USMLE pediatry Treatment

1) The parents of a 16-year-old girl bring their daughter to the Emergency Department due to their concerns regarding her recent behavior. Her mother reports, “She has always been a straight “A” student and has had an uneventful childhood until now.” Her developmental and medical history are insignificant except for a diagnosis of asthma when she was eight-years-old. Over the last two months, she has been spending time with new friends, dressing differently, and has become increasingly defiant. This morning, her parents received a call from her school counselor who reported that the patient missed three days of school last week and is in danger of having to attend next course because she is falling math. Last night, she did not return home until 3 am despite the fact that her curfew was 11 pm. The patient is annoyed and states, “What’s the big deal? I was just hanging out with my friends.” Initially, she refused to answer any questions. Her cooperation improves, however, when assessed without her parents present. Review of symptoms was negative and she confirms that her asthma was controlled. She denies abusing any substances. She confirms that her grades have dropped because she is tired of school. She also says, “I really don’t care if I fail, but I’m not going to next course. Me and my friends have plans.” She would not provide any further details. After interviewing both the parents and the adolescent individually, which of the following is the most appropriate course of action?

2) A worried and anxious pregnant mother brings her 3-year-old son to the emergency room after he experienced several episodes of vomiting and abdominal pain for the past two hours. His vomit is coffee ground in appearance. He is irritable and lethargic. His BP is 80/40 mmHg and pulse rate is 120/min. Examination shows a normal oropharynx; chest auscultation is within normal limits. Abdomen is soft and mildly tender at the epigastrium; there is no hepatosplenomegaly. Extremities are cold to touch. Initial laboratory studies show: Hemoglobin 10.3 g/L, Leukocyte count 14, 500/mm3, Bicarbonate 18 mEq/L. Chest x-ray is normal limits. Abdominal imaging shows radiopaque tablets in the stomach. Intravenous normal saline is started. Which of the following is the most appropriate next step in management?

3) A 12-year-old African American male with known sickle cell disease presents with a 2 hours history of right-sided arm weakness ans slurred speech. He has been hospitalized before for pain crises and pneumonia. He takes hydroxyurea, oxycodones as needed, and folic acid. His temperature is 36.6 C, BP is 153/83 mmHg and HR is 112/min with regular rhythm. On physical examination, he has right arm weakness and mild dysarthria. His laboratory values are the following: Hemoglobin 8.2 mg/dL, WBC count 14, 000.mm3, Platelet count 210, 000/mm3, Creatinine 0.9 mg/dL. CT of the head shows no evidence of intracranial bleeding. Which of the following is the best initial management for this patient?

4) A 1-day-old full-term boy is in the neonatal intensive care unit with cyanosis. His BP is 80/40 mmHg in all 4 extremities, HR is 140/min, and respirations are 55/min. Pulse oxymetry shows 80% and does not improve with 100% inspired oxygen by face mask. He is breathing comfortably, but his fingertips and oral mucosa are blue. A continuous machine-like murmur is heard on auscultation. Chest x-ray shows clear lung fields bilaterally. Which of the following is the best next step in management of this patient?

5) A 3-year-old boy is brought to the physician for help with toilet training. He recently started day care and screams "no" when teachers try to place him on the toilet. He has bowel movements every other day and strains when he passes hard, pellet-like stools. The boy is a picky eater but loves milk and drinks up to 30 oz of chocolate milk daily. He has no medical problems and takes no medications. His weight and height have been tracking along the 75th percentile. Examination shows a cooperative, well-nourished boy. He runs well and can climb onto the examination table independently. He speaks in short sentences that are mostly understandable. The boy's abdomen is soft, nontender, and nondistended. He has normal Tanner I male genitalia. A small fissure is noted on the anal verge. Which of the following is the best next step in management of this patient?

6) A 6-week-old girl comes to medical attention because of a bright red plaque on her neck. The plaque is slightly raised, measures 2 cm in greatest diameter, and blanches partially on pressure. The mother reports that the lesion appeared in the second or third week and has been gradually increasing in size. Which of the following is the most appropriate next step in management?

7) You are examining a newborn infant in the well-baby nursery. The infant was the product of a benign pregnancy and vaginal delivery; he appears to be in no distress. Interestingly, your measurement of fronto- occipital head circumference is about 2 cm larger than the initial measurement done several hours before. Your examination otherwise is significant for tachycardia and a “squishy” feel to the entire scalp. You can elicit a fluid wave over the scalp. Management of this condition should include which of the following?

8) A 5-year-old boy is brought to his pediatrician's office after he falls from his bicycle and strikes his head against the sidewalk. There were no witnesses to this incident, which occurred 8 hours ago. The child is otherwise healthy, up-to-date on his immunizations, and not taking any medications. On physical examination, his vital signs are stable. He has a 5 × 4 cm abrasion on his forehead. He is alert and oriented to date, place and self. His motor and sensory examinations are normal and reflexes are normal. Which of the following constitutes reasonable management?

9) The parents of a 16-year-old girl complain that she does not get enough sleep. They recently discovered that she stays awake most nights until 1:00 AM reading and text messaging her friends. She wakes at 6:30 AM for school, and complains of sleepiness during the day. On weekends she sleeps until noon. Her parents have tried taking away her computer and phone, but she still would go to bed at the same time. The parents are looking for advice in dealing with their “night owl” daughter. Which of the following is appropriate advice for this family?

10) A 15-year-old boy comes to the physician for advice about his facial acne. On examination, the patient has mild to moderate acne, mostly consisting of open comedones, some closed comedones, and a few pustules on the forehead and cheeks. Which of the following is the best advice to give this patient?

11) A female infant is born full-term to a 24-year-old Caucasian primigravida. The delivery was uncomplicated. The Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. The prenatal course was complicated with asymptomatic bacteriuria that was treated with an antibiotic. The mother took multivitamins during her last trimester, occasionally took acetaminophen for back pain throughout the pregnancy, and denies smoking and alcohol consumption. Physical examination of the infant reveals a blood-tinged vaginal discharge and bilaterally enlarged mammary glands. What is the best next step in the management of this patient?

12) The mother of a 2-year-old girl reports that her daughter complains of burning when she urinates and that she has foul-smelling discharge from her vagina. She has some slight staining on the front of her underwear, but denies fever, nausea, vomiting, or other constitutional signs. The child does not attend day care, and she has demonstrated no change in behavior. The physical examination is normal with an intact hymen, but the child’s vulva is reddened and with a malodorous scent noted. Her urinalysis and culture are normal. Management of this condition includes which of the following?

13) A 12-year-old boy comes to the emergency department at midnight with a complaint of severe scrotal pain since 7 PM. There is no history of trauma. Which of the following is the most appropriate first step in management?

14) A 12-year-old boy presents with an intensely pruritic rash for 3 days. He just went on a camping trip, during which he wore only short-sleeve shirts and short pants. His temperature is 37.6 C (99.7 F), blood pressure is 96/62 mm Hg, pulse is 65/min, and respirations are 12/min. There are numerous erythematous papules and vesicles on both arms and legs. Most of them are in a linear array. Which of the following is the most appropriate pharmacotherapy?

15) A 5-year-old boy suddenly begins coughing while eating peanuts. He is choking and gagging. When he is brought to the emergency department, but he is awake and is able to give his name. On physical examination, his vital signs are stable. On examination of the chest, inspiratory stridor and intercostal and suprasternal retractions are apparent. Which of the following is the most appropriate initial step in management?

16) A 9-year-old boy is rushed to the emergency department after having a seizure. He is visiting his grandparents for the weekend. His past medical history is insignificant. When the grandmother is questioned about any medications, she replies with, "He isn't taking any medications, but I'm taking nortriptyline, and my husband is taking atenolol and enalapril." The boy's blood pressure is 80/40 mmHg and pulse is 90/min. Physical examination reveals dry oral mucosa and dilated pupils. His answers are adequate, but delayed. EKG shows wide QRS complexes. What is the best next step in the management of this patient?

17) A 1-month-old infant is brought to the office for a routine neonatal visit. His prenatal and birth histories are unremarkable. His vital signs are normal. Examination reveals a harsh, loud holosystolic murmur over the left, lower sternal border. Palpation reveals a thrill over the precordial region. There is no cyanosis, and pulmonary auscultation reveals no rales. Chest radiograph reveals a heart of normal size and a slight increase in pulmonary vascularity. EKG is normal. Which of the following is the most appropriate course of action?

18) A 19-year-old male college student returns from spring break in Fort Lauderdale, Florida, with complaints of acute pain and swelling of the scrotum. Physical examination reveals an exquisitely tender, swollen right testis that is rather hard to examine. The cremasteric reflex is absent, but there is no swelling in the inguinal area. The rest of his genitourinary examination appears to be normal. A urine dip is negative for red and white blood cells. Which of the following is the appropriate next step in management?

19) A 7-day-old female neonate is brought to your office for a 2-day history of jaundice and poor feeding. According to the mother, she has vomited twice but doesn't appear febrile. She is regularly breastfed. Her birth history is unremarkable. On examination, she appears listless, and mild jaundice, along with signs of dehydration, are noted. Her blood pressure is 78/52mm Hg, pulse rate is 150/min, and temperature is 36 C (96 F). Her family history is insignificant. What is the most appropriate next step in the management of this patient?

20) The father of a 1-week-old infant comes to the office in a panic. He has just noticed on his child a right anterior shoulder mass that seems ten- der. The father is an osteosarcoma survivor and fears the child has the same malignancy. In reviewing the baby’s discharge papers, you note the child was a term, appropriate-for-gestational-age vaginal delivery with a birth weight of 3200 g (7 lb, 1 oz). Apgar scores were 9 at 1 and 5 minutes. Your examination is significant for a large firm mass on the right clavicle; the rest of the examination is normal. Management of this problem should include which of the following?

21) A 7-year-old girl complains of increased urinary frequency, dysuria and itching on urination. Her urinalysis is consistent with a urinary tract infection. This is her 20th infection in the past year, despite adequate antibiotic coverage. Further imaging of her bladder, kidneys and ureter reveals is consistent with vesicoureteral reflux. Which of the following is the next appropriate step?

22) A 3-year-old girl is believed to have swallowed a marble. She presents to the emergency department unable to speak and begins to become cyanotic. Initial attempts at endotracheal intubation are unsuccessful. Which of the following is the most appropriate next step in management?

24) A previously normal newborn infant in a community hospital nursery is noted to be cyanotic at 14 hours of life. She is placed on a face mask with oxygen flowing at 10 L/min. She remains cyanotic, and her pulse oximetry reading does not change. An arterial blood gas shows her PaO2 to be 23 mm Hg. Bilateral breath sounds are present, and she has no murmur. She is breathing deeply and quickly, but she is not retracting. While you are waiting for the transport team from the nearby children’s hospital, you should initiate which of the following?

26) A mother brings her 4-year-old son to see you. She seems to be very concerned about her child's bedwetting. As you explore the history, the mother tells you that she started his toilet training when he was 2 years old. The child responded to his mother's efforts and slowly was able to reduce the frequency of bedwetting. However, he did not completely succeed and still occasionally wets his bed. She has become so concerned that she demands you to order tests and prescribe some drugs to resolve the problem. What is your best next step in the management of this boy?

27) A 20-year-old female is brought to the Emergency Room by her college roommate who states that the patient vomited all night. The patient complains of a sore throat and says she has not eaten for the last two days. She admits to a "sugar problem" and quit taking her medication because she has not been eating. Examination reveals an ill-appearing woman. Her temperature is 37.9 C (100.2 F), blood pressure is 118/78 mm Hg, pulse is 160/min, and respirations are 30/min. The patient's lips and mucous membranes are dry. There is a fruity odor noted to the patient's breath. The lung and cardiac examination are unremarkable except for mild tachypnea and tachycardia. Laboratory analysis shows: Sodium 130 mEq/L, Potassium 6.1 mEq/L, Chloride 100 mEq/L, Bicarbonate 8 mEq/L, Urea nitrogen 10 mg/dL, Creatinine 1.0 mg/dL, Glucose 680 mg/dL, pH 7.15, pCO2: 30 mm Hg, pO2: 85 mm Hg, Urinalysis is positive for ketones. Which of the following is the most appropriate initial step in management?

28) A new mother complains that her 6-week-old infant frequently regurgitates small volumes of formula during and after feedings. Physical examination demonstrates a happy baby who has gained half a pound since his last visit. No abdominal masses are noted. Which of the following is the best next step in management?

29) A 3-year-old girl presents to the pediatrician's office. The mother states that the girl has been having big, bulky stools that float in the toilet. She also has intermittent diarrhea. On examination, her height is 88 cm (34.6 in, <5th percentile) and weight is 15.8 kg (34.8 lb, <5th percentile). In addition, she has an uncle who died of recurrent lower respiratory infections. Which of the following would be most effective for alleviating the gastrointestinal symptoms of this patient?

30) A 14-year-old girl with a history of seizures is admitted to the hospital with the diagnosis of status epilepticus. Her valproic acid level is in the therapeutic range. You arrange a 24-hour video electroencephalogram (EEG). During the EEG, she has several episodes of tonic and clonic movements with moaning and crying, with no loss of bowel or bladder control. The neurologist tells you that during the events the EEG had excessive muscle artifact but no epileptiform discharges. Which of the following treatments is the most appropriate for this condition?

31) A 5-year-old African-American boy is brought to the office by his mother due to a painful right knee, fever and chills over the last 2 days. The child was diagnosed with pharyngitis 2 weeks ago, and was treated with a 10-day course of penicillin G. His temperature is 38.8 C (102F) and pulse rate is 102/min. On examination, his right knee joint is swollen and erythematous, with a decreased range of motion. The laboratory findings are significant for leukocytosis and an elevated ESR. X-rays of both the right hip and knee joints are normal. What is the most appropriate treatment for the patient's condition?

32) A 12-year-old boy comes to the emergency department with severe shortness of breath, cough, and fever. He was diagnosed with cystic fibrosis when he was five years old. He is currently not taking any medications. His temperature is 39.4 C (103F), blood pressure is 80/40 mmHg, pulse is 120/min, and respirations are 30/min. He is excessively using his accessory respiratory muscles. Lung auscultation reveals bilateral lower lobe crackles and expiratory wheezing. Pulse oximetry shows Sa02 of 85% that improves to 92% after oxygen supplementation. Which of the following antibiotics or combinations is the best choice for this patient?

33) A 7-month-old boy is brought to his physician because of increased agitation and restlessness. Lung examination reveals crackles and decreased breath sounds bilaterally. Chest x-ray films are notable for bilateral pneumonia. Arterial blood gas analysis reveals an oxygen tension of 45 mm Hg and a carbon dioxide tension of 60 mm Hg. Which of the following is the most appropriate next step in management?

34) You have just given a 10-year-old boy an injection of pollen extract as prescribed by his allergist. You are about to move on to the next patient when the boy starts to complain about nausea and a funny feeling in his chest. You note that his face is flushed and his voice sounds muffled and strained. Which of the following is the first priority in managing this episode of anaphylaxis?

35) A 5-year-old girl without past history of UTI is in the hospital on antibiotics for Escherichia coli pyelonephritis. She is still febrile after 4 days of appropriate antibiotics. A renal ultrasound revealed no abscess, but a focal enlargement of one of the lobes of the right kidney. CT of the abdomen reveals a wedge shaped area in the right kidney distinct from the normal tissue with minimal contrast enhancement. Appropriate management of this patient includes which of the following interventions?

36) A 6-year-old boy is brought to the office due to a sudden onset of petechiae and epistaxis. Three weeks ago, he had an upper respiratory tract infection which resolved uneventfully. Physical examination shows a few petechiae over the trunk and extremities, but is otherwise unremarkable. Laboratory studies show: Hb 13.5g/dL, WBC 7, 000/mm3, Differential count normal, Platelets 60, 000/mm3. What is the most appropriate next step in the management of this patient?

37) A 6-year-old boy is brought to the pediatrician because of a 3-day history of skin lesions. On physical examination, he has multiple yellow, crusted erosions below the nares and on the cheeks, chin, and upper extremities. The rest of the examination is normal. Which of the following is the most appropriate treatment for this condition?

38) A 10-year-old girl comes to medical attention because of recurrent attacks of wheezing and dyspnea. The attacks occur mostly at home or, if outdoors, soon after exercise. Exacerbations are noted in springtime. The severity of symptoms is mild- Pulmonary function tests show that peak expiratory flow (PEF) and forced respiratory volume per second (FEVj) are reduced during an attack but are relatively normal during symptom-free intervals. Height and weight are in the 60th percentile. Complete blood count shows 8% eosinophils; all other parameters are normal. Cutaneous testing shows the patient to be allergic to a variety of allergens, including dust mites, animal dander, and several pollens. Which of the following is the most effective step in management?

39) A 3-year-old African-American female is brought to the office due to a swelling in her abdomen. According to her parents, this swelling was first noted when she was 3 months old, and has been increasing in size over the past 6 months. It is more pronounced during crying and coughing. Examination reveals a soft swelling of the umbilical region that is 3 cm in diameter and covered by skin. It can be easily reduced through the fibrous ring at the umbilicus. The child is afebrile and in good health. What is the most likely diagnosis and best course of action for this patient?

40) The mother of a 2-year-old male child states that she has noticed white, cheeselike material arising from his foreskin and also that he cannot fully retract the foreskin behind the glans penis. Which of the following is the correct advice for this parent?

41) You are called to examine a newly delivered infant, who is 41 weeks gestation and a product of an uncomplicated pregnancy. Physical examination reveals a matted mass of edematous bowel loops protruding from the abdomen. There is no covering over the bowel loops. The umbilical cord appears normal. Which of the following is the best next step in the management of this patient?

42) A frantic mother telephones the pediatric office. She reports that her 10-year-old boy accidentally splashed Drano (a strongly corrosive, alkaline drain cleaner) on his face, and he is screaming in pain complaining that his right eye hurts terribly. Which of the following is the best advice to give to the mother?

43) A 3-year-old boy is brought to the emergency department because of a worsening cough over the past week. His temperature is 38.9 C (102 F), and inspiratory stridor is noted. A plain film of the neck reveals subglottic swelling. He is noted to have copious thick secretions and a barking cough. He has not had such events previously, and his parents deny recent contact with sick children. The patient is in respiratory distress and is noted to be retracting his subcostal muscles to breathe. Which of the following is the next most appropriate step in management?

44) A 14-year-old boy is hit by an automobile while walking across the street and is immediately taken to the emergency department. On arrival, he is conscious and complains of shortness of breath and chest pain. Physical examination reveals an ecchymotic area over his right chest and subcutaneous emphysema. Breath sounds are absent on the right side. His trachea is deviated to the left, and his right hemithorax is tympanic to percussion. Which of the following is the most appropriate initial step in management of this patient?

46) A 4-year-old boy is brought to the emergency department for a painful and swollen right forearm. He was bitten and scratched by a family cat 2 days ago in the affected area. His temperature is 39.6 C (103.2 F). The right forearm is erythematous, edematous, and tender to touch. Which of the following is the most appropriate antibiotic treatment for this patient?

47) A 6-year-old boy is brought to the office by his parents after hearing that chicken pox is infectious and can occur in unimmunized contacts. One week ago, he and his family visited relatives, and one of his cousins had chicken pox at that time. He and his two other siblings are apparently healthy, and never had any "chicken pox shots." What is the best next step in the management of this patient?

48) A 5-year-old Mexican female child is brought to the office for the evaluation of a pruritic vulva for the past fifteen days. The pruritus is felt mostly during the night. Her 4-year-old cousin who visited them four weeks ago has a similar complaint. On examination, there is no vaginal discharge, but the vulva is erythematous. The rest of the physical examination is normal. What is the most appropriate next step in the management of this patient?

49) A newborn girl is noted to be drooling saliva, and she chokes violently when she is first fed. On physical examination, she is found to have abdominal distention and an imperforate anus. There is no fistula to the perineum or vagina. Examination of the urine reveals no meconium in it. Echocardiogram and renal sonogram are reported as negative for other congenital defects. X-ray films show abundant gas in the gastrointestinal tract. Pictures taken with a metal marker taped to the anus, and the baby hanging upside down, show that there is a significant distance (2.5 cm) between the blind end of the rectum and the anal marker. Before a diverting colostomy is performed, which of the following steps should be taken?

54) A 16-year-old boy presents with a temperature of 38.4 C (101 F) and low back, wrist, and knee pain. He had a sore throat 1 month earlier. His arthritis is diffuse. Pea-sized swellings are noted over the skin on his knees. He has a serpiginous erythematous area on his anterior trunk. His blood and throat cultures are negative, and his CBC is unremarkable. His antistreptolysin-O (ASO) titer is high. Which of the following is the most appropriate therapy?

55) A 2-year-old child is brought by an anxious mother to the emergency department because of difficulty in breathing for the past 12 hours. The child has a history of runny nose that started 3 days ago. He suddenly developed a progressively increasing difficulty in breathing. The mother reports that the child "sounds like a barking dog when he coughs." The child's temperature is 37.7C (99.9F), respirations are 30/min, blood pressure is 90/60mm Hg, and pulse rate is 104/min. He is coughing and using his accessory muscles of respiration. His oxygen saturation is 98% on 2L of oxygen. He is diagnosed with laryngotracheobronchitits, started on humidified oxygen, and kept in an upright position. After 20 minutes, he becomes more irritable, his oxygen saturation drops to 92%, respirations increase to 40/min, and pulse increases to 120/min. His blood pressure and temperature are unchanged. What is the most appropriate next step in the management of this patient?

56) A 16-year-old girl is being evaluated for primary amenorrhea. Her birth history is significant for low birth weight and bilateral swelling of the hands and feet. Her blood pressure is 170/96 mmHg. She has a short stature and webbed neck. Her karyotype examination results show 22 pairs of autosomes, one X, and one Y chromosome. Which of the following statements is true regarding this patient's condition?

57) An 8-year-old girl presents with well-controlled, moderately persistent asthma. Her therapies consist of occasional use of short-acting β-agonists, daily inhaled steroids, and a leukotriene inhibitor. She presents with white patches on her buccal mucosa. You recommend which of the following?

58) A 7-year-old boy is referred for genetic testing because his father was diagnosed with medullary cancer of the thyroid. The father underwent a total thyroidectomy, and in the preoperative workup it was determined that he also had a pheochromocytoma, and that tumor was removed also. The father did not have parathyroid hyperplasia at the time, his phenotype was normal, and his final diagnosis was MEN- 2A. The child is tested and found to have RET mutations in the peripheral white blood cells. The child has normal phenotype, normal levels of calcitonin, normal levels of catecholamines, metanephrines, and VMA, and normal levels of calcium and parathyroid hormone. Which of the following is the most appropriate management?

59) A 4-year-old girl with sickle cell disease presents to the emergency department with a temperature of 39.6 C (103.2 F). Other than irritability, the physical examination is unremarkable. Laboratory evaluations reveal a white blood cell count of 18,200/mm3, with 88% polymorphonuclear neutrophils, 10% lymphocytes, and 2% monocytes, and a hemoglobin of 7.6 g/dL. Which of the following is the most appropriate next step in management?

60) A 9-month-old, chubby, healthy-appearing boy is brought to the pediatrician because of episodes of colicky abdominal pain and blood-tinged stools. The pain lasts from 1 to 10 minutes and causes the infant to double up; he then appears normal until his next bout of colic. During the examination, the infant has another episode, at which time a vague mass can be felt on the right side of the abdomen, and the right lower quadrant has an "empty" feeling to deep palpation. Which of the following is the most appropriate initial step in management?

61) You are seeing a 2-year-old child, brought by his father for a well-child examination. In providing age-appropriate anticipatory guidance, you should tell him which of the following?

62) A 7 -day-old male infant is brought by his mother complaining of decreased movements of his right arm. She denies any trauma or fall. Pregnancy was uneventful, but delivery was complicated with shoulder dystocia. Examination reveals the presence of crepitus and bony irregularity over the clavicular area and Mora reflex is absent on the right. Which of the following is the most appropriate management?

63) A 16-year-old girl has had a fever, vomiting, and watery diarrhea for the past 24 hours. She also complains of intermittent abdominal pain and generalized myalgia. On examination, she is slightly lethargic. Her temperature is 39.4 C (103 F), blood pressure is 75/50 mm Hg, and pulse is 150/min. Her conjunctivae and pharynx are hyperemia. She has a generalized erythematous maculopapular rash that spares the wrists. Which of the following will be the most appropriate treatment?

64) An 8-month-old infant, who is up-to-date with his immunizations, is brought to the clinic by his mother. The mother states that she overheard other mothers talking about a varicella vaccination that their children have received. She does not want her son to have the chickenpox virus and therefore, wants him to receive the vaccine today. The physician explains that the infant has not yet reached the recommended age for the vaccine. If this visit is in November, when is the earliest that this patient can return for the varicella vaccine?

65) An 11-year-old girl is brought to the office by her mother due to headaches for the last 4 hours. The headaches are bifrontal, and are accompanied by nausea, vomiting, and sensitivity to light and noise. It is her second episode, and both episodes were preceded by dark spots in her visual field. The first episode was 2 weeks ago. She doesn't report any numbness or tingling in her extremities, and no behavioral change or decline in school performance was noted. Her vital signs are stable, and she is afebrile. The physical examination is normal. What is the most appropriate next step in the management of this patient?

66) A previously healthy one-year-old child is brought to the physician for a routine wellness visit. Her parents report that she drinks six glasses of whole milk a day, but is a very picky eater. She is developmentally appropriate. Her parents are concerned that she might be anemic because she frequently eats ice and sometimes dirt. On examination, her temperature is 88.6F (37 C), pulse is 118/min, and respiratory rate is 21 /min. Her height and weight are both at the 50th percentile for her age. She appears well nourished and her physical examination is unremarkable. Laboratory findings include the following. Complete blood count: Hemoglobin 10.5 g/dL, MCV 70 fl, Reticulocytes 1.0%, Platelets 250,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 56%, Lymphocytes 33%, Monocytes 10%. Which of the following is the most appropriate next step in the management of this child?

67) An inner city family has been using a neighbor to care for their 3-year-old child while the parents work. The neighbor is diagnosed with pulmonary tuberculosis. PPD test of the 3-year-old is negative. Which of the following is indicated for the 3-year-old?

69) An 8-year-old male presents to the emergency department with decreased mental status. His mother states that she has noticed he has been drinking and urinating more frequently over the past several weeks. He was hard to wake up this morning and complained of abdominal pain. Physical examination reveals an afebrile drowsy male with clear airways and mild tachycardia. Mucous membranes are dry and his lips are cracked. His abdomen is mildly tender to palpation diffusely, but there is no rebound or guarding. Laboratory evaluation reveals a glucose of 560 mg/dL and potassium of 5.9 mEq/L.An arterial blood gas analysis reveals a pH of 7.18. A urinalysis is positive for ketones and glucose. CT scan of the abdomen is normal. A chest x-ray film is clear. Two hours after initiation of treatment the physician adds potassium to the patient's IV fluids. Which of the following best explains this therapeutic decision?

70) An 8-month-old girl is brought to the clinic for a well-baby checkup. Her antenatal and birth histories are unremarkable. Her vital signs are stable, and all developmental milestones are appropriate. On examination, a head tilt is noted. Ophthalmoscopic examination reveals a red reflex and normal corneal light reflex. The cover test reveals moderate esodeviation of the left eye. What is the most appropriate next step in the management of this patient?

71) A 17-year-old adolescent comes to your office seeking help for “heavy” menses. Your review of systems also reveals weekly epistaxis. Her only significant past history includes a tonsillectomy at age 6 after which she required blood transfusion for excessive bleeding. Her family history includes several people who seem to bleed and bruise more easily than others. The patient’s mother required a hysterectomy after child birth for excessive hemorrhage. You order a variety of laboratory tests. The patient has a hemoglobin of 6.5 mg/dL with an MCV of 60%; her platelet count is 350,000/µL. Her von Willebrand antigen and her von Willebrand factor (vWF) activity (ristocetin cofactor activity) are decreased. Her vWF is reported as normal but in decreased amounts. You have been unable to reach her to report the findings, but when she calls about 1 week later she reports she is having a mild to moderate nosebleed. You initiate therapy with which of the following?

72) A 12-year-old boy is brought to the office by his mother due to a two-week history of generalized edema which is gradually progressing. His past medical history is insignificant. He is not taking any medications. His blood pressure is 110/80 mmHg, pulse is 85/min, respirations are 18/min, and temperature is 36.7C (98F). The laboratory findings are as follows: Serum sodium 140 mEq/L, Serum potassium 3.7 mEq/L, Serum albumin 2.1 g/dl, Serum globulin 6.0 g/dl, Serum creatinine 1.0 mg/dl. Urinalysis reveals proteinuria 3+. What is the best next step in the management of this patient?

73) A parent brings in a 5-year-old boy being treated for acute lymphocytic leukemia (ALL). He states a friend who is staying with them at their home has just come down with chicken pox. Your patient has not had chicken pox or received immunization with varicella vaccine. What is the appropriate treatment?

74) A young mother claims that her 4-week-old child sleeps best on his stomach. You tell her that the safest sleep position for infants is which of the following?

75) You receive a call from the parents of a 1 year old who is due for his well-child visit next week. They have just received a letter from their daycare center that an employee has hepatitis A. Which of the following is the best treatment plan?

76) A 3-month-old infant is brought to the emergency department for severe vomiting over the past 6 hours. The mother tells the physician that she has vomited at least 4 times during this period. She also noticed the infant was having difficulty feeding for 2 days. On examination, she is very fussy, and there is a swelling over the left side of the head. CT of the head shows a skull fracture of the left parietal bone with no evidence of intracranial damage. The mother explains that the baby rolled off the sofa onto the floor yesterday. Which of the following is the most appropriate next step in management?

77) One of your asthmatic patients arrives for a check-up. The mother reports that the child seems to need albuterol daily, especially when exercising, and she has coughing fits that awaken her from sleep about twice a week. Her grandmother had recommended a Chihuahua as a “cure” for her asthma, but her mother has seen no difference since the arrival of the pet. Appropriate treatment measures would include which of the following?

78) A 5-month-old child regularly regurgitates a large portion of her feeds. A pH probe study showed significant periods of low esophageal pH. The child has normal growth and no other significant past medical history. Which of the following is the best management at this point?

79) A 7 -year-old boy is brought to your office with a mild fever and neck swelling. His mother says that the boy has been complaining of neck pain for a couple of days and she noticed a tender neck lump yesterday. All of his vaccinations are up-to-date. He has no known allergies. Physical examination reveals a tender and fluctuant anterior cervical mass. Which of the following is the best medication for this patient?

80) A 21-year-old female, G1P0, who recently emigrated from Zimbabwe presents for prenatal counselling in her 34th week of pregnancy. She received no prenatal care. Ultrasound evaluation reveals lower-than-normal fetal length and markedly reduced fetal head size. Which of the following could have prevented this condition?

81) A 4-week-old infant presents with tachycardia, tachypnea, and poor weight gain. His arterial blood gas shows a pH of 7.34, a PaCO2 of 41 mm Hg, and a PaO2 of 74 mm Hg. A chest radiograph shows cardiomegaly. Echocardiography reveals a structurally normal heart, left ventricular dilatation, a left ventricular ejection fraction of 20%, and mild mitral and tricuspid regurgitation. IV administration of which of the following medications is the best initial step in management of this patient?

83) At the 2-week checkup of a term female infant, the mother reports a grayish and sometimes bloody vaginal discharge since birth. The infant’s mother and grandmother are the only caretakers. Examination of the external genitalia reveals an intact hymen with a thin grayish mucous discharge. Which of the following is the most appropriate next step?

85) A 9-year-old African-American boy is brought to ER with high fever, poor appetite, and irritability. His heart rate is 140/min and his blood pressure is 80/60 mmHg. He has been hospitalized several times before for poorly localized abdominal pain. He also has a history of hematuria. The boy has not received several routine vaccinations because his mother is afraid that they will cause autism. His hematocrit is 22% and the reticulocyte count is 12%. The patient dies several hours after the admission. This patient's death may have been prevented by which one?

87) An infant born at term to a 22-year-old woman has a weak cry and is cyanotic at birth. His fingertips and oral mucosa appear blue. His blood pressure is 80/40 mmHg and his heart rate is 140/min. Chest xray shows clear lung fields bilaterally. PaO2 measured by arterial cannulation is 38 mmHg, and improves only minimally on 100% inspired oxygen. Which of the following is the best next step in managing this patient?

88) An 8-week-old female infant is brought to the office by her Caucasian mother for a well-baby examination. She was born at 34 weeks gestation, and weighed 2.9kg (6.5 Ib) at birth. She has been exclusively breastfed since birth, and her growth and development are normal for her age. The physical examination is normal, except for mild pallor. At this time, what is the most appropriate nutritional intervention for this patient?

89) A 6-year-old boy is brought to the clinic due to persistent leg pain. Over the last few months, he has been constantly complaining of pain in his legs. The painful episodes occur only at night, and last a few hours each. His mother has been treating him with over-the-counter medications. He is able to walk and run to school without any complaints. He has no fever, chills and history of trauma. On examination, there is no obvious trauma to his legs, and the limb exam is completely normal. His parents are very worried and ask that you "do something.” Which of the following is the most appropriate next step in management?

90) A 1-year-old presents for a well-child checkup, but the parents are concerned about giving the child his immunizations. Which of the following is a true contraindication to the administration of the fourth DTaP (diphtheria and tetanus toxoid and acellular pertussis) vaccine?

91) An 11-year-old boy presents with fever and sore throat. A rapid-strep test confirms streptococcal pharyngitis. He is leaving for a summer camp in 2 days. In the past, he has had problem finishing the whole course of antibiotic treatment. Which of the following is the best treatment for his streptococcal pharyngitis?

92) A 6-year-old boy is brought to the office by his mother for the evaluation of a "skin disease." The physical examination reveals multiple vesiculopustular lesions on his face and neck. Some lesions are colored golden-yellow and encrusted. The crust is thick and adherent to the underlying skin. The rest of his physical examination is within normal limit. What is the most appropriate treatment for his skin condition?

93) A 15-year-old Caucasian boy is injured during a football game. He is taken to the emergency department for x-ray films of his leg to rule out a possible fracture. The radiologist reports that the boy has evidence of an aggressive bone tumor with both bone destruction and a soft tissue mass. Later, the pathologist reports that the bone biopsy reveals a bone cancer with some of the tumor tissue displaying neural differentiation. Which of the following is the most appropriate next step in management?

94) A 7-year-old boy has a history of repeated urinary tract infections that have been treated by the empiric use of antibiotics. The parents are not satisfied with the care the child is receiving, and they take him to a pediatric urologist. Evaluation by voiding cystourethrogram shows that the patient has vesicoureteral reflux without ureteral or upper tract dilatation (grade one reflux). Which of the following is the appropriate management for this child?

95) A previously healthy 4-year-old girl is brought to the office due to a 12-day history of persistent, thick, nasal discharge, nasal congestion, headache, cough, and intermittent low-grade fever. The cough is worse at night, but there is no wheezing. Her temperature is 37.2C (99F), pulse is 90/min, and respirations are 15/min. Examination shows an alert, interactive child breathing comfortably. She has clear tympanic membranes, congested posterior nasal pharynx with thick and purulent mucus, and red, swollen nasal turbinates. Her maxillary sinuses are mildly tender. Her lungs are clear on auscultation. What is the most appropriate next step in the management of this patient?

96) A 16-year-old boy with a history of ulcerative colitis presents to the physician complaining of diarrhea and a rash. He states that his appetite has been decreased recently, and also complains of nausea and abdominal pain in addition to watery diarrhea. He has an erythematous rash on his distal arms and legs that "burns". His mother reports that he has had poor concentration and has been irritable lately. Vital signs are stable. Examination reveals a beefy red tongue that appears swollen. Abdominal examination is normal. The rash resembles a sunburn and is located on his distal arms and legs. It is symmetrical and tender to palpation. Neurological examination is normal. This patient's symptoms are most likely due to a deficiency of which of the following vitamins?

97) You are called by a general practitioner to consult on a patient admit- ted to the hospital 4 days ago. The patient is a 7-month-old white boy with poor weight gain for the past 3 months, who has not gained weight in the hospital despite seemingly adequate nutrition. You take a detailed diet his- tory from his foster mother, and the amounts of formula and baby food intake seem appropriate for age. Physical examination reveals an active, alert infant with a strong suck reflex who appears wasted. You note generalized lymphadenopathy with hepatomegaly. In addition, you find a severe case of oral candidiasis that apparently has been resistant to treatment. Which of the following is the most appropriate next step in the evaluation or treatment of this child?

99) A 13-year-old girl returns to her physician for followup of a strep throat, for which she had been treated 3 weeks previously. After performing a throat culture, the physician asks how school is going. There is dead silence. Her mother says that her daughter has missed the last 4 weeks of school. Which of the following is the most appropriate initial step in management?

100) A 1 -year old child is brought in for a well-baby check-up. His parents report that he has been of good health and began walking a few weeks earlier. They are concerned that he tends to bump into things and falls more than his older sister did. Family history is significant for retinoblastoma. On examination, the pediatrician notes leukocoria of the left eye. No significant lymphadenopathy is present, and there is no enlargement of the liver or spleen. The child's height and weight are normal for age. Which of the following is the most appropriate next step in management?

101) A 4-year-old boy presents with 5-day history of fever and increased irritability. His temperature is 40.2 C (104.3 F), blood pressure is 98/68 mm Hg, pulse is 112/min, and respirations are 24/min. On physical examination, he is noted to have bilateral cervical lymphadenopathy, cracked lips, strawberry tongue, and bilateral conjunctival injection. His palms and soles are erythematous. There is a polymorphous macular rash generalized on his body. Which of the following is the most appropriate pharmacotherapy?

102) A 16-year-old male, despondent over a recent breakup, tries to commit suicide by taking an unknown quantity of an unknown material he found at home. He is brought to the emergency center by his parents within 30 minutes of the ingestion. For which of the following household materials and medications should he be given activated charcoal as part of his emergency center treatment?

103) A previously healthy 2-year-old male is brought to the emergency department after experiencing a seizure-like episode. His parents report that he has been healthy with the exception of mild upper respiratory symptoms for the past 24 hours. During the episode, his parents state that he fell down and had rhythmic, jerking movements of his arms and legs. The episode lasted about three minutes. The patient was sleepy when the emergency personnel arrived. Vital signs are temperature 39.2 c (102.5 F), pulse 120/min, and respiratory rate 25/min. The patient is alert and oriented in the emergency department. On examination, there is mild rhinorrhea and the left tympanic membrane is erythematous, bulging, and poorly mobile. The neck is supple. A complete neurological exam is unremarkable. After treating this patient's fever, which of the following is the next best step in the management of this patient?

104) A 15-year-old female with a history of bipolar disorder and psychosis presents to her physician's office requesting a pregnancy test. Her last menstrual period was 2 months ago. She states that her menses usually occur every 30 days. She is sexually active with one partner and occasionally uses condoms. She is concerned because she has gained 10 pounds in the last two months, and also complains of breast tenderness and milky white discharge from both nipples. She denies headaches, nausea, vomiting, diarrhea, or fever. Her vital signs are normal. Physical examination is unremarkable. A urine pregnancy test is negative. Which of the following is most likely responsible for this patient's symptoms?

105) A 14-year-old boy is seen in the ER because of a 3-week history of fever between 38.3C and 38.9C (101F and 102F), lethargy, and a 2.7-kg (6-lb) weight loss. Physical examination reveals marked cervical and inguinal adenopathy, enlarged tonsils with exudate, small hemorrhages on the soft palate, a WBC differential that has 50% lymphocytes (10% atypical), and a palpable spleen 2 cm below the left costal margin. Which of the following therapies should be initiated?

107) A 12-year-old boy with cystic fibrosis presents to the emergency department with a 3-day history of severe coughing, which is productive of a yellow-greenish purulent sputum. He had fever and chills at home. He also complains of chest congestion and chest pain that is worse with coughing. On physical examination, his temperature is 39.6 C (103.2 F), blood pressure is 98/68 mm Hg, pulse is 102/min, and respirations are 24/min. He is noted to be lethargic. He has rales on the left lower lung field on auscultation, and chest radiography shows an infiltrate in the left lower lobe. Which of the following is the most appropriate initial antimicrobial therapy for this patient?

108) A 14-year-old high school student arrives to your clinic for well-child care. In reviewing his records you determine that his most recent immunization for tetanus was at 4 years of age. Which of the following should you recommend?

109) A 15-month-old boy is brought to the ER because of fever and a rash. Six hours earlier he was fine, except for tugging on his ears; another physician diagnosed otitis media and prescribed amoxicillin. During the interim period, the child has developed an erythematous rash on his face, trunk, and extremities. Some of the lesions, which are of variable size, do not blanch on pressure. The child is now very irritable, and he does not interact well with the examiner. Temperature is 39.5C (103.1F). He continues to have injected, immobile tympanic membranes, but you are concerned about his change in mental status. Which of the following is the most appropriate next step in the management of this infant?

110) The 3-year-old sister of a newborn baby develops a cough diagnosed as pertussis by nasopharyngeal culture. The mother gives a history of having been immunized as a child. Which of the following is a correct statement regarding this clinical situation?

111) A 3-month-old boy is brought to the pediatrician because of a red growth on his arm. The pregnancy had been uncomplicated, and the infant has been meeting all development milestones. He has been healthy so far and has received all scheduled immunizations. He is currently being breast-fed. His skin was clear at birth, but when he was 2 months old, his mother noted a light red growth on his arm. Within the past month, it has increased in size and has turned bright red. Which of the following is the most appropriate treatment for this disorder?

112) A 2-year-old boy is hospitalized for severe pneumonia requiring endotracheal intubation and mechanical ventilation. His hemoglobin level is 13.2 mg/dl and his WBC count is 3,200/mm3. The absolute level of CD3- positive lymphocytes is normal but the level of CD 19-positive lymphocytes is very low. This patient would benefit most from which of the following as a maintenance therapy?

113) A male infant is born to a primigravid woman whose pregnancy was uneventful. The delivery was uncomplicated. Physical examination of the newborn reveals deformity of the feet, specifically adduction of the anterior aspect of the foot with a convex lateral border and concave medial border. The ankle movements are normal, and passive and active movement of the foot overcorrects the deformity into abduction. AP radiographs reveal mild adduction of the metatarsals at the tarsometatarsal articulation, and an increased angle between the 1st and 2nd metatarsals. What is the best next step in the management of this patient?

114) You are called to a delivery of a term infant, about to be born via cesarean section to a mother with multiple medical problems, including a 1-month history of a seizure disorder, for which she takes phenytoin; rheumatic heart disease, for which she must take penicillin daily for life; hypertension, for which she takes propranolol; acid reflux, for which she takes aluminum hydroxide; and a deep venous thrombosis in her left calf diagnosed 2 days ago, for which she was started on a heparin infusion. The obstetrician is concerned about the possible effects of the mother’s multiple medications on the newborn infant. Which of the following medications is most likely to cause harm in this newborn infant at delivery?

116) After 10 days of nasal congestion and rhinorrhea, a 3-month-old infant develops a severe hacking cough during which he repeatedly turns dusky and appears to choke on or to vomit profuse thick, clear nasopharyngeal mucus. For 7 days, the coughing continues unabated. On physical examination, he is afebrile and his lungs are clear. His chest x-ray is normal. His WBC count is 24,000/mm3, with 15% polymorphonuclear cells, 82% lymphocytes, and 3% monocytes. Which of the following antibiotics should be used to treat this patient?

117) A 3-year-old boy from a refugee camp is brought to the clinic for examination. His medical history is unknown. On examination, there is marked photophobia. He appears malnourished, and his weight is <5th percentile for age after hydration. His bones and ribs are prominent, and little subcutaneous fat is identified. His abdomen is concave with decreased bowel sounds. There is marked scaling and fissuring at the corners of his mouth, as well as inflammation and cracking of his lips. His tongue is atrophic. The tongue and oropharyngeal mucous membranes are dark red. Conjunctival pallor is present. There are pinkish-red, erythematous, scaly patches on his eyebrows, cheeks, and nose. This dermatitis is also present on the scrotal skin and extends onto the medial aspect of both thighs. Otherwise, his skin is very pale, and his fingernails and toenails are brittle. What is the most appropriate intervention for this patient?

118) An infant is delivered vaginally to a 30-year-old G1P1 woman whose pregnancy was uneventful. Examination of the newborn reveals mild atrophy of the left calf. His left calcaneum and talus are in equinus and varus positions, his midfoot is in varus position, and his forefoot is in adduction. Dorsiflexion and plantar flexion of the ankle are limited. The neurologic examination is normal. What is the next best step in the management of this patient?

119) An 8-month-old infant arrives to the emergency department (ED) with a 2-day history of diarrhea and poor fluid intake. Your quick examination reveals a lethargic child; his heart rate is 180 beats per minute, his respiratory rate is 30 breaths per minute, and his blood pressure is low for age. He has poor skin turgor, 5-second capillary refill, and cool extremities. Which of the following fluids is most appropriate management for his condition?

120) You are seeing an established patient, a 4-year-old girl brought in by her mother for vaginal itching and irritation. She is toilet trained and has not complained of frequency or urgency, nor has she noted any blood in her urine. Her mother noted she has been afebrile and has not complained of abdominal pain. Mom denies the risk of inappropriate contact; the girl also denies anyone “touching her there.” Your physical examination of the perineum is significant for the lack of foul odor or discharge. You do note some erythema of the vulvar area but no evidence of trauma. Which of the following is the most appropriate course of action?

121) A 7 -year-old boy is brought to the office by his mother due to nocturnal enuresis. He has been wetting his bed at night for the past two years. He is otherwise healthy and has no psychological or behavioral problems. His mother is desperately asking for your help because she has tried alarms and bladder training, all to no success. What is the most appropriate next step in the management of this patient?

122) A 5-year-old child was hit in the right eye by a toy. He is rubbing at his eye, which is watering profusely. There is a small abrasion at the corner of the eye. He is mildly photophobic, but his pupils are equal, symmetric, and reactive to light and accommodation. His vision is normal. Which of the following is the most appropriate next step in the management of this patient?

123) A 16-year-old male is brought to the emergency department with a crush injury due to a farm accident. His immunization status is unknown. The wound is heavily contaminated with soil, and you are concerned about tetanus. Which of the following is the most appropriate management step?

124) Children with sickle cell anemia are at increased risk of developing overwhelming infection with certain microorganisms. Which of the following is the most reasonable step to prevent such infection?

125) A 1-year-old child is brought in for a regular "well baby" check-up. The child appears to have strabismus. The reflection of a bright light from the ceiling of the examination room comes from a different place in each eye. The family explains that the child has always looked that way, and there has been no recent change in the appearance of his eyes. Which of the following is the most effective management?

126) A 15-year-old girl with type 1 diabetes mellitus presents to her primary care doctor for a routine checkup. Perusal of her blood sugar chart indicates that her recorded blood glucose levels are routinely between 120 and 150 mg/dL before breakfast, dinner and bedtime, with the normal being 116 mg/dL. She is on NPH and regular insulin. Which of the following is the next appropriate step?

127) A 5-year-old girl is diagnosed with Bordetella pertussis infection after an outbreak in the day-care center. She is prescribed erythromycin for 14 days. She lives with her parents and 13-year-old sister whose immunizations are up to date. What is the most appropriate way to limit the risk of infection in household contacts?

128) A 15-year-old girl is brought to the pediatric emergency room by the lunchroom teacher, who observed her sitting alone and crying. On questioning, the teacher learned that the girl had taken five unidentified tablets after having had an argument with her mother about a boyfriend of whom the mother disapproved. Toxicology studies are negative, and physical examination is normal. Which of the following is the most appropriate course of action?

129) On a newborn boy’s first examination, you note a prominent occiput, a broad forehead, and an absent anterior fontanelle. The baby’s head is long and narrow. The remainder of the physical examination, including a careful neurological evaluation, is normal. You note that the baby was born via cesarean section for cephalopelvic disproportion. When you enter the mother’s room, the first question she asks is about her baby’s head shape. Which of the following is the most appropriate statement to the mother about this infant’s condition?

130) A 9-year-old boy comes to the office for a pre-participation physical examination for summer camp. His parents report that he still has episodes of bed-wetting. The boy’s father confides that he also had bedwetting until he was 10. They are concerned about the bed-wetting, but they are more concerned about their son’s upcoming week at summer camp and that the other boys may harass him for wetting the bed. Which of the following statements about nocturnal enuresis is correct?

131) A 10-year-old boy presents with red discoloration of the urine since the morning. He is healthy and otherwise asymptomatic. He denies dysuria, frequency, urgency, flank, or abdominal pain. His BP is normal. His examination is within normal limits including abdomen and genitourinary system. There is no rash or edema. His urine is pink in color; urinalysis is negative for hemoglobin or protein. No white cells, red cells, or bacteria are noted. Which of the following is the most appropriate next step?

132) A bat is found in the bedroom of a 4-year-old patient while the boy is sleeping. The family and the patient deny close contact with or bites from the bat. Which of the following is a correct statement regarding this situation?

134) You are asked to evaluate a 4-year-old boy admitted to your local children’s hospital with a diagnosis of pneumonia. The parents state that the child has had multiple, intermittent episodes of fever and respiratory difficulty over the past 2 years, including cyanosis, wheezing, and dyspnea; each episode lasts for about 3 days. During each event he has a small amount of hemoptysis, is diagnosed with left lower lobe pneumonia, and improves upon treatment. Repeat radiographs done several days after each event are reportedly normal. His examination on the current admission is significant for findings similar to those described above, as well as digital clubbing. Which of the following is the most appropriate primary recommendation?

135) A male infant, born to a 32-year-old white female, develops a bluish discoloration of the extremities and oral mucous membranes at 30 minutes of life. On examination, the infant is found to have tachypnea, nasal flaring and respiratory grunting. Auscultation reveals poor air entry on the left with a shift of cardiac sounds to the right. The abdomen has a scaphoid shape. The antenatal history is significant for polyhydramnios in the mother. The neonatologist on call suspects a diagnosis of congenital diaphragmatic hernia. What is the most appropriate next step in the management of this neonate?

136) A few weeks after a presumed viral respiratory infection, a 4-year-old girl presents with bruising and petechiae. Bone marrow examination reveals increased numbers of megakaryocytes but is otherwise normal. Hb is 13.5 g/100 mL. Platelet count is 30,000/mm3. Which of the following would be appropriate for this child at this time?

137) You are advised by the obstetrician that the mother of a baby she has delivered is a carrier of hepatitis B surface antigen (HBsAg-positive). Which of the following is the most appropriate action in managing this infant?

138) A routine prenatal ultrasound reveals a male fetus with meningomyelocele. The 24-year-old primigravid mother is told the infant will require surgery shortly after birth. You counsel her about the etiology of this defect and the risk of further pregnancies being similarly affected, and state which of the following?

139) A 7-year-old child is scheduled for an elective tonsillectomy. The most important instruction to the parents should be to make sure that the child does which of the following?

140) A 10-month-old girl is seen in clinic for a routine checkup. She weighs 11 kg (24.2 lb). The infant's mother reports that she drinks whole cow's milk and takes solid food poorly. The infant's activity is decreased, but her muscle tone is good and her developmental milestones are up to date. The only significant abnormal physical finding is parlor. Which of the following is the most appropriate next step in management?

141) A 3-year-old male presents after having a tonicclonic seizure lasting about 1 minute. On examination, the child now has no neurologic abnormalities. He has a temperature of 40.3°C and has an obvious otitis media on the left but no other abnormalities on physical examination. You correctly counsel the family with which one of the following statements?

146) You are awakened in the night by your 2-year-old son, who has developed noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils, and a barking cough. He has had a mild upper respiratory infection (URI) for 2 days. Which of the following therapies is indicated?

147) You receive a telephone call from the mother of a 4-year-old child with sickle-cell anemia. She tells you that the child is breathing fast, coughing, and has a temperature of 40°C (104°F). Which of the following is the most conservative, prudent course of action?

148) A 7-year-old child is brought by his mother for a school physical. His growth parameters show his height to be 50th percentile and his weight to be significantly higher than 95th percentile. His mother complains that he always seems sleepy during the day and that he has started complaining of headaches. His second-grade teacher has commented that he has difficulty staying awake in class. His mother complains that he wakes up the whole house with his snoring at night. Which of the following is the most appropriate next step in evaluating and managing this condition?

149) A 7-year-old boy is brought to your office with a sore throat, decreased appetite, and nausea. His past medical history is insignificant. All of his vaccinations are up-to-date. He has no known allergies. His temperature is 39.0°C (102.5°F), blood pressure is 110/70 mmHg, pulse is 104/min, and respirations are 16/min. On examination, the pharynx and tonsils are red, sv1ollen, and have white exudates on their surface. There is also bilateral tender cervical lymphadenopathy. The rapid diagnostic test for streptococcal antigen is positive. What is the most appropriate next step in management?

150) A 6-month-old infant is diagnosed with her first episode of otitis media. She does not have any allergies to medications. Which of the following medications would be the recommended initial therapy for this infant?

151) A 4-year-old child with grade III vesicoureteral reflux has recurrent UTIs despite adequate antibiotic prophylaxis. Which of the following is the most appropriate next step in the treatment of this patient?

152) A previously healthy 16-year-old girl presents to the emergency center with the complaint of “falling out.” She was with her friends at a local fast food restaurant when she felt faint and, according to her friends, lost consciousness for about a minute. There was no seizure activity noted, but the friends did notice her arms twitching irregularly. She is now acting normally. She denies chest pain or palpitations, and her electrocardiogram (ECG) is normal. Further management of this patient should include which of the following?

153) A female infant is born by vaginal delivery at 39 weeks' gestational age without any significant complications. There is no history of any genetic diseases in the family. She is noted to have a port-wine stain on the right side of her face that is 4 cm in length and 3 cm in width. Which of the following treatment modalities offers the best palliation for cosmetic purposes?

154) A previously healthy 3-year-old boy brought in by his parents for help with potty training. The boy refuses to use the toilet. If his parents try to place him on the toilet, he becomes upset and cries. He has regular urination in his diaper. He has 1-2 soft bowel movements a day. In the office, you note that the child speaks in short sentences that are mostly understandable. He runs well and can climb up on the examination table without help. His physical examination is unremarkable. Which of the following is the next best step in the management of this patient?

155) A 14-year-old boy presents with the complaint of “breast swelling.” The boy reports that he has been in good health and without other problems, but has noticed over the past month or so that his left breast has been “achy” and that he has now noticed some mild swelling under the nipple. He has never seen discharge; the other breast has not been swelling; and he denies trauma. Your examination demonstrates a quarter-sized area of breast tissue under the left nipple that is not tender and has no discharge. The right breast has no such tissue. He has a normal genitourinary examination, and is Tanner stage 3. Which of the following is the best next course of action?

156) A 3-year-old boy is brought to the office by his Caucasian mother because his speech is difficult to understand. He is a very slow learner, is unusually calm, stays to himself, doesn't hug his parents, prefers to play by himself, speaks in mumbles, and repetitively tries to make towers with cubes. He becomes very aggressive if he is stopped from his activities. He was born at term from an uncomplicated pregnancy and delivery, and his physical growth has been normal. His brother used to be aggressive as a child, and was diagnosed with attention deficit hyperactivity disorder. In the office, the patient is sitting quietly and trying to make towers with cubes. He seems to be oblivious of his environment. On calling his name thrice, he turns towards you once and then resumes playing with the cubes. What do you tell his mother?

157) A term infant is born to a known HIV-positive mother. She has been taking antiretroviral medications for the weeks prior to the delivery of her infant. Routine management of the healthy infant should include which of the following?

158) As you are about to step out of a newly delivered mother’s room, she mentions that she wants to breast-feed her healthy infant, but that her obstetrician was concerned about one of the medicines she was taking. Which of the woman’s medicines, listed below, is clearly contraindicated in breast-feeding?

159) A 13-year-old girl presents with lethargy, fever, severe headache, and a stiff neck. On examination, a unilateral fixed, dilated pupil and papilledema are noted. Which of the following is the most appropriate initial step in managing this patient?

160) A newborn infant requires repeated resuscitation in the delivery room because of failure to breathe and cyanosis. During spells of crying, which appear to alleviate the cyanosis, his breath and heart sounds are normal, as is direct laryngoscopy. Vigorous respiratory movements appear ineffectual. Immediate management of this infant consists of which of the following?

161) A previously healthy 12-year-old boy is brought to the physician the day after a nocturnal crisis of difficulty breathing, chest tightness, and cough. He has a history of atopic dermatitis that resolved around 6 years of age. He now has no apparent respiratory distress. His breathing is regular, and his respirations are 12/min. Blood pressure, pulse, and temperature are normal. Chest examination reveals only a few crackles that quickly clear after coughing and mild end-expiratory wheezes. Which of the following is the most appropriate next step in diagnosis?

163) A new born infant is in respiratory distress and requires several attempts at resuscitation in the delivery room because of difficulty breathing and frequent cyanosis. The neonatologist notes that during crying, her breathing improves and breath and heart sounds are normal. Direct laryngoscopy is unremarkable as well. Deep inspirations by the neonate are ineffective. Which of the following is the most effective intervention?

164) A 2-month-old female infant born at term is brought to the office for a well-baby visit. Her antenatal and birth histories are unremarkable. Her developmental milestones are all normal for her age. Ophthalmoscopic examination reveals a white reflex in the right eye. The rest of the examination is normal. What is the most appropriate next step in the management of this patient?

165) A 13-year-old girl presents with a 1-week history of a sore throat and a nonproductive cough. She has been previously healthy and has not been exposed to any other sick person. She has not been taking any medications. On examination, she has normal oxygen saturation and a low-grade fever. The remainder of the examination is unremarkable. Which of the following is the most appropriate pharmacotherapy?

166) An otherwise healthy 5-year-old boy is brought to the emergency department of a small hospital because of a simple 3-cm laceration in his forehead. The patient is crying and frightened. The practitioner decides to perform conscious sedation before suturing the laceration. Support personnel and equipment are available for monitoring the patient's vital status and carrying out resuscitation measures if needed. Which of the following is the most appropriate pharmacologic agent to achieve a safe level of conscious sedation in this situation?

167) A 2-year-old child was recently adopted from India. She appears to be healthy, and there are no abnormal symptoms. Her weight and height are at 25th percentile for age. Her examination is normal. On screening, you find a positive TB skin test using purified protein derivative (PPD) with 20 mm induration. She has a history of receiving a BCG vaccination at birth. Your management plan is to do which of the following?

168) A baby is born to a mother who is positive for hepatitis B surface antigen (HBsAg). Your plan is to do which of the following?

169) An 18-month-old boy has received 5 days of amoxicillin for otitis media. He continues to have fever, and on physical examination, the right tympanic membrane is bulging with purulent fluid behind it. Which of the following is the best antibiotic to use?

170) A one-month-old child is brought to the office due to persistent vomiting for the last six days. His mother complains of increasing episodes of projectile vomiting. These episodes occur every time she attempts to feed him, and have persisted despite changing formulas. On physical examination, peristaltic waves are seen over the upper abdomen, and an olive-sized mass is palpated. Laboratory studies reveal a potassium level of 3.0mEq/mL. Which of the following is the most appropriate next step in management?

171) A 4-year-old female is brought to the emergency department for evaluation of vaginal discharge. She has had foul-smelling vaginal discharge for 1 week. Her mother has also noted a small amount of vaginal bleeding. The mother called her primary physician and was told to use an over-the-counter cream and to stop letting the child take bubble baths. However, the symptoms have not improved. The child complains of pruritus in her vaginal area. She was potty trained at age 2. While mother is at work, the baby is with her stepfather. On examination, the perineal area is erythematous with a purulent, foul-smelling vaginal discharge. Visual inspection of the vagina reveals a greenish foreign body inside the vagina. Which of the following is the next best step?

172) A 1-year-old child is brought to the physician for a routine visit. He was born full term with a birth weight of 71b 8oz (34 kg) and a birth length of 20 in (50.8cm). He has had no major illnesses or hospitalizations His parents report that he was breastfed exclusively for 6 months. He now eats a variety of baby foods and is being transitioned to whole milk. He can pull up to stand and cruise around holding onto objects, but cannot walk independently yet. He can feed himself small pieces of table food with his thumb and first finger. The only words he knows are mama, dada, and ball. His parents are concerned about his growth because some of the other children in his day care class are bigger than him. On physical examination, he weighs 221bs (10 kg) and is 30 in (76.2cm) long. A complete examination is unremarkable. Which of the following should you tell his parents?

173) A 12-year-old girl with a history of asthma has been admitted to intensive care units two times in the past and has had three emergency department visits during the past 12 months. Her only medication is inhaled albuterol as needed, and she uses it two to three times a day. She has nocturnal symptoms about two times a week. She is free of symptoms now but reports that she gets short of breath easily. Which of the following pharmacologic interventions is most appropriate?

174) The mother of a 2-year-old boy comes to the physician because her child awakens at night, with a blank gaze, screaming in bed without recognizing his parents. These episodes have occurred three times in the past 2 weeks, always in the first few hours of the night. The child goes back to sleep and seems to retain no memory of the episode the next morning. Which of the following is the most appropriate next step in management?

175) A 2-month-old child of an HIV-positive mother is followed in your pediatric practice. Which of the following therapies should be considered for this child?

176) An 8-year-old boy is brought to your office with the complaint of abdominal pain. The pain is worse during the week and seems to be less prominent during the weekends and during the summer. The patient’s growth and development are normal. The physical examination is unremarkable. Laboratory screening, including stool for occult blood, CBC, urinalysis, and chemistry panel, yields normal results. Which of the following is the best next step in the care of this patient?

177) A 23-year-old man comes to the emergency department (ED) at 2:00 am due to severe pain all over his body for the past few hours. He was diagnosed with sickle cell anemia at 6 months of age, and has had previous episodes of unbearable pain in his chest, abdomen, thighs and lower back. He was hospitalized six times in the past twelve months. He does not have regular follow-up visits up with his physician, and comes to see him "only if required." His blood pressure is 110/80 mmHg, pulse is 80/min, respirations are 16/min and temperature is 37 C (98F). Adequate hydration and analgesics are administered in the ED. What is the best intervention to prevent his painful episodes?

178) A 5-year-old boy is brought to an emergency room because of a painful, swollen knee joint. The boy had fallen while playing, and the joint had subsequently begun to swell. The mother reports that the boy was known to have hemophilia B. Replacement of which of the following is indicated?

179) The parents of a 10-year-old girl with newly diagnosed, generalized tonic-clonic epilepsy come to the physician seeking advice regarding what they should do when the child has a seizure. Which of the following suggestions is appropriate?

180) A 12-year-old boy is brought to the clinic because of a several-month history of strange behavior. According to his parents, the boy occasionally will start staring and not respond. He will also have tears in his eyes. These episodes last several seconds and he then returns to his baseline. He has not sustained any head trauma and is on no medications. Which of the following drugs is the most appropriate treatment?

181) A 9-month-old is brought to the emergency center by ambulance. The child had been having emesis and diarrhea with decreased urine output for several days, and the parents noted that she was hard to wake up this morning. Her weight is 9 kg, down from 11 kg the week prior at her 9-month checkup. You note her heart rate and blood pressure to be normal. She is lethargic, and her skin is noted to be “doughy.” After confirming that her respiratory status is stable, you send electrolytes, which you expect to be abnormal. You start an IV. Which of the following is the best solution for an initial IV bolus?

182) You are admitting to the hospital a 3-month-old infant who has been having poor feeding, emesis, and diarrhea for 3 days. In the emergency center, her electrolytes were found to be: sodium 157 mEq/L, potassium 2.6 mEq/L, chloride120 mEq/L, bicarbonate 14 mEq/L,creatinine1.8 mEq/L, blood urea nitrogen(BUN) 68 mEq/L, and glucose195 mEq/L. She was given a fluid bolus in the emergency center and has subsequently produced urine. Which of the following is the most appropriate next step in her management?

183) At exploratory laparotomy for blunt abdominal trauma, a 14-year-old boy is found to have a ruptured spleen. The spleen is shattered into multiple fragments, and there are other serious intraabdominal injuries that will require significant operative time. For the above reasons, it is decided that a quick splenectomy is indicated, and it is done. In the postoperative period, this young man should receive which of the following treatments?

185) A 4-week-old male infant has been spitting up his formula feedings for the past few days. He does not vomit bilious material or blood. The spitting up is gradually becoming more frequent, and forceful vomiting ensues. The vomitus seems to shoot straight out and nearly hit the wall. On examination, the baby seems hungry and is chewing his fist. His mucous membranes appear dry. A small, round mass, about the size of an adult thumbnail, is palpated in the upper abdomen. Laboratory data reveal Na+ of 133 mEq/L, K+ of 3.5 mEq/L, CI of 93 mEq/L, and HC0 3 - of 29 mEq/L. Which of the following is the most appropriate next step in management?

186) A 12-year-old girl was hit in the face by a baseball 15 minutes earlier and has had her mandibular incisors knocked out. Which of the following represents the best plan of action?

187) A woman brings her 3-year-old son to the emergency room after witnessing him swallow a diskshaped battery. She adds that he vomited once on the way to the hospital. The vomitus was non-bloody and did not contain the battery. Physical examination of the child's chest is unremarkable. Plain radiographs reveal that the battery is located in the esophagus. What is the most appropriate next step in the management of this patient?

188) A 5-year-old girl is brought to medical attention by her parents 12 hours after the onset of generalized tonicoclonic seizures. She never had similar episodes in the past. The girl is otherwise healthy. Her temperature is 37 C (98.6 F). Physical examination is unremarkable. There is no evidence that the girl had a fever at the onset of the convulsive episode. The parents fear that seizures may damage the child's brain and may eventually recur. Which of the following is the most appropriate next step in management?

189) A previously healthy 5-month-old boy has been irritable and has had a decreased oral intake for 2 days. His rectal temperature is 37.4 C (99.3 F), pulse is 220/min, and respirations are 50/min. The radial and posterior tibial pulses are diminished with good brachial and femoral pulses. ECG shows tachycardia; QRS complexes are narrow without preceding P waves. Which of the following is the most appropriate initial step in management?

190) A patient comes to your office for a hospital follow-up. You had sent him to the hospital 3 weeks earlier for persistent fevers but no other symptoms; he was diagnosed with endocarditis and is currently being treated appropriately. Advice to this family should now include which of the following?

191) A mother calls you on the telephone and says that your 4-year-old son bit the hand of her 2-year-old son 48 hours previously. The area around the injury has become red, indurated, and swollen, and he has a temperature of 39.4°C (103°F). Which of the following is the most appropriate response?

192) A toddler is brought to the emergency department with burns on both of his buttocks. The areas are moist, have blisters, and are exquisitely painful to touch. The parents explain that the child accidentally pulled a pot of boiling water over himself. Which of the following is the most important step in management?

193) An 8-year-old boy presents to your office for a second opinion. He has a 2-year history of intermittent vomiting, dysphagia, and epigastric pain. His father reports he occasionally gets food “stuck” in his throat. He has been on a proton pump inhibitor for 18 months without symptom relief. His past history is significant only for eczema and a peanut allergy. Endoscopy was performed 6 months ago; no erosive lesions were noted and a biopsy was not performed. You arrange for a repeat endoscopy with biopsy. Microscopy on the biopsy sample reveals many eosinophils. Treatment of this condition should include which of the following?

194) A 4-year-old girl presents to the emergency department with fever and a petechial rash. A sepsis workup is performed, and IV antibiotics are administered. Gram-negative diplococci are identified in the CSF. Which of the following is true of this condition?

195) A 3-year-old boy suddenly begins choking and coughing while eating peanuts. On physical examination he is coughing frequently. He has inspiratory stridor and mild intercostal and suprasternal retractions. Initial management should include which of the following?

196) A 9-month-old child comes in for a routine visit. She has had several episodes of otitis media in the past, but no major illnesses or hospitalizations. Her mother is concerned because the child was previously happy and social around other people, but now cries if her mother is not in the room. The child constantly wants to be held by her mother and becomes upset if her mother walks into the next room. Her grandmother keeps her during the day, and she now cries when her mother leaves her in the morning. Developmentally, she is crawling and waves bye-bye. She does not yet respond to her name or say words. She previously babbled but stopped several months ago. When you hide a toy with your hand, she lifts your hand to look for the toy. Which of the following is the best next step in the management of this child?

197) A one-month-old child is brought to the office due to persistent vomiting for the last six days. His mother complains of increasing episodes of projectile vomiting. These episodes occur every time she attempts to feed him, and have persisted despite changing formulas. On physical examination, peristaltic waves are seen over the upper abdomen, and an olive-sized mass is palpated. Laboratory studies reveal a potassium level of 3 mEq/mL. What is the most appropriate management for this patient?

200) A 2-year-old girl is playing in the garage with her Chihuahua, only partially supervised by her father, who is weed-whacking around the garden gnomes in the front yard. He finds her in the garage, gagging and vomiting. She smells of gasoline. In a few minutes she stops vomiting, but later that day she develops cough, tachypnea, and subcostal retractions. She is brought to your emergency center. Which of the following is the most appropriate first step in management?

201) A 3-day-old girl has trouble feeding and pulmonary congestion. The mother says that the infant is so busy breathing, that she literally has no time to suckle. The girl was born at home, with the delivery attended by a midwife. Physical examination confirms that she is in respiratory distress and shows bounding peripheral pulses with a loud continuous precordial machinery like murmur. X-ray films show increased pulmonary vascular markings. Shortly thereafter, the infant goes into overt heart failure. Which of the following would most likely be required to correct this problem?

202) A 12-year-old girl presents with a 2-month history of vaginal discharge. She describes it as clear and states that it stains her underwear. She says that she hates boys, and that "no way" has she ever had sex or even kissed a boy. She reports having had developing breasts for 2 years and thinks that her growth spurt was about a year ago. Genital findings include a pubic hair stage of Tanner III with no evidence of redness or irritation of the vulvovaginal area. A slight amount of odorless, clear mucus is seen. Microscopic examination of the mucus reveals epithelial cells and a few bacteria, but no white cells. The pH is between 3.5 and 4. Which of the following is the most appropriate next step in management?

203) A 10-year-old girl is involved in a motor vehicle accident, sustaining multiple injuries to her head, arms, and abdomen. Her blood pressure is 90/60 mm Hg, and her pulse is 120/min. Her forearm is disfigured, and bone can be seen through the wound. She is breathing periodically and has cyanotic lips. Her abdomen is rigid, and there is flank discoloration. Which of the following is the most appropriate next step in management?

204) A 15-year old girl presents with a 5-day history of sore throat, low-grade fever, and easy fatigability. Physical examination shows bilateral tonsillar enlargement with exudate. Her spleen is palpable 3 cm below the left costal margin. Her throat culture is negative for group A Streptococcus. Monospot test is positive. Which of the following is the most appropriate management for this patient?

206) A 4-year-old female is brought to the emergency department for evaluation of vaginal discharge. She has had foul-smelling vaginal discharge for 1 week. Her mother has also noted a small amount of vaginal bleeding. The mother called her primary physician and was told to use an over-the-counter cream and to stop letting the child take bubble baths. However, the symptoms have not improved. The child complains of pruritis in her vaginal area. She was potty trained at age 2. While mother is at work, the baby is with her stepfather. On examination, the perineal area is erythematous with a purulent, foul-smelling vaginal discharge. Visual inspection of the vagina reveals a greenish foreign body inside the vagina. Which of the following is the next best step?

207) A mother calls you frantic because she has just been diagnosed with chicken pox. She delivered 7 days ago a term infant that appears to be eating, stooling, and urinating well. The child has been afebrile and seems to be doing well. Which of the following is the most appropriate step in management?

208) A 10-year-old girl is brought to the physician because of throat pain, anorexia, and fever for 2 days. Her temperature is 38.9 C (102 F). The patient's history is negative for allergic diseases. She has had two episodes of pharyngotonsillitis over the past several years. Examination reveals a purulent exudate in the posterior oropharynx and enlarged tonsils. There is bilateral tender enlargement of anterior cervical lymph nodes. Cardiac and chest auscultation is normal. A rapid strep test is positive. Which of the following is the most appropriate next step in management?

209) A 12-year-old girl is seen by a pediatrician for a mild case of pneumonia. She is treated with an intramuscular injection of penicillin. About 15 minutes later, she develops extreme itchiness, accompanied by the development of wheals scattered over her chest and extremities. She also begins to wheeze and complain of difficulty breathing. The color of her lips and face remains rosy. Which of the following is the most appropriate first step in management?

210) A 5-year-old boy is brought to the physician for evaluation of left hip pain after his parents saw him limping this morning. He spent time on the playground yesterday but his parents do not think he was injured then. The boy complains that the pain in his hip worsens when he moves or walks. For the past 3 days, he has had a runny nose and congestion. Review of systems is otherwise negative. His grandmother has rheumatoid arthritis treated with methotrexate. His temperature is 37.2° C (99° F), blood pressure is 100/65 mm Hg, pulse is 92/min, and respirations are 18/min. Physical examination shows a wellappearing child with clear rhinorrhea and intermittent dry cough. Lungs are clear to auscultation bilaterally. His left hip is slightly abducted and externally rotated with mildly decreased range of motion. He is able to stand and bear weight. The remainder of his examination is normal. X-rays of both hips are normal. His laboratory results are as follows: Complete blood count: Hemoglobin 12.5 g/dL, Platelets 287,000/mm3, Leukocyte count 8,500/mm3, Neutrophils 30%, Eosinophils 1%, Lymphocytes 64%, Monocytes 5%, Erythrocyte sedimentation rate 30 mm/h, C-reactive protein 9 mg/L (N: ≤ 8 mg/L). Which of the following is the best next step in management of this patient?

211) A 3-week-old male infant is brought to the office for the evaluation of red eyes. His temperature is 37.2 C (99F), pulse is 100/min, and respirations are 34/min. On examination, the infant has conjunctival congestion and scant mucoid discharge. The rest of the physical examination is normal. What is the most appropriate next step in the management of this patient?

212) A 6-month-old infant is brought to the clinic for the evaluation of sudden episodes of jerky movements of the neck, arms, and legs onto the trunk for past month. These episodes occur in clusters, last for a few minutes, and are often preceded by a cry. Her development has been normal. Her vital signs are normal. She is at 50th percentile for height, weight and head circumference. She has multiple small 1- 2 cm oval irregular hypopigmented macules on her trunk and extremities. A head CT scan reveals cortical tubers in the cerebral cortex and multiple subependymal nodules in the lateral ventricles. Her EEG shows "hypsarrhythmia." What is the best medication for this patient's seizure?

213) A 9-year-old male is brought to the emergency department with respiratory disease after being stung by a bee. He requires resuscitation with epinephrine injection. On discharge, which of the following recommendations to the boy's mother is most appropriate?

214) A 7 -year-old Caucasian boy is brought to the clinic due to malaise and headache for the past 2 weeks. He was apparently normal until 3 weeks ago, when he went on a hiking trip with his family to Connecticut. His father found a tick attached to his thigh; however, a red macule remains at the site where the tick was attached. One week after the tick was removed, a red ring developed around the macule, and then the ring appeared to grow larger by expanding outward, leaving an area of central clearing. What is the most appropriate next step in the management of this patient?

215) You have an 11-day-old term infant in your office for a well-child visit. The mother notes that she received a letter that day from the state’s Department of Health reporting that her child’s newborn screen had come back abnormal, indicating possible galactosemia. Which of the following is the most appropriate management at this point?

216) A 9-year-old boy is being evaluated for a syncopal episode. He was playing basketball when the syncope occurred. The episode lasted about 1-2 minutes, and then the patient woke up on his own. His mother also noticed that he has been having hearing problems. His physical examination is unremarkable. An ECG shows a prolonged Q-T interval, with a QTc of 0.49 sec. Which of the following is the most appropriate management if he has long Q-T syndrome?

217) A 9-year-old girl is seen in the office for unsteady gait and weakness in the lower limbs. On examination she is found to have a wide-based gait with constant shifting of position to maintain her balance. There is decreased vibratory and position sense in the lower extremities, and ankle jerks are absent bilaterally. Her feet are deformed with high plantar arches. MRI of the brain and spinal cord shows marked atrophy of the cervical spinal cord and minimal cerebellar atrophy. Nerve conduction velocity results are within normal limits. EKG shows T-wave inversions in the inferior and lateral chest leads. The mother says that her other child, a 3-year-old boy, is completely normal. He shares toys with his sister and plays well with other children at playschool. He is able to copy squares and crosses but is unable to copy a triangle. Which of the following statements would you advance while discussing the girl's condition with her mother?

218) An 8-year-old African American boy is brought in for evaluation of a mass on the scalp. On examination, he is afebrile and nontoxic. There is a boggy mass on his scalp with alopecia. His posterior cervical lymph nodes are enlarged but nontender. Which of the following is the most appropriate treatment?

219) The parents of a 14-year-old boy are concerned about his short stature and lack of sexual development. By history, you learn that his birth weight and length were 3 kg and 50 cm, respectively, and that he had a normal growth pattern, although he was always shorter than children his age. The physical examination is normal and his growth curve is shown on the next page. His upper-to-lower segment ratio is 0.98. A small amount of fine axillary and pubic hair is present. There is no scrotal pigmentation; his testes measure 4.0 cm3 and his penis is 6 cm in length. In this situation, which of the following is the most appropriate course of action?

220) A 6-year-old boy has multiple, honey-colored, crusted lesions on his face, periungual areas, and forearms. The first lesion appeared 2 weeks ago on his philtrum. Since then the lesions have spread to his hands and arms. Each began as a small pustule on an erythematous base and eventually ruptured to form the crusted lesions now present. His temperature is 100.6 F, pulse is 100/min, and respirations are 14/min. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate treatment?

221) An 11-month-old African American boy has a hematocrit of 24% on a screening laboratory done at his well-child checkup. Further testing demonstrates: hemoglobin 7.8 g/dL; hematocrit 22.9%; leukocyte count 12,200/μL with 39% neutrophils, 6% bands, 55% lymphocytes; hypochromia on smear; free erythrocyte protoporphyrin (FEP) 114 μg/dL; lead level 6 μg/dL whole blood; platelet count 175,000/μL; reticulocyte count 0.2%; sickle-cell preparation negative; stool guaiac-negative; and mean corpuscular volume (MCV) 64 fL. Which of the following is the most appropriate recommendation?

222) A 7-year-old girl presents with hives, which developed after a bee sting. She has no other symptoms. The hives resolve with diphenhydramine. Which of the following is the most appropriate management?

225) A 9-month-old infant is seen in the pediatrician's office because of failure to gain weight. Her length and weight are both below the 5th percentile at her age. The patient's chart indicates that at the age of age of 6 months, her length and weight were at the 50th percentile. A careful history reveals that the mother returned to work when the infant was 6 months old, and the grandmother assumed the care of the infant most of the time since then. She is receiving 6-8 oz of iron-fortified, cow protein-based formula every 4 hours. Which of the following is the best initial step in the management of this infant?

226) A 5-year-old boy is brought to the physician's office because of a cough. He has episodes of successive and rapid coughs, which seems like he is choking, followed by a deep and loud inspiratory sound. He has vomited a few times after these bursts of cough. His symptoms have been progressively worsening for the past week, and were preceded by congestion, serous rhinorrhea and sneezing. His past medical history is insignificant. His vital signs are stable. Lung auscultation is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient?

227) A 2-week-old baby girl is brought to the clinic for the evaluation of vaginal discharge. Her mother has noticed a cloudy white vaginal discharge mixed with blood since yesterday. She was born by normal vaginal delivery at term, and no congenital anomalies were noted at birth. Physical examination reveals a blood-stained, odorless vaginal discharge. Her vital signs are stable. What is the most appropriate next step in the management of this patient?