and parental concerns about developmental delays. He is fifth percentile for weight and 33rd percentile for height. An office based hemoglobin level is 8.4 mg/dL. Which of the following is the most common side effect the infant may experience after starting oral iron supplementation therapy?

The Correct Answer is: D Oral iron commonly causes GI upset. Anaphylaxis (A) commonly occurs with parenteral iron therapy. Stools will darken and not be clay colored (B), which occurs in the absence of bile production.

Upon performing a newborn examination, the clinician notes a widened pulse pressure, paradoxical splitting of S 2 , and a "machine"-like murmur heard best at the second intercostal space, left sternal border, and inferior to the clavicle. Which of the following is the most likely diagnosis?

The Correct Answer is: D Patent ductus arteriosus (PDA) is an isolated abnormality that occurs in infants. There is also a paradoxical splitting of S 1 and S 2

A 5-week-old male infant presents with a 1-week history of vomiting which occurs shortly after feeding. The mother describes the vomiting as forceful and the vomitus is occasionally blood streaked; the infant has not had diarrhea. You note that the infant appears slightly dehydrated and has lost weight since a routine check at 2 weeks. Which of the following is the most likely diagnosis? A peptic ulcer disease B viral gastroenteritis C Hirschsprung disease D pyloric stenosis E intussusception

The Correct Answer is: D Pyloric stenosis usually presents with forceful/projectile vomiting between 2 and 4 weeks of age.

A mother presents with a 10-year-old female with a complaint of thinning hair. On physical exam there are no areas of alopecia, broken hairs, scaling, or erythema. A hair pull produces 12 to 14 hairs. Examination under microscopy indicates that the follicles are intact and normal in appearance. What is the most likely diagnosis? A Tinea capitus B Anagen dysplasia C Alopecia areata D Telogen effluvium

The Correct Answer is: D Telogen effluvium is a condition of hair thinning that can occur at any age. It is a reaction to a physical or mental stressor.

The mother of a four-month-old brings her son in for evaluation of cyanosis. The mother noted the cyanosis in the last two days, and it is most evident when he is feeding or crying. He was previously healthy with no medical problems. On physical examination, a grade III/VI systolic ejection murmur is present at the left sternal border in the third intercostal space, and radiates to the back. What is the most likely diagnosis

The Correct Answer is: D Tetralogy of fallot is the correct answer. The epsiodes of cyanosis described by the mother represent "tet spells." Atrial septal defect is incorrect, as it is not associated with cyanosis; while the murmur may be located at the left sternal border, it is most often heard in the second intercostal space and is associated with a widely split S2. Transposition of the great arteries is incorrect, as there is typically no significant murmur present and they present as neonates with profound cyanosis.

A 7-year-old girl is brought in by her mom for evaluation of a rash. She has had a fever for a few days and woke up this morning looking like she had been slapped on both cheeks. Other than supportive care, which instruction below represents the best patient education for this patient?

The Correct Answer is: D The "slapped cheek" appearance to the rash is consistent with a Parvovirus B19 etiology for erythema infectiosum. It is a droplet infection that is no longer contagious once the rash breaks out. It generally has a benign course and patients recover fully with supportive care. Splenic involvement is not typically a part of the course, so she may resume activities as she feels able.

A 5-year-old boy presents to urgent care complaining of painful lesions in his mouth that have made eating difficult the past 2 days. The mother confirms he has been unable to eat for 48 hours, but has been able to sip water. On physical exam he has a temperature of 102.6 F; numerous small vesicles and ulcers on the buccal mucosa and tongue, inflamed gingiva; and tender anterior cervical adenopathy. Which of the following is the most likely diagnosis? A Aphthous ulcers B Hand, foot, and mouth disease C Herpangina D Herpes simplex gingivostomatitis E Viral pharyngitis

The Correct Answer is: D The classic presentation of initial herpes simplex infection (D) includes multiple small, painful vesicles or ulcers on the mucousa with gingival involvement, fever, and adenopathy. (A), (B), and (C) all present with ulcers, but typically involve an isolated area (A), or the tonsils and posterior pharynx (B and C).

A 5-year-old boy presents to urgent care complaining of painful lesions in his mouth that have made eating difficult the past 2 days. The mother confirms he has been unable to eat for 48 hours, but has been able to sip water. On physical exam he has a temperature of 102.6º F; numerous small vesicles and ulcers on the buccal mucosa and tongue; inflamed gingiva; and tender anterior cervical adenopathy. Which of the following is the most likely causative organism? A Coronavirus B Coxsackie virus A16 C Group A beta-hemolytic strep D Herpes simplex 1 E Rhinovirus

The Correct Answer is: D The classic presentation of initial infection with herpes simplex virus 1 (D) includes multiple small, painful vesicles or ulcers on the mucousa with gingival involvement, fever, and adenopathy. Coxsakie virus A16 (B) causes hand, foot, and mouth disease. Coronavirus (A) and rhinovirus (E) cause viral pharyngitis.

A 12-month-old female presents with bilateral lichenification, scaling, and excoriations in the antecubital fossae and popliteal fossae. Which of the following should treatment include?

The Correct Answer is: D The first line treatment for atopic dermatitis is a topical steroid, such as triamcinolone ointment. Oral hydroxyzine is an antihistamine that is used to control pruritis in atopic dermatitis.

Which of the following is the first sign of puberty in a normal male? A appearance of axillary hair B appearance of pubic hair C deepening of the voice D enlargement of the testes

The Correct Answer is: D The first sign of pubertal development in boys is the enlargement of testicular size and occurs at the mean age of 11.6 years. Genital stages accelerate before pubic hair development, which occurs, on average, at 13.4 years of age.

A 2-month-old female presents for a well child check. The mother has no concerns and feels that the child is doing well. On exam, there is no evidence of cyanosis and the peripheral pulses are normal and equal. However, there is a fixed and widely split S2, a right ventricular heave, and a systolic ejection murmur present. The murmur is heard best at the left sternal border second intercostal space. What is the most common abnormality present on an ECG? A Atrioventricular heart block B Atrial fibrillation C Bifasicular block D Right axis deviation E Supraventricular tachycardia

The Correct Answer is: D The most likely diagnosis is an atrial septal defect, which usually shows right axis deviation on ECG. The other ECG abnormalities listed do not commonly occur with an atrial septal defect.

A 16-year-old boy is seen for a sports physical prior to starting football. On auscultation, a grade II/IV holosystolic murmur is appreciated at the apex. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the axilla. With the Valsalva maneuver, the murmur decreases in intensity. Given the patient's physical exam findings, which of the following is the most likely diagnosis?

The Correct Answer is: D The murmur of mitral regurgitation can be described as a holosystolic murmur, usually heard best at the apex, so choice D is the most appropriate answer. Isometric hand grip exercises increase the intensity of the murmur of mitral regurgitation by increasing arterial and left ventricular pressure, which increases the flow across the mitral valve, thereby increasing the murmur's intensity. The murmur of mitral regurgitation is heard best at the apex. Radiation, if it occurs, is frequently to the axilla.

A 5-year-old boy presents with a tense, fluid filled blister on his fingertip. What organism is most likely to be found when the lesion is cultured? A Herpes simplex virus B Parvovirus B19 C Pseudomonas aeruginosa D Staphylococcus aureus

The Correct Answer is: D This child has blistering distal dactylitis. This is a form of impetigo, and is caused by either streptococcus pyogenes or staphylococcus aureus.

A 2-year-old girl has developed a "barking" cough and a low-grade fever. She has some runny nose and her voice is somewhat raspy and hoarse. When approached by the PA, she becomes somewhat upset and exhibits mild inspiratory stridor. She appears otherwise well and has no drooling or dyspnea. What is the most likely etiology of this child's illness? A Adenovirus B Coxsackievirus C Cytomegalovirus D Parainfluenza virus E Respiratory syncytial virus

The Correct Answer is: D This child has the classic presentation for croup. Sixty-five percent of croup is caused by a parinfluenza virus infection. Adenoviruses tend to cause severe pharyngitis/tonsillitis with tender, enlarged cervical nodes (A),

The parents of a four-month-old child present with concern regarding a birthmark on the child's scalp and left side of face. The lesion has been present since birth and is growing. It has an orange, pebbly appearance. What is the appropriate treatment? CT scan with contrast to rule out underlying brain malformation B laser therapy C no treatment, as the lesion will spontaneously resolve D excision prior to puberty due to increased risk of basal cell carcinoma

The Correct Answer is: D This lesion is consistent with a nevus sebaceous. It will grow as the child grows. After puberty, the lesion becomes thicker with a warty appearance. There is a slight increase in incidence of basal cell carcinoma as the patient ages. It is recommended that the lesion be excised prior to puberty, when these changes occur in response to hormone secretion

A six-month-old male has recurrent diaper rashes, which are not responding to ketoconazole cream or zinc oxide diaper creams. Physical exam shows well demarcated perianal erythema, with scattered red papules on the buttocks. A KOH is negative. What would appropriate management include? A hydrocortisone 2.5% ointment bid x 2 weeks B tretinoin 0.25% cream bid x 2 weeks C lotrisone cream bid until resolved D topical mupirocin bid until resolved

The Correct Answer is: D This rash is consistent with a perianal staph or strep infection. This bacterial infection is easily treated with topical mupirocin. If the rash does not resolve after two weeks of topical treatment, treatment with an oral antibiotic such as Keflex is usually successful. Treatment with a topical steroid may worsen the infection.

A 12-year-old boy is being seen for concerns of development of breast tissue. Upon physical exam, he is noted to have a firm, slightly tender mass under the left areola. What is the most appropriate action at this time? A referral to pediatric surgery for resection B measurement of serum hCG C measurement of testosterone and estrogen levels D reassurance and observation

The Correct Answer is: D Type 1 idiopathic gynecomastia in adolescent men presents with a firm mass under the areola ("breast bud") typically during sexual maturation stages (SMR), stages II to III. This is a result of normal estrogen and androgen activity at the breast tissue level. Appropriate action is observation and to reassure the patient that the condition will likely resolve in 1 to 2 years.

A 17-year-old female patient presents to your family practice office complaining of a persistent sore throat for the past 2 weeks duration. She is extremely fatigued, and she tells you that her boyfriend has had similar symptoms for about a week. Her vital signs are a blood pressure of 116/72 mm Hg, pulse 88 beats/min, respirations of 16 beats/min, and temperature of 101.1˚F taken orally. Her white blood cell count (WBC) reveals 14,800 mcL with more than 10% atypical lymphocytes. On physical examination you find significant yellowish-grey pharyngeal exudate, cervical lymphadenopathy as well as an enlarged spleen. Her rapid strep is negative. What should be your treatment of this patient?

The Correct Answer is: D With this patient's presentation and a negative rapid strep test, other etiologies beyond group A beta-hemolytic strep should be seriously considered. In light of her symptoms including fatigue, her WBC, and that her significant other is having similar symptoms, infectious mononucleosis is highest on the differential diagnosis. A Monospot test would rule this possibility in or out. She should refrain from contact sports until her infection and any associated splenomegaly has resolved.

A 12-year-old male exhibits prominent brown scaling on his neck, trunk, and extremities with involvement of flexural regions. The palms and soles are spared. What is the most likely diagnosis? A Epidermolysis bullosa simplex B Extensive keratosis pilaris C Lamellar ichthyosis D X-linked ichthyosis

The Correct Answer is: D X-linked ichthyosis is a recessive condition affecting males. The patient will have large scales that appear brown in color. This condition spares the palms and soles, and begins between the ages of two to six weeks.

A 3-year-old male is brought to your office with a red, tearing right eye. The mother stated that the child was playing in another room with his 4-year-old brother. All she heard was the child beginning to cry. Upon physical exam, the child is intermittently crying, and his right eye is red and tearing. The child is continually rubbing the eye. The anterior chamber is clear and the pupil is equal and reactive. What is your next step in evaluating this patient? A Contact child protective services B Order a head CT scan C Perform a tonometry D Obtain a visual acuity E Perform a fluorescein stain

The Correct Answer is: E A corneal abrasion must be ruled out in a child with a red eye.

Measles is one of the few exanthemas where the primary lesions are both macules and papules. These lesions may coalesce to become confluent. The pathognomonic lesion of measles is the Koplik spot, which is a blue-white papule with surrounding erythema appearing on the oral mucosa.

The Correct Answer is: E A loop (E) or alternative instrument should be used to pull the noodle outward and away from the tympanic membrane. Organic material may swell when wet, and irrigation (C and D) or the insertion of anesthetic solution (B) is not recommend

A 5 year-old girl presents to the clinic with her mother who is concerned about her daughter's energy level since starting full day kindergarten. CBC reveals a hemoglobin of 12.3 g/dl, hematocrit of 36%, MCV of 62 fL, and an MCHC of 34 g/dL. Serum ferritin levels are normal. What is the most likely hemoglobin electrophoresis results for this patient? A Decreased HbA2 and increased HbF levels B Decreased HbA2 and HbF levels C Increased HbA2 and normal HbF levels D Increased HbA2 and HbF levels E Normal HbA2 and HbF levels

The Correct Answer is: E Alpha thalassemia presents with a normal hemoglobin electrophoresis, since all adult hemoglobin are alpha-containing and affected equally. Beta thalassemia major may present with increased HbA 2 and/or HbF levels (C and D). Beta thalassemia minor typically presents with increased HbA 2 (C).

A fracture involving the medial epicondyle will most likely cause damage to which nerve?

The Correct Answer is: E Because the ulnar nerve passes through the cubital tunnel, which is a groove on the posterior aspect of the medial epicondyle, any fractures involving the medial epicondyle can also cause damage to the ulnar nerve. The median nerve is most susceptible to injury at the carpal tunnel. Branches of the radial nerve can become entrapped on the lateral side of the elbow and the associated symptoms are often confused with lateral epicondylitis. Radial nerve injuries are more commonly associated with humeral shaft fractures. The axillary nerve is significantly proximal to the medial epicondyle and the peroneal nerve is in the leg

A 21-year-old female patient presents with a large area of swelling localized to the front of the knee, between the patella and the skin after a fall directly on her knee. She has been stating that her knee is becoming more difficult to move due to the swelling and pain. She is otherwise healthy with no other medical problems. Her exam reveals a tender, fluctuant area just anterior to the patella without warmth. She does not appear to have any effusion, and her ligament stability testing is normal. Based on these findings, what is the most likely diagnosis? A Anterior cruciate ligament tear B Medial meniscal tear C Pes anserine bursitis D Posterior cruciate ligament tear E Prepatellar bursitis

The Correct Answer is: E Bursae are synovial fluid filled sacs that facilitate the reduction of friction between adjacent structures. They may be found between the skin and various bony prominences or between tendons, ligaments and bone. They can become injured by an acute direct impact or gradual repetitive stress such as what might occur if someone was required to do extensive kneeling on the job. They may also be sites of infection with staphylococcus aureus and streptococcus species being the most common pathogens. The knee contains two primary bursae. The prepatellar bursa lies directly below the skin and above the patella. It is often acutely injured with a fall or other traumatic impact. A localized swelling can occur quickly and this fluid accumulation is not intracapsular as occurs with a joint effusion after an anterior cruciate ligament tear, meniscal tear or posterior cruciate tear. Meniscal injuries tend to produce a smaller effusion than cruciate ligament tears.

What is the most common clinical cardiac abnormality that is associated with acute rheumatic heart disease? A Hypotension B Arrhythmia C Ischemia D Ventricular aneurysm E Carditis

The Correct Answer is: E Carditis is the most common finding in rheumatic heart disease. This can present with the sequelae of pericarditis, cardiomegaly, heart failure (either right or left sided), and either a mitral or aortic murmur.

A 16-year-old boy is seen for a sports physical prior to starting football. He denies any symptoms. His physical examination is normal, except for a grade II/VI holosystolic murmur auscultated at the cardiac apex. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the axilla. With the Valsalva maneuver, the murmur decreases in intensity. Given the patient's physical exam findings, which of the following is the most appropriate next diagnostic study? A Chest x-ray B Transesophageal echocardiogram C Holter monitor D Treadmill exercise stress test E Transthoracic echocardiogram

The Correct Answer is: E Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool that can evaluate for the presence of valvulopathy or congenital heart disease in this young patient.

A 3-year-old girl presents to the otolaryngologist for evaluation of a persistent left ear infection and drainage that have failed to respond to multiple antibiotic regimens. Which of the following is the most likely causative organism for this patient's condition? A Aspergillus B Chlamydia pneumoniae C E. coli D Streptococcus pneumoniae E Staphylococcus aureus

The Correct Answer is: E Chronic otitis media is typically caused by P. aeruginosa, H. influenzae, S. aureus (D), Proteus species, Klebsiella pneumoniae, or Moraxella catarrhalis. Aspergillus (A) and E. coli (C) are associated with otitis externa and streptococcus pneumoniae (D) is the most common bacterial cause of otitis media

An 18 month infant with congenital heart disease is diagnosed with acute bronchiolitis secondary to respiratory syncytial virus. Which of the following therapies should be initiated? A Albuterol B Amoxicillin C Azithromycin D Prednisone E Ribavirin

The Correct Answer is: E High-risk infants (i.e., congenital heart disease) who develop RSV are eligible for treatment with ribavirin.

A 23 year-old male with cystic fibrosis inquires about the availability of treatments that can help improve his lung function. Which of the following treatments is most effective at reversing the pulmonary effects of cystic fibrosis? A Albuterol B Azithromycin C Inhaled hypertonic saline D Inhaled levofloxacin E Ivacaftor

The Correct Answer is: E Ivacaftor (E) is the only treatment that restores function of the CFTR protein in cystic fibrosis patients with a G551D mutation thereby reversing the effects of the disease, approximately 5% of all cystic fibrosis patients have the G551D mutation.

A 15-year-old male presents complaining of a sore throat, headache, and mild cough that started 8 days ago and has progressed to include a worsening cough and increasing fatigue. His chest x-ray reveals bilateral hilar infiltrates, CBC is normal and a nasal secretions test positive for mycoplasma pneumoniae by PCR. What is the most appropriate therapy? A Amoxicillin B Cefuroxime C Clindamycin D Ciprofloxacin E Doxycycline

The Correct Answer is: E Mycoplasma pneumoniae is commonly treated with macrolides, doxycycline (E), or respiratory fluoroquinolones. Mycoplasma pneumonia doesn't respond to beta-lactam antibiotics (A, B) or non-respiratory fluoroquinolones (D).

A 10-year-old male patient has been seen in the clinic on several occasions, with complaints of fatigue and fevers of unknown origin. On prior CBC, he was noted to have a hypereosinophilia. Today's smear reveals multiple small lymphoblasts, with scanty, light-blue cytoplasm after being stained with Wright-Giemsa, and inconspicuous nucleoli. Initial therapy for the patient should include which of the following? A Bone marrow biopsy and repeat CBC B Hematologic support for thrombocytopenia C Immediate referral for radiation therapy D Placement of an indwelling catheter and IV fluids E Prevention of metabolic and infectious complications

The Correct Answer is: E Prevention of metabolic and infectious complications are the immediate therapies of choice in this patient with ALL. This is done to prevent complications of hyperuricemia, hyperphosphatemia, and infection. Bone marrow biopsy, while important, is not a therapy. Platelet transfusions are only used if there are signs of bleeding and a low platelet count (usually less than 20,000).

Which of the following is a common adverse effect associated with the use of stimulants such as methylphenidate for attention-deficit hyperactivity disorder (ADHD)? A diarrhea B hypoglycemia C hypotension D paresthesias E reduced appetite

The Correct Answer is: E Stimulants (eg, amphetamines, methyl-phenidate) are considered first-line therapy in the majority of cases of ADHD. Both amphetamines and methylphenidate block dopamine and norepinephrine reuptake, while amphetamines also stimulate norepinephrine release. Elevated levels of CNS norepinephrine have been associated with an anorexigenic effect, leading to reduce caloric intake.

A 16-year-old male high school wrestler presents to your family practice clinic with a fluctuant 3 cm by 3 cm abscess to his back superior and lateral to his scapula. Which of the following is the most appropriate treatment? A amoxicillin-clavulanate orally for 10 days B cephalexin orally for 10 days C trimethoprim sulfamethoxazole orally for 10 days D vancomycin intravenously for 10 days E incision and drainage is likely to resolve the abscess without the need for medications

The Correct Answer is: E The causative agent of this abscess is most likely caused by community-acquired methicillin-resistant S aureus (caMRSA). Infectious Diseases Society of America (IDSA) guidelines issued in January of 2011 generally recommend incision and drainage alone for fluctuant abscesses in an otherwise immunocompetent patient.

What is the treatment of choice for rheumatic fever? A Macrolides B Cephalosporin C Fluoroquinolone D Aminoglycosides E Penicillin

The Correct Answer is: E The goal is to eradicate the Streptococcus bacteria. Penicillins are the drug of choice, with the dose being benzathine penicillin G, 1.2 million units intramuscularly every four weeks as the ideal regimen

A 14-year-old girl presents 1 week after the neighbor's cat bit her hand. In the first 3 days after the bite she developed a shallow ulcer at the bite site. Because her parents knew the cat was up to date on shots, they treated the ulcer with topical antibiotics and did not seek medical care. Now, the patient has low-grade fever and headache and feels tired. Axillary nodes on the affected side are swollen. The ulcer on the hand is nearly healed. The best treatment option is A doxycycline 100 mg bid × 21 days B Augmentin 500 mg po bid × 10 days C azithromycin 500 mg po qd × 7 days D acyclovir 400 mg po bid × 10 days E no therapy required

The Correct Answer is: E The history and course of illness are consistent with cat-scratch fever. It is caused by infection with Bartonella henselae. Cat scratch or bite transmits it to humans. Clinical course usually begins with papule or ulcer at the site within a few days of the bite. Fever, headache, and malaise develop 7 to 21 days later. Lymph drainage of the site may result in swollen, tender, and/or suppurative nodes. Clinical diagnosis is the norm but special cultures or biopsy is possible. The symptoms usually resolve spontaneously with no specific therapy required. Complications may include encephalitis or disseminated disease in immunocompromised patients.

A 17 year-old male is training for an Ironman triathlon and notes excessive coughing, chest tightness and wheezing when running. Which of the following is the most appropriate treatments for this patient? A Albuterol B Cromolyn C Fluticasone D Ipratropium bromide E Salmeterol

The Correct Answer is: E The mainstay of treatment for exercise-induced asthma are beta-2 agonists. Due to the duration of physical activity this patient should be treated with a long-acting beta-2 agonist, salmeterol (E) instead of albuterol (A).

An infant is born to an HIV-positive mother who received three-drug treatment during pregnancy. Which of the following, if positive, indicates HIV infection in the infant? A HIV ELISA and Western Blot on cord blood B HIV ELISA and Western Blot at 1 month of age C HIV ELISA and Western Blot at 6 months of age D HIV ELISA and Western Blot at 12 months of age E HIV ELISA and Western Blot at 24 months of age

The Correct Answer is: E The median age at which infants no longer show the maternal antibody for HIV is 10 months; by 18 months, they all do not. HIV ELISA and Western blot are not appropriate for testing pediatric patients until after that age

A 4-month-old male presents for a well child check. He is healthy, and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely diagnosis? A Atrial septal defect B Coarctation of the aorta C Patent ductus arteriosus D Tetralogy of fallot E Ventricular septal defect

The Correct Answer is: E The patient in this scenario is exhibiting the classic signs of a ventricular septal defect. An atrial septal defect has a fixed, widely split S2, with a right ventricular heave as well as a systolic ejection murmur, which is best heard at the left sternal border second intercostal space.

An 11-month-old African-American male presents to the pediatric office with lethargy, jaundice and splenomegaly. A CBC reveals hemoglobin of 8.0 mg/dl and a hematocrit of 25%. Peripheral smear appearance is available below. A Acute lymphocytic leukemia B Alpha thalassemia minor C Beta thalassemia minor D G6PD deficiency E Sickle cell disease

The Correct Answer is: E The patient's clinical presentation is most consistent with sickle cell disease and is confirmed by the presence of sickle cells and target cells on the peripheral smear.

The most commonly fractured long bone in both adults and children is which of the following? A Femur B Fibula C Humerus D Radius E Tibia

The Correct Answer is: E The tibia is the most commonly fractured long bone in the body for both adults and children. The fractures are often the result of sporting activities in the young and may occur from a simple fall in the elderly - especially those with osteoporosis. Motor vehicle accidents are another common cause of tibial fractures. Humerus fractures are relatively rare in adults, but are the second most common fractures to occur at birth - behind only the clavicle in frequency. The radius is the most commonly fractured bone in the upper extremity, but still less common in frequency than the tibia.

A 1-year-old boy is brought to the emergency department by his parents, who state that the child refuses to walk or crawl and begins crying when they stand him. He seems calm while lying on the examination table. Vitals are as follows: Temp: 38°C, HR: 70, RR: 15. Bruising is noted in several places. His parents deny trauma, but have noticed that he bruises easily. What other physical finding would you expect? A Conjunctival hemorrhages secondary to shaken baby syndrome B Pain response over the wrists secondary to passive range of motion C Pain response with passive range of motion to the hip secondary to slipped epiphysis D Pharyngitis and sand paper rash secondary to a staph infection E Swelling and warmth over the knee secondary to hemarthroses

The Correct Answer is: E This patient has hemophilia A. Hemarthroses usually occur when an affected child begins to walk. Due to his hemophilia, easy bruising can occur. Hemarthroses can cause low-grade fevers without infection being present, so choice D is incorrect. Wrist joints are less involved then knees, ankles, and elbows.

A 12-year-old boy who is 60" tall and weighs 190# is found on routine physical examination to have 2+ glucose and trace ketones in his urine. His fasting glucose is 140 mg/dL and hemoglobin A1C is 6.0%. What is the next step in this child's management? A Initiation of insulin treatment B Prescription of oral metformin C Referral for a glucose tolerance test D Watchful waiting E Weight loss and exercise

The Correct Answer is: E Treatment of type 2 diabetes and pre-diabetes in children varies with the severity of the disease. If the HbA1C is near normal and ketones are not significantly increased, the first line of treatment is lifestyle modifications, including nutrition counseling for the entire family, weight loss, and exercise. Insulin (A) is not indicated in early type 2 disease. If life style changes are not successful, addition of metformin (B) is the next step. Glucose tolerance tests (C) are rarely needed in children. Watchful waiting (D) is inappropriate as continued elevated glucose levels put the child at risk for micro- and macrovascular damage.

A 16-year-old girl presents to the office complaining of a very sore throat, swollen lymph nodes, fever, and general malaise. Her examination reveals a temperature of 102.2°F, enlarged exudative tonsils, tender cervical lymphadenopathy, and borderline enlarged spleen. Rapid strep screen is negative. Which of the following laboratory findings best supports the most likely diagnosis? A decreased white blood cell count B increased monocytes on white cell differential C thrombocytosis D decreased levels of antibody to Epstein-Barr viral capsid antigen E increased atypical lymphocytes on white blood cell differential

The Correct Answer is: E With a negative rapid strep screen, the most likely explanation for this presentation is acute infectious mononucleosis. The fever, fatigue, tonsillar hypertrophy, and splenomegaly are all classic symptoms and signs.

A 23-year-old college basketball player twists her ankle while practicing. She explains the injury that is consistent with an inversion mechanism. Based on this history, what ligament would you expect to be the most likely injured in the ankle of this patient?

The anterior talofibular ligament is the first, and often only, ligament damaged in inversion ankle sprains. As the force of the inversion increases, other lateral ankle ligaments can be involved. When the anterior tibiofibular ligament is involved, this is referred to as a high ankle sprain and such injuries generally have a prolonged recovery time. Calcaneofibular ligaments are generally the second most frequently injured of the lateral ankle ligaments and when injury occurs it is typically in combination with the anterior talofibular ligament. The deltoid ligament is a very strong ligament on the medial aspect of the ankle. Eversion stresses the deltoid ligament, but strong eversion forces are rare and when they do occur, an avulsion fracture of the medial malleolus is more likely than a significant ligament tear. The posterior talofibular ligament is one of the lateral ankle ligaments and can be injured in an inversion injury, but the rate of injury to this ligament lags far behind the anterior talofibular or calcaneofibular ligaments.

A 1-year-old adopted Chinese infant is brought into the pediatrician's office for a routine visit. The parents are concerned because they think the child is short for her age. They do not have very much information relating to the birth of the child, other than that she was considered slightly short at birth and she had a seizure at one month of age. The foster parents of the child were not concerned, since the infant was somewhat chubby and ate well. She has no history of hypotonia. Upon exam you note normal shaped eyes with mild nystagmus. The infant is less than the third percentile for weight and her limbs are in normal proportion to her height. Her lung and heart exam are normal. CBC is normal. What is the most likely cause of her short stature?

The correct choice is A, congenital growth hormone deficiency. Parents of children with this disorder typically become concerned when the child is between one and two years of age. This patient fits the characteristic picture of this disorder, with short stature, increased fat mass, and hypoglycemia due to relatively unopposed insulin action

A 5-year-old girl is seen in your office with a several week history of increased thirst, weight loss, and blurred vision. She has a positive family history for diabetes mellitus, hypertension, and stroke. Her urine dipstick chemical testing reveals positive glucose and negative ketones, protein, blood, and nitrites. Which of the following laboratory test results would support a diagnosis of diabetes mellitus in this patient? A random plasma glucose > 200 mg/dL B random urine glucose dipstick > 1+ C plasma hemoglobin A1c < 7% D fasting plasma glucose > 110 mg/dL E 2-hour postprandial plasma glucose > 135 mg/dL

The correct choice is A, random plasma glucose > 200 mg/dL. The most recent recommendations from the international committee of diabetes experts list the following as diagnostic criteria, which must be confirmed before use: 1) Symptoms of diabetes and a random plasma glucose > 200 mg/dL 2) Fasting plasma glucose > 126 mg/dL 3) Two-hour plasma glucose > 200 mg/dL during a standard 75 gram oral glucose tolerance test More recently, the American Diabetes Association has also included a hemoglobin A1c level equal to or greater than 6.5% as a diagnostic criteria as well. None of the other choices fit into this list of diagnostic criteria. (Masharani et al., 2007, Chapter 18)

A 12-month-old infant is being worked up for congenital growth hormone deficiency. Her length at birth was short and she has been consistently less than the third percentile on her height chart. Her past medical history is only significant for three seizures since birth. Upon exam you note that she has a full face and her body proportions are normal. The remainder of the exam is normal. What is the most likely cause of her seizures? A Abusive head trauma B Brain tumor C Arteriovenous malformation D Hypoglycemia E Cerebrovascular accident

The correct choice is D, hypoglycemia. Patients with growth hormone deficiency will not have the counter regulatory action of growth hormone against insulin. This will allow unregulated insulin action causing hypoglycemia and possible associated seizures.

A young child and his parents have been adhering to the treatment plan for type 1 diabetes, as discussed with their health care provider. It includes a change in diet, as well as blood glucose and ketone monitoring. They noticed that the amount of insulin needed decreased after the first two weeks. What is this time period commonly called?

The correct choice is E, honeymoon phase. During this time, some pancreatic beta cell function may recover, although within eight weeks to two years most patients will show absent or negligible pancreatic beta cell function

polyarticular juvenile rheumatoid arthritis

The most likely diagnosis in this patient is polyarticular juvenile rheumatoid arthritis (JRA). This form of JRA is seen in approximately 35% of patients with JRA. It is characterized by symmetrical involvement of five or more joints. Systemic JRA, also known as "Still disease," is seen in about 10% to 15% of children with JRA. It is characterized by daily intermittent fever spikes and a transient, nonpruritic, pale pink, blanching macular, or maculopapular rash found on the trunk.

The typical hemoglobin electrophoresis for beta thalassemia minor has

The typical hemoglobin electrophoresis for beta thalassemia minor has an elevated level of hemoglobin A 2 . In a normal infant there is mainly HgF and HgA 1 with minimal amounts of A 2 . Bart hemoglobin is diagnostic for the alpha thalassemias after the neonatal period is over. Beta thalassemia major will only have fetal hemoglobin on electrophoresis. Because of the high incidence of false-negatives in hemoglobin screenings in the neonatal period, it is important for the provider to do a full work-up of microcytic, hypochromic anemias to ensure proper diagnosis.

Marfan syndrome.

This patient has clear signs and symptoms that are suspicious for Marfan syndrome. The complications of Marfan syndrome include cardiovascular issues, especially valvular and aortic disease. An echocardiogram is an appropriate, non-invasive initial first-step to begin your investigation to rule out significant valvular and/or aortic root abnormalities.

A 14-year-old female presents with a 24-hour history of episodic outbreaks on her hands and feet. She describes the outbreaks as beginning on the sides of her fingers and toes, with small intensely pruritic vesicles. What should be the next step in treatment?

This patient is experiencing probable dyshidrotic eczema. It is necessary to rule out a secondary bacterial infection, so a bacterial culture is necessary. It is also necessary to rule out a fungal infection or parasitic by performing a KOH

A 7-year-old child is brought into the office by her mother who states that the child "is still wetting the bed at night." The child has already decreased liquid intake and uses the bathroom before going to bed. The mother is worried that there is something wrong with the child. Upon examination there is no abnormality. Urinalysis is negative. Which of the following is the treatment of choice for this disorder? A bed-wetting alarm B desmopressin acetate (DDAVP) C imipramine D amitriptyline

This patient is presenting with signs and symptoms of primary nocturnal enuresis, which is the wetting only at night during sleep without any sustained period of dryness. It is mainly considered a parasomnia occurring in deep sleep. T Treatment includes limiting liquids at bedtime and routine bathroom training during the day. If these are unsuccessful, the next option is a bed-wetting alarm. This device is attached to the child's undergarment and vibrates when the child is wet to arouse the child to be aware of their need to urinate. If the alarm is unsuccessful, then the next step is medication—DDAVP (desmopressin acetate) or imipramine.

Which type(s) of Salter-Harris fractures can generally be treated with closed reduction and cast immobilization?

Types I, II, and III

A 10-year-old child is seen with his parents for a routine check up. During the review of symptoms, his parents mention that their son has been extremely thirsty and is going to the bathroom to urinate frequently. The patient agrees. The parents are concerned that their son has developed diabetes mellitus. The family history is negative for diabetes mellitus, but the mother has a history of familial hypothalamic diabetes insipidus. Screening blood work includes a CBC, hemoglobin A1c, and renal function tests, all of which are within the reference range. Which of the following serum analytes would you expect to be deficient? A Sodium B Glucose C Thyroxine D Prolactin E Vasopressin

Vasopressin The correct choice is E, vasopressin. The reader must first understand that the patient's symptoms are classic for diabetes insipidus, with the increased thirst, frequency, and polyuria.

Vitiligo

Vitiligo is the most likely diagnosis. Vitiligo is an autoimmune disorder that affects the melanocytes. There is often a history of trauma that can precede an occurrence of vitiligo. The course for vitiligo is variable. Sometimes it will resolve spontaneously. Other times, it will continue to progress despite treatment. Post-inflammatory hypopigmentation are areas of lighter pigment, not complete depigmentation, which result from a resolved inflammatory process. The pigment will return over time. A hypertrophic scar is one which is enlarged but stays within the borders of the original injury. No pigment changes are associated with these scars.

A 17 year-old male notes acute onset of dyspnea, excessive non-productive coughing, "wheezing" and upper chest tightness when running. Symptoms usually resolve in a few minutes and he is able to resume running. He is prescribed albuterol with no improvement. Which of the following is the most likely diagnosis in the patient?

Vocal cord dysfunction (E) is commonly misdiagnosed as asthma or is a comorbidity in patients with asthma. The history of acute onset and rapid disappearance of symptoms is consistent with vocal cord dysfunction, and not typical of cystic fibrosis (C), or GERD (D). The presence of urticarial or swelling of the face or lips would support the life-threatening diagnosis of angioedema (A). Bronchiectasis (B) typically presents with a chronic productive cough and additional pulmonary symptoms based on the underlying cause and severity.

A 16-year-old girl is brought to the emergency department by ambulance after reportedly ingesting "a bottle of aspirin." Vital signs are temperature 37.8°C oral; pulse 94/min; respirations 30/min; blood pressure 100/68 mm Hg. What would you expect the blood gases to show that would confirm she had swallowed the aspirin? A anion gap metabolic acidosis with respiratory acidosis B nonanion gap metabolic acidosis with respiratory alkalosis C anion gap metabolic acidosis with respiratory alkalosis D nonanion gap metabolic acidosis with respiratory acidosis

anion gap metabolic acidosis with respiratory alkalosis Because salicylates are a gastric irritant, symptoms of vomiting and diarrhea occur soon after the overdose, which may contribute to the development of dehydration. Salicylates stimulate the respiratory center leading to hyperventilation and hyperpnea resulting in respiratory alkalosis and compensatory alkaluria. A characteristic feature of salicylate intoxication is the coexistence of a respiratory alkalosis with a widened anion gap metabolic acidosis. (

A 3-day-old infant has bilateral copious, yellow-green eye discharge and conjunctival inflammation. A Gram stain of this discharge reveals gram-negative intracellular diplococci. Which of the following antibiotics is the drug of choice for this infection? A ceftriaxone B cephalexin C erythromycin D gentamicin

ceftriaxone Gonococcal ophthalmia neonatorum presents as a unilateral or bilateral serosanguineous discharge and then within 24 hours the discharge becomes mucopurulent, followed by conjunctival injection and edema of the eyelids. The usual incubation period for Neiserria gonorrhea is 2 to 5 days; however, the infection may be present at birth or delayed greater than 5 days if there has been instillation of silver nitrate prophylaxis. An alternate drug is cefotaxime (100 mg/kg/24 hours IV or IM every 12 hours for 7 days or 100 mg/kg as a single dose), which is also a third-generation cephalosporin. Although erythromycin drops (0.5%) are used prophylactically for N gonorrhea, this is not an effective treatment. Gentamicin would be used for Pseudomonas, and Chlamydia is treated with erythromycin. Cephalexin as a first-generation cephalosporin does not have coverage for gram-negative bacteria.

An 8-year-old boy began vomiting earlier in the day and complained of "feeling terrible." His mother says he has slept most of the day and is hot to the touch, although she has not taken his temperature. He is also complaining of a sore throat and that his neck is sore. On examination, his temperature is 103F and he appears unwell. His pharynx is beefy red, the tonsils are enlarged, and covered with a thick exudates. His anterior cervical nodes are tender and markedly enlarged. What additional physical finding is most consistent with this presentation? A bloody diarrhea B circumoral pallor C diffuse rales D petechiae on the distal extremities E vesicular skin lesions with a honey-colored crust

circumoral pallor The clinical picture is that of a Group A Streptococcal infection which, in this age group, presents with fever, malaise, repeated vomiting, a sore throat with tonsillar exudates, and tender, enlarged anterior cervical nodes. Additional physical findings include petechial lesions on the soft palate and mucosal surfaces, circumoral pallor, and a coated tongue. Diarrhea is not common in streptococcal infections.

A 9-year-old female child presents with tachycardia, tachypnea, shortness of breath, bibasilar rales, and distended jugular veins. Which of the following is the most likely cause for her signs and symptoms? A rheumatic heart disease B sickle cell anemia C viral myocarditis D patent ductus arteriosus

he correct answer is (D). This patient is presenting with signs of congestive heart failure. The most common causes of heart failure in children/adolescents are due to acquired heart disease. Congenital heart diseases, such as malformations of the heart—patent ductus arteriosus and ventricular septal defects, are the most common causes of heart failure in infants-toddlers, and are second to fluid overload in neonates.

A 24-month-old infant presents for his routine physical examination. The parents state that he has been following all of his developmental milestones. On examination, the clinician hears a grade II/VI murmur along the left sternal border, which radiates into the left axilla and the left side of the back. The child also has decreased femoral pulses bilaterally. The clinician orders a chest X-ray. Which of the following is the expected finding on X-ray based on the presentation? A notching or scalloping of the ribs B boot-shaped heart—right ventricular hypertrophy C "egg on string"—narrowed mediastinum D absence of the main pulmonary artery

otching or scalloping of the ribs The patient's presentation is consistent with findings of coarctation of the aorta. The pathognomonic finding in coarctation is decreased or absent femoral pulses. However, the majority of children show no signs of coarctation in infancy and develop signs and symptoms during childhood, most notably unequal pulses and blood pressure between arms and legs (arms greater than legs). In addition, a grade II/VI ejection murmur is heard at the aortic area and left sternal border that radiates into the left axilla and left back. Chest X-ray shows a normal-sized heart, a prominent aorta, indents at the level of the coarctation, and a dilated poststenotic segment resulting in the "figure 3" sign.