You are seeing a 10-year-old boy and his 13-year-old sister for the first time. When you review the medical records provided by their mother, you find normal medical histories, vital signs, and physical examination results for the children. However, the family history indicates that two of the children's uncles are receiving hemodialysis and are deaf and one grandfather died of kidney disease. You obtain a screening urinalysis (UA) in both children. The boy's UA reveals moderate blood, negative protein, and 20 to 30 red blood cells/high-power field (RBC/hpO; the girl's UA reveals trace blood with 5 to 10 RBC/hpf. Of the following, the MOST accurate statement regarding the prognosis for these children is that

You are called to evaluate a male infant at 50 hours of age because he has not voided. He was born at term and has breastfed poorly, but has passed stool. He appears uncomfortable on physical examination, with a large abdomen and seemingly palpable bladder. There is no respiratory distress. The external genitalia are normal, and both testes descended. Of the following, the MOST appropriate initial step in this infant's evaluation is

You receive a call from a teenage patient, who tells you that she is having palpitations and feels somewhat lightheaded. You refer her to your local emergency department, where no symptoms are discerned and physical examination findings are normal. The emergency department sends a copy of the patient's electrocardiogram by facsimile to your office for you to review. Of the following, the BEST interpretation of the girl's electrocardiogram is

A 14-year-old boy who had a sore throat and fever 2 weeks ago presents to the emergency department still dressed in his football gear from the practice field, where he complained of acute abdominal pain. He exhibits tachypnea, tachycardia, and mild hypotension and complains of intense pain in the left upper quadrant. Of the following, the MOST definitive study to diagnose this child's condition is

You are evaluating a 14-year-old boy who has a body mass index of 40 kg/m2. His mother and 25-year-old sister have type 2 diabetes. A fasting blood glucose concentration for the boy is 110 mg/dL (6.1 mmol/L). Of the following, the MOST appropriate next step to screen for diabetes is to

A 12-month-old male infant presents for an ear re-evaluation 1 month after being treated for his fourth episode of otitis media. His parents describe a normal birth history and normal development. The child is breastfed and does not attend child care. His immunizations are up to date through 6 months of age, including three doses of the conjugated pneumococcal vaccine. There is no history of sinusitis, pneumonia, sepsis, meningitis, or urinary tract infections. After the boy's last otitis media infection, your colleague measured the child's serum immunoglobulin (lg) concentrations, and results included a low IgG of 150 mgldL (1.5 giL), a normal lgM of 80 mgldL (0.8 giL), and a normal IgA of 40 mgldL (0.4 giL). Of the following, the next BEST laboratory test to evaluate this infant's antibody function is

You are admitting a 35-week gestation newborn to the neonatal intensive care unit for respiratory distress at 4 hours of age. She requires assisted ventilation. The resident working with you asks what test of pulmonary function is preferred in your initial assessment of this newborn. Of the following, the BEST response is

A 7-year-old boy comes to your office with complaints of daily bedwetting for 2 months. He was completely toilet trained by 4 years of age and had been dry at night except for occasional (about once per month) minor bedwetting until recently. He denies daytime enuresis, dysuria, frequency, urgency, fever, abdominal pain, or constipation. He has no history of urinary tract infections. His physical examination reveals weight and height at the 75th percentiles and no abnormalities. Of the following, the MOST important next step in this child's evaluation is to obtain:

A 17 -year-old girl complains of clumsiness over the past 3 days. She has had moderate headaches for 1 month and neck discomfort for 3 days. Physical examination reveals rightsided dysmetria and left upper and lower extremity numbness to pinprick and weakness, graded as 4/5. The remainder of her examination results are normal. Of the following, the MOST appropriate evaluation to establish this patient's diagnosis is:

You are supervising a pediatric resident in her continuity clinic. She is evaluating a 4-week-old male infant who has had projectile vomiting after feeding for the past week. After reviewing the patient's electrolyte levels, she obtains an electrocardiogram (ECG) and asks you to help interpret it. The ECG reveals flat T waves. Of the following, the MOST likely electrolyte abnormality suggested by the electrocardiographic fmdings is:

A 15-year-old postmenarcheal girl presents with persistent right lower quadrant discomfort of 6 weeks' duration and a feeling of abdominal fullness. Her last menstrual period was 3 weeks ago. Results of a urine pregnancy test are negative, and urinalysis results are normal. Ultrasonography reveals a weiJ-defmed right ovarian cyst fLIJed with multiple echoes. Of the following, the BEST next step for the management of this patient is

A 16-year-old girl is brought to the emergency department by ambulance after her mother found a suicide note on her bed. The girl claims that she took "20 or 30" ibuprofen tablets 4 hours ago and nothing else. Although she is tearful, her physical examination findings are normal. Of the following, the MOST appropriate next step in the management of this patient is to

A nurse asks you to examine a 26-hour-old infant who recently developed a rash. On physical examination, you note erythematous macules over the trunk, face, and proximal extremities. Most of the macules have tiny central pustules. The infant is breastfeeding well, and the remainder of the physical examination fmdings are normal. No lesions were present at birth. Of the following, analysis of the pustular contents is MOST likely to reveal

A 16-year-old girl is being seen in your clinic because of headaches for the past month that sometimes awaken her at night. At her last visit 2 years ago, she was well, 5 ft 2 in tall, and weighed 105 lb, with Sexual Maturity Rating (SMR) 4 breast development and SMR 4 pubic hair, but she had not reached menarche. On examination at this visit, she is 5 ft 2 in tall, weighs 110 lb, and still has not begun menstruating. On evaluation, you note bitemporal visual field deficits, perhaps worse on the left. In addition to magnetic resonance imaging and an ophthalmologic evaluation, the laboratory test that is MOST likely to be most diagnostically revealing is

An 8-year-old boy is inattentive at home and school, has difficulty completing his homework, and is failing reading. Physical examination findings are normal, he has friends at school, and the family has been living in their newly built home for the past 3 years. You begin to discuss a diagnosis of attention-deficit/hyperactivity disorder, and his mother asks you what tests you will perform to try to determine the cause of the problem. Of the following, your BEST response is that you will order

You are examining a 5-year-old girl who always bas bad significant daytime wetting and a history of recurrent urinary tract infections. Findings on physical examination are normal except for the presence of a sacral dimple above the gluteal cleft. Her urinalysis reveals a specific gravity of 1.005, pH of 5.5, no blood, no protein, and no white or red blood cells. Magnetic resonance imaging of the spine reveals spinal dysraphism. Of the following, the MOST important next step to determine the cause of this child's primary enuresis is to obtain

A 1-month-old infant presents with frecklelike macules (Item Q49A) over his face and extremities. The hospital record reveals that he had multiple papules and pustules distributed over his entire body, including palms and soles, at birth. The infant appears to be very healthy and thriving. Of the following, analysis of the pustular contents in the newborn period MOST likely would have revealed

A 17-year-old boy who has a 5-year history of Crohn disease comes in with a flare of his illness, characterized by fever, diarrhea, and a 15-lb weight loss. He admits he has "forgotten to take his medicines lately." Physical examination demonstrates a very thin patient who has a perianal fistula. Abdominal computed tomography scan demonstrates thickening of the ileum and ascending colon. You are trying to decide whether to administer enteral nutrition (through a nasogastric tube) or begin parenteral nutrition. Of the following findings associated with Crobn disease, the BEST indication for instituting parenteral nutrition is

A 12-month-old boy comes to the emergency department with a 3-day history of intractable vomiting and watery diarrhea. His mother reports decreased urine output for the past 24 hours. His heart rate is 180 beats/min, and his blood pressure is 85/40 mm Hg. He is lethargic but responds to stimulation. His mucous membranes are very dry, his skin turgor is decreased, and his capillary refill is 3 seconds. The remainder of his physical examination findings are unremarkable. Of the following, the laboratory data that are MOST consistent with this patient's clinical presentation are

A 4-year-old boy presents to your clinic for a second opinion. He has a 3-week history of diarrhea, abdominal pain, and tenesmus. The parents state that he seems to be getting worse, and nobody has been able to help them despite "a bunch of tests on his poop." His stool output has increased from four to five per day to eight to ten per day during the past week, and he now has a temperature of 102°F (38.9°C). They are starting to see what appears to be blood in the toilet after he goes to the bathroom. According to the parents, the boy was in good health until1 week after they returned from a fishing trip on the Amazon river. Physical examination reveals a moderately ill-appearing boy who has diffuse abdominal pain. During your examination, he passes a very foul-smelling stool that appears to be a mixture of blood and pus, which you send to the laboratory for analysis. Of the following, the MOST appropriate next test is

A 12-year-old girl presents to the emergency department with nausea, vomiting, and abdominal pain of 1 month's duration. Physical examination reveals a large, smooth mass encompassing almost the entire lower abdomen. Computed tomography scan confirms a mass, and biopsy documents Burkitt lymphoma. She immediately begins receiving chemotherapy, and 12 hours later she develops the classic electrolyte and urinary findings consistent with tumor lysis syndrome (TLS). Of the following, the laboratory fmdings MOST consistent with TLS are

A 5-year-old girl is brought to accident and emergency with a 24-hour history of vomiting and diarrhoea and now her eyes and skin have gone very yellow. She has been taking oral rehydration salts and is still passing urine. She is normally healthy and there is no family history of jaundice. On examination her heart rate is 130 and respiratory rate is 26. She is alert, warm and well perfused. The chest is clear, heart sounds are normal and the abdomen is soft with a 2cm liver edge. What should the management be?

A 5-week-old baby was admitted today to the chiJdren's ward with bronchiolitis. The nasopharyngeal aspirate identified respiratory syncitial virus. He was saturating to 96 per cent in air this morning and was feeding two-thirds of his usual amount of formula milk. You are asked to review him as his work of breathing is worsening now it is night time. He has nasal USMLE Pediatry2e/Paraclinic flaring, intercostal and subcostal recession, tachypnoea and crepitations and wheeze heard bilaterally. What do you expect his capilJary blood gas to show?

Clara is a 14-year-old girl who was diagnosed with muscular dystrophy when she was younger. She now mobilizes in a wheelchair and other co-morbidities include a scoliosis and cardiomyopathy. She is being seen for her annual review in clinic. Which of these would best represent the respiratory complications of muscular dystrophy?

A 10-day-old baby boy was brought to accident and emergency with a distended abdomen. On questioning, he was born at term with no antenatal concerns. Until2 days ago he had been feeding well and not vomiting, he had been wetting nappies, but mother has not witnessed a good urinary stream. On examining the child, you imd a mass, dull to percussion, arising out of the pelvis, and he has had no wet nappies for the last day. You suspect he may have posterior urethral valves. Which one test will help to diagnose this underlying condition?

An 18-month-old boy presented to the GP with a history of eating soil. He had been in the garden this afternoon as his mother put the washing out. She found him eating the soil and took him straight inside. On examination, he is well and alert but has pale conjunctivae. He is not tachycardic or tachypnoeic. His diet consists of predominantly of breast milk. What is the most likely result of his haemoglobin and haematinics?

A 9-year-old girl presents to accident and emergency with fever, vomiting and dysuria. She is wearing a steroid bracelet and has a steroid card stating she is on daily prednisolone for severe asthma and eczema and is therefore at risk of adrenal suppression. She is tachycardic at 140 bpm and you are concerned that her blood pressure is low. Her capillary glucose is 3.0 mmol/L. What is the single most important investigation?

A 4-year-old boy was diagnosed with nephrotic syndrome 6 months ago and has required a long course of oral corticosteroids to maintain remission of the condition. He has developed truncal obesity and you are concerned he may be developing Cushing's syndrome. Which of the following is not a complication of Cushing's syndrome?

You are asked to assist the lead surgeon with a midline laparotomy in theatre. The patient has small bowel obstruction confirmed by CT imaging. Before the start of the operation, you are asked what layers, from superficial to deep, would be cut through during a midline laparotomy incision. Which of the following is the most likely answer?

You are asked to review a 45-year-old man on the surgical ward by the nursing staff. Checking through the notes, you observe that he is 1 day following an open anterior resection for rectal carcinoma. He describes severe central abdominal pain associated with dyspnoea. The abdomen is soft but generally tender throughout. His symptoms have occurred despite an epidural that was inserted prior to surgery. What is the most effective form of analgesia in this setting?

A 64-year-old man undergoes a laparoscopic gastric bypass for obesity. His baseline blood pressure is 150/80 mmHg. Intraoperatively, there was a small serosal tear which was sutured laparoscopically. The patient had some bleeding during the dissection of the lesser omentum, which was controlled with diathermy. The patient did not require intraoperative transfusion. Postoperatively on return to the high dependency unit, the patient is mechanically ventilated and his blood pressure is 80/40 mmHg. His urine output is 15 mL/h. Which of the following is the best means of improving his urine output?

You are called urgently to see a 67-year-old man who is 24 hours following uncomplicated laparoscopic cholecystectomy. The patient is human immunodeficiency virus-positive and has a past history of thrombocytopenia and at pre-assessment his platelet count was 60 x 109/L. He is complaining of chest pain and breathlessness and his abdomen is noticeably more distended than in the initial postoperative period with significant peri-umbilical tenderness. His postoperative electrocardiogram shows lateral ischaemia and his current haemoglobin level is 7.5 g/dL. He is tachycardic and his blood pressure is 115/75 mmHg. The next appropriate step is?

A 22-year-old woman with known Crohn's disease is about to undergo an emergency subtotal colectomy with ileostomy. Prior to surgery the patient has been on 30 mg of prednisolone daily for more than 3 months. The best management to prevent an addisonian crisis would be?

You are asked to assist your consultant who is operating on a 43-year-old human immunodeficiency virus positive man involved in a road traffic accident. The following precautions have been shown to decrease risk of HIV transmission, with the exception of?

A 62-year-old man is about to undergo an elective abdominoperineal resection for a low rectal carcinoma. He usually takes 5 mg warfarin per day for atrial fibrillation. His most recent international normalized ratio (INR) is 2.9. Which of the following is the best preoperative strategy?

A 34-year-old man is about to undergo a left hemicolectomy for colorectal carcinoma. He is an insulin-dependent diabetic. The most appropriate perioperative management is?

A 62-year-old man is awaiting an elective femoropopliteal bypass for peripheral vascular disease. He is a smoker of 60 pack years and is being treated for hypertension and hypercholesterolaemia with ramipril 5 mg each morning and simvastatin 10 mg orally at night. Three weeks ago he was admitted following an ST elevation myocardial infarction. His current blood pressure is 170/110 mmHg. Which of the following best describes the preoperative strategy?

A 37-year-old man is admitted with abdominal pain and treated for pancreatitis; 48 hours following his admission you are asked to assess the patient as he has become increasingly confused and aggressive. Observations are not possible, but you note he appears to be breathing hard, he is tremulous and has pruritus. Choose an appropriate management strategy?

A 70 kg patient is 1 day following total hip replacement. He has not started eating and drinking. He is being rehydrated with dextrose/saline (4% dextrose and 0.18% saline). Which one of the foJJowing best describes this type of fluid therapy?

A 22-year-old man is admitted following a stab injury to the right groin. He is bleeding profusely from the wound. His blood pressure is 80/40 mmHg and his pulse is 140 beats/min. He is agitated and mildly confused. His skin is cool and mottled. In this scenario, which is the best mode of fluid delivery?

A 22-year-old man is admitted following a stab injury to the right groin. He is bleeding profusely from the wound. His blood pressure is 80/40 mmHg and his pulse is 140 beats/min. He is agitated and mildly confused. His skin is cool and mottled, which one of the following statements regarding fluid resuscitation is most correct?

A 40-year-old man weighing approximately 70 kg is being kept nil by mouth due to small bowel obstruction. He is afebrile at 36.7 °C. Which of the following regimens best describe the patient's requirements over the first 24 hours?

A 68-year-old man is 6 days following open anterior resection with defunctioning ileostomy. The patient is afebrile at 36.7 °C. He is eating and drinking normally. The nursing staff informs you the stoma output is 3 L/day. His mucous membranes are dry and the patient feels thirsty. Which one of the following statements regarding fluid therapy is most correct?

A 45-year-old patient is 1 week following an attack of severe acute pancreatitis. He has been unable to start eating as this precipitates severe pain. Physical examination reveals a soft abdomen with epigastric tenderness. Bowel sounds are scanty. He is afebrile. His amylase in normal and C-reactive protein is 200 mg/L. Which of the following statements regarding management of nutrition is correct?

After a multidisciplinary review, a 55-year-old patient is commenced on enteral feeding. After 24 hours, he complained of severe diarrhoea. What is the most appropriate step in managing this patient?

A 75-year-old Caucasian man is on the intensive care unit following an emergency Hartmann's procedure for an obstructing sigmoid carcinoma. He is currently 6 days post-procedure. His past history includes chronic obstructive pulmonary disease. The nursing staff report high nasogastric aspirates despite slow enteral feeding at 10 mL/hour. On examination, his abdomen is mildly distended, and generally tender with no peritonism. His stoma looks healthy, but has not started to work yet. His bowel sounds are absent. What is the best way to manage this patient's nutrition?

A 30-year-old man is on the surgical ward following an assault resulting in severe head injury. The speech and language therapist is unhappy with the patient's swallow as he regurgitates fluid and is at risk of aspiration. Which of the following is the best long-term strategy for addressing this patient's nutritional requirements?

You see a patient on the Intensive Care Unit who has been admitted with severe pancreatitis. He is having a central venous catheter inserted for intravenous fluid monitoring. Other than using a central venous cannula to measure central venous pressure during fluid resuscitation, from the list below choose the answer which correctly describes a long-term use of a central venous cannula?

You see an 18-year-old lady in the theatre admission lounge who is due to have a removal of a right breast fibroadenoma under general anaesthesia. You ask her whether she has had anything to eat or drink after midnight on the same day as the operation. From the list below, which of the following correctly applies to preoperative starvation in adults?

You are asked to see a patient one day post total thyroidectomy who has a serum calcium of 2.0 and is complaining of muscular cramps. Which of the following is the most appropriate next step in this patient's management?