Pediatric USMLE ( 626-750 )

A 2-week postmature neonate exhibits severe respiratory distress immediately after birth. Previously, greentinged meconium was noted in the amniotic fluid. Which of the following is the most appropriate next step in management?

A 12-year-old girl has a solitary thyroid nodule found on routine examination; she has no symptoms. Which of the following is the most appropriate next step for this patient?

A 12-year-old African American boy is brought to the office due to a 2-day history of high-grade fever and chills. He was apparently well before the onset of fever. He has no bone pain. He has sickle cell disease and has had 4 hospitalizations for painful crises and one episode of osteomyelitis. His blood pressure is 90/60 mm Hg, pulse is 100/min, respirations are 22/min and temperature is 38.9 C (102F). He appears drowsy. His laboratory report shows a total WBC count of 16,000/mm3 with 12% bands and Hb of 9.0 g/dl. Which of the following is the most likely cause of this patient's condition?

A 12-year-old male is brought to your office by his mother because of a several history of back pain. He also experienced bed wetting recently. His past medical history is insignificant. He tried acetaminophen for pain relief. He does not smoke or consume alcohol. His temperature is 36.7 C (98 F), blood pressure is 110/65 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals a palpable "stepoff" at the lumbosacral area. Straight-leg raising test is negative on both sides. Perianal sensation tested by pinprick test is decreased, but anal reflex is normal. What is the most probable diagnosis in this patient?

A 16-month-old is taken to the emergency room after falling while learning to walk. The toddler has an enlarging, swollen bruise on his forehead, which is now over two inches across. The parents say that the bruise is noticeably larger than it was when they entered the emergency room an hour earlier. A blood sample is drawn, and the child oozes blood at the puncture site for 25 minutes. Clotting studies on the blood sample show a prolonged PTT and a normal PT. Follow-up studies show very low levels of factor VIII. Which of the following is the most likely diagnosis?

A 7-day-old boy who is the product of an uncomplicated gestation is brought to the physician because of hypospadias. The baby is otherwise healthy, and is urinating without any difficulty. On physical examination, vital signs are stable, lungs are clear and the heart is beating at a regular rate. The only abnormal physical finding is the hypospadias. Urinalysis is negative for infection. Which of the following is the most appropriate next step?

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?

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?

A 10-year-old boy was healthy until about 10 days ago when he developed 7 days of fever, chills, severe muscle pain, pharyngitis, headache, scleral injection, photophobia, and cervical adenopathy. After 7 days of symptoms he seemed to get better, but yesterday he developed fever, nausea, emesis, headache and mild nuchal rigidity. Cerebrospinal fluid (CSF) shows 200 white blood cells (WBC) per microliter (all monocytes) and an elevated protein. Correct statements about this infection include which of the following?

A previously healthy 8-year-old boy has a 3-week history of low-grade fever of unknown source, fatigue, weight loss, myalgia, and headaches. On repeated examinations during this time, he is found to have developed a heart murmur, petechiae, and mild splenomegaly. Which of the following is the most likely diagnosis?

A 10-year-old boy is brought by his parents to the emergency department for the evaluation of headaches, fever, chills, and a rash over his neck, chest, and axillae. The rash appeared today, and for the past two days the child was complaining of a sore throat. He has no history of allergies, and his immunizations are up-to-date. His blood pressure is 112/70 mmHg, pulse is 1 08/min, respirations are 20/min, and temperature is 38.3C (101 F). Examination reveals an erythematous rash with a sandpaper-like texture, and which blanches with pressure. There is submandibular tender lymphadenopathy, and the throat is erythematous with gray-white exudates. What is the most likely diagnosis?

A 2-year-old boy is referred to your office for the evaluation of a white eye reflex. His mother suspects a hearing problem because he does not respond when she calls out his name. The physical examination reveals a continuous, machinery murmur over the right 2nd intercostal space and purple lesions on his arms and chest. The initial investigations reveal thrombocytopenia. What is the most likely diagnosis?

A 10-year-old male fell while riding his scooter down a steep hill. In the Emergency Department, his injuries included a fractured wrist and a lacerated spleen, which required surgical removal. Two years later he is diagnosed with bacterial pneumonia. Which of the following bacterial agents is the most likely pathogen for this patient's pneumonia?

A 15-year-old girl presents with diplopia after prolonged reading and ptosis that worsens in the afternoon. On examination, she is noted to have bilateral ptosis, impaired extraocular muscle movements, facial weakness, and generalized hypotonia and weakness increasing with repetition. Which of the following is the best diagnostic test for this disorder?

A 12-year-old boy presents to his pediatrician with frequent episodes of headache, nausea, blurry vision, and sweating. On physical examination, his temperature is 37.4 C (99.3 F), blood pressure is 148/94 mm Hg, pulse is 92/min, and respirations are 18/min. The rest of his examination is unremarkable. His 24-hour urinary vanillylmandelic acid (VMA) and metanephrines are increased. An abdominal CT reveals an extrarenal mass above the left kidney. Which of the following is the most appropriate pharmacotherapy?

A 12-year-old girl with mild asthma comes to the office for a health maintenance visit. Her mother states that she is using her albuterol inhaler 2-3 times a week and that she has a cough that wakes her up at night about 3 times a month. On physical examination, she has diffuse inspiratory and expiratory wheezes. She has no accessory muscle use. Pulse oximetry shows 95% oxygen saturation on room air. Which of the following is the most appropriate treatment for her at this time?

You find a discrete, whitish polyp that extends through the tympanic membrane in a child with a history of recurrent otitis media. This most likely represents which of the following?

A 20-month-old child is brought to the ED because of fever and irritability and refusal to move his right lower extremity. Physical examination reveals a swollen and tender right knee that resists passive motion. Which of the following is the most likely to yield the diagnosis in this patient?

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?

A 5-day-old male premature infant in the NICU develops a decreased level of consciousness, hypotonia and decreased spontaneous movements. He was delivered vaginally at 32 weeks of gestation, and his birth weight was 1800g. Examination reveals a lethargic infant with a weak and high-pitched cry, prominent scalp veins, tense fontanels, and eyes directed downward, poor suckling, hypotonia. CT scan reveals dilation of the entire ventricular system, with distinct enlargement of the subarachnoid space over the cerebral cortex. What is the most likely cause of the patient's condition?

A 12-month-old infant presents with bilious vomiting and abdominal distention for 10 His mother states that the infant has been constipated since birth and failed to pass meconium during the first 48 hours of life. On examination, he is very irritable. His length and weight are both below the 5th percentile according to his age. His abdomen is moderately distended. After a digital rectal examination, a fair amount of stool ejects out from the anus. Which of the following is the most likely diagnosis?

A 9-year-old boy is brought to the pediatrician's office for bed-wetting. His mother states that he has never been dry at night. Occasionally, he has problems controlling his bladder during the day. On physical examination, his blood pressure is 98/56 mm Hg. Both his weight and height are below the 5th percentile for his age. His bladder is enlarged and palpable above the symphysis pubis. Which of the following is the most likely cause of his problem?

A 4-day-old female infant presents to the emergency department with vomiting and abdominal distention. The mother states that the vomitus was green. The infant also has had difficulty feeding and has been hard to console. The mother had an uncomplicated pregnancy. The infant passed meconium within 12 hours after birth. She also had several small, seedy, yellowish stools each day since birth. On physical examination, she is very irritable, her anterior fontanelle is slightly depressed. Her abdomen is distended. Which of the following is the most likely diagnosis?

An 8-year-old boy presents to the pediatrician's office with a headache for the past 3 weeks. His mother also states that he has been more tired and has had frequent nose bleeding for the past month. On physical examination, his height and weight are both below the 5th percentile for his age. His blood pressure is 152/86 mm Hg in all four extremities. His pulse is 74/min, and respirations are 16/min. His heart examination is normal with no murmur. His peripheral pulses are strong and symmetric. Urinalysis and serum electrolytes are ordered. Which of the following is the most appropriate next step in diagnosis?

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?

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?

A previously healthy 11-year old boy presents to the physician with a fever and persistent vomiting for 4-5 days. Initially, the emesis was clear, but now it contains streaks of bright red blood. Findings on a physical examination, complete blood count, and serum electrolytes are within normal limits. Which of the following is the most likely cause of the hematemesis?

A 7 -year-old boy is brought to the emergency department after falling on his outstretched hand. On examination, there is minimal swelling at the right elbow. The skin on the right forearm appears tense, and severe pain is present. The brachial pulses are good bilaterally, and sensations are intact in both upper limbs. X-rays of the right upper limb show a displaced anterior fat pad. Which of the following statements is true about this condition?

An 8 week old female infant is bought to the office by her Caucasian mother for a well-baby examination. She was born at 34 weeks gestation, and weighed 2.9kg (6.51b) 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?

A 6 year old boy is bought 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?

Parents bring a 5-day-old infant to your office. The mother is O negative and was Coombs positive at delivery. The term child weighed 3055 g (6 lb, 1 oz) at birth and had measured baseline hemoglobin of 16 g/dL and a total serum bilirubin of 3 mg/dL. He passed a black tarlike stool within the first 24 hours of life. He was discharged at 30 hours of life with a stable axillary temperature of 36.5°C (97.7°F). Today the infant’s weight is 3000 g, his axillary temperature is 35°C (95°F), and he is jaundiced to the chest. Parents report frequent yellow, seedy stool. You redraw labs and find his hemoglobin is now 14 g/dL, and his total serum bilirubin is 13 mg/dL. The change in which of the following parameters is of most concern?

You are called to a delivery of a women with no prenatal care; she is in active labor but has no history of amniotic rupture. The biophysical pro- file done in the emergency center revealed severe oligohydramnios. When you get this infant to the nursery, you should carefully evaluate him for which of the following ?

A 3-month-old infant has a history of chronic constipation. A fulminant watery diarrhea develops over a period of 2 days, and the infant is taken to the emergency department in an obviously severely dehydrated state. Plain x-ray films of the abdomen demonstrate a massively dilated transverse colon. Which of the following is the most likely diagnosis?

A mother brings her 9-month-old daughter to the pediatrician with complaints of a rash. The mother states that the infant had a high fever [temperature up to 40.0 C (104 F)] for 3 days prior to developing the rash, but is now afebrile. The mother also says that the infant has had a runny nose and a slight cough for the past 3 days. On examination, there is a fine macular rash on the infant's trunk and neck. The examination is otherwise within normal limits, and the infant is playful and smiling. Which of the following is the most likely diagnosis?

A newborn infant becomes markedly jaundiced on the second day of life, and a faint petechial eruption, first noted at birth, is now a generalized purpuric rash. Hematologic studies for hemolytic diseases are negative. Acute management should include which of the following?

A 14-year-old girl, angry at her mother for taking away her MP3 player, takes an unknown quantity of a friend’s pills. Within the first hour she is sleepy, but in the emergency center she develops a widened QRS complex on her electrocardiogram (ECG), hypotension, and right bundle branch block. The therapy you would initiate for this ingestion is which of the following?

A 3-year-old boy of African descent is brought to your office by his stepfather because of easy bruising. He says that the child bruises easily even without trauma. The child started playing games by himself recently. He has a past history of clavicular fracture, which the stepfather attributes to a fall down a set of stairs. The history of the biological father is unknown. On examination, there is a right knee effusion with decreased range of motion, and multiple soft tissue hematomas on the thigh. What is the most appropriate diagnostic step in management?

An 8 year old boy with sickle cell disease present with left leg pain and a high fever He has been refusing to walk since yesterday. On physical examination, his temperature is 39.8 C (103.6 F), blood pressure is 122/68 mm Hg, pulse is 102/min, and respirations are 20/min. His left femur is tender to palpation 3 cm above the left knee, and there is marked soft tissue swelling. A plain film of his left leg is normal. A bone scan shows increased uptake around the metaphysis of the left femur. Which of the following is the most likely pathogen?

A 20-month-old presents to the office with a 2-day history of a harsh, barking cough. His mother states that the cough sounds like a seal. She also states he has not had any fever, although he had a runny nose earlier in the week. On examination, he is notably hoarse with inspiratory stridor. He is not drooling and is sitting on his mother's lap comfortably. The rest of his examination is within normal limits. Which of the following is the most likely diagnosis?

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 x-ray 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?

An 18-year-old male undergoes elective hernia repair. During the operation, he suffers considerable blood loss, and receives a blood transfusion. He then experiences an anaphylactic transfusion reaction. He is resuscitated and further hospital course is uncomplicated. His past medical history is significant for recurrent sinopulmonary infections and intermittent episodes of diarrhea since childhood. Which of the following is the most likely cause of his symptoms?

An 8-month-old previously preterm infant with bronchopulmonary dysplasia presents to the emergency department with lethargy. His regular medications include furosemide and spironolactone. His temperature is 37.4 C (99.3 F), blood pressure is 68/32 mm Hg, pulse is 110/min, and respirations are 10/min. He has poor skin turgor and dry mucous membranes. Laboratory chemistry evaluation reveals: sodium, 131 mEq/L; potassium, 3.0 mEq/L; chloride, 84 mEq/L; bicarbonate, 38 mEq/L; blood urea nitrogen, 36 mg/dL; and creatinine, 0.4 mg/dL. An arterial blood gas shows pH, 7.52; PaCO2, 49 mm Hg; and PaO2, 92 mm Hg. Which of the following is the most likely explanation for these findings?

A 4-year-old girl is brought to the physician by her mother who is concerned because her child has a vaginal discharge. Starting 2 days ago, the child began scratching her vulva and complaining of burning with urination. The child is otherwise healthy and has never had a similar problem. Examination reveals normal structural anatomy for a 4-year-old girl. There is no evidence of atrophy. There is an inflammatory erythema on the medial aspects of the labia majora and excoriations. There is a mucous discharge with a few flecks of blood intermixed. Which of the following is the most likely cause of a vaginal discharge in this patient?

A 1-year-old child presents with failure to thrive, frequent large voids of dilute urine, excessive thirst, and three episodes of dehydration not associated with vomiting or diarrhea. Over the years, other family members reportedly have had similar histories. Which of the following is the most likely diagnosis?

A 6-month-old infant has poor weight gain, vomiting, episodic fevers, and chronic constipation. Laboratory studies reveal a urinalysis with a pH of 8.0, specific gravity of 1.010, 1+ glucose, and 1+ protein. Urine anion gap is normal. Serum chemistries show a normal glucose and a normal albumin with a hyperchloremic metabolic acidosis. Serum phosphorus and calcium are low. What is the best diagnosis to explain these findings?

A 2-year-old girl is taken to a pediatrician because she has developed a rash and seems unusually unsteady when she tries to walk. Physical examination demonstrates a diffuse rash on body parts exposed to sun. Also noted are short stature, possible mental retardation, and ataxia. Screening studies demonstrate increased total amino acids in the urine. Which of the following is the most likely diagnosis?

A 24-month-old girl is brought to the pediatrician's office for evaluation because her mother noticed a yellowish discharge on the girl's underwear for the past 3 days. She had no fever, but her mother said she has been fussier recently. On physical examination, the girl is appears excessively anxious about contact with the physician. Her introitus is inflamed, and the hymeneal edge is jagged at the 8 o'clock position. A vaginal culture is taken. Which of the following organisms, if isolated from the vaginal vault, would constitute the most definitive evidence of sexual abuse?

A 10-year-old boy, the star pitcher for the Salt Lake City Little League baseball team, had a sore throat about 2 weeks ago but did not tell anyone because he was afraid he would miss the play-offs. Since several children have been diagnosed with rheumatic fever in the area, his mother is worried that he may be at risk as well. You tell her that several criteria must be met to make the diagnosis but the most common finding is which of the following?

You are asked to evaluate an infant born vaginally 3 hours previously to a mother whose only pregnancy complication was poorly controlled gestational diabetes. The nursing staff noticed that the infant was breathing abnormally. On examination, you find that the infant is cyanotic, has irregular, labored breathing, and has decreased breath sounds on the right side. You also note decreased tone in the right arm. You provide oxygen and order a stat portable chest radiograph, which is normal. Which of the following studies is most likely to confirm your diagnosis?

A 6-year-old female is brought to the physician with a rash and joint pains. Her mother reports that she has been previously healthy except for a sore throat a few weeks ago. One week ago, the patient developed pain in her knees. The knee pain resolved after a few days, but now her ankles and wrists are tender. She has also developed a pink rash on her trunk that is non-pruritic. Vital signs are temperature 38.3 0c (101 0F), pulse 85/min, and respiratory rate 20/min. On examination, there is pain and stiffness during manipulation of the wrists and ankles. A faint, erythematous, centrifugal rash on her trunk and proximal limbs is present. Laboratory studies show: Complete blood count Hemoglobin 12.5 g/dL MCHC 32% MCV 85 fl Reticulocyte count 0.1% Platelet count 200,000/mm3 Leukocyte count 6,500/mm3 Neutrophils 56% Eosinophils 1% Lymphocytes 33% Monocytes 10% C-reactive protein 3.5 mg/dL Erythrocyte sedimentation rate 38 mm/hr Which of the following is the most likely diagnosis ?

A 14 year old African American girl present to the ER with a mild fever and severe right-sided thigh pain. She is agitated and requests quick pain relief. Her heart rate is 120/min and blood pressure is 120/70 mmHg. She says that she had a similar episode one year ago and was placed in the hospital for intravenous pain management. Her brother had similar episodes and died of an infection at 10 years of age. Which of the following would you most expect to see on this patient's peripheral blood smear

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:

A 10 month old infant has poor weight gain a persistent cough and a history of several bouts of pneumonitis. The mother describes the child as having very large, foul- smelling stools for months. Which of the following diagnostic maneuvers is likely to result in the correct diagnosis of this child?

A previously healthy 18-month-old male comes to the physician for evaluation of fever. His mother reports that he has had a fever ranging from 1 02.2 0F (39.0 0c) to 104.0 0F (40.0 0c) for the past five days. He has also become increasingly irritable with decreased appetite. His mother reports that he does continue to take some liquids. There are no known sick contacts. On examination, the infant's temperature is 102.5 0F (39.2 0C), pulse is 120/min, and respiratory rate is 20/min. He is irritable during the examination. There is conjunctival erythema bilaterally, with serous drainage from both eyes. His oropharynx is erythematous and his lips are fissured. There is a 2 cm anterior cervical lymph node palpable on the right side. His neck is otherwise supple and he is able to flex his chin to his chest without difficulty. There is mild abdominal tenderness to palpation. His hands and feet are slightly erythematous and edematous and there is a maculopapular rash on the trunk. Which of the following is the most likely diagnosis?

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?

A 4196 g (9 lb 4 oz) infant is delivered via vaginal delivery to a 31-year-old mother with gestational diabetes. The delivery was complicated by shoulder dystocia. He is taken to the newborn nursery where his initial plasma glucose level is 20 mg/dL. The initial spun hematocrit is 65%. Which of the following congenital anomalies is this baby most likely to have?

A 2-week-old infant is brought to the office for a newborn visit. His mother states that the he has been a very slow eater and that he is constipated, not having had a bowel movement in 3 days. On physical examination, the infant has poor muscle tone, an enlarged tongue, an umbilical hernia, an enlarged anterior fontanelle, and hypothermia. He also looks slightly jaundiced, with slightly dry skin and brittle hair. Which of the following is the most likely diagnosis?

A 4-year-old male is brought to the physician with fever and headache. His symptoms began two days ago with low-grade fever, cough, and congestion. Last night, he developed a temperature of 102 F (38.9 C) and became fussy and less active. Today, he is crying and complaining of a headache. His parents report that he has vomited twice today. In the office, his temperature is 102.5 F (39.o c), pulse is 110/min, and respiratory rate is 20/min. On examination, he is irritable and shows signs of photophobia. His oropharynx is erythematous. Nuchal rigidity is present and when the neck is flexed, the patient flexes his lower extremities. The remainder of the physical examination is normal. Lumbar puncture is performed and the results are shown below. CSF Glucose 60 mg/dL Protein 80 mg/dL RBC 10/mm3 WBC 100/mm3 Neutrophils 10% Lymphocytes 70% Monocytes 20% Gram stain negative Which of the following organisms is most likely responsible for this patient's presentation?

A 12-year-old boy is brought to the emergency department with a temperature of 39.1 C (102.4 F) at home, difficulty speaking, and odynophagia for 2 days, Physical examination reveals marked erythema of the right tonsil pillar and edema of the uvula with deviation to the left. In addition to anaerobic bacteria, which of the following organisms is most likely to be isolated from a tonsillar pillar aspirate?

A neonate is noted to have many abnormalities, a number of which are located in the midline. The infant has cleft lip and cleft palate. His eyes are very small and have fissures of the iris, shallow supraorbital ridges, and slanted palpebral fissures. He is deaf, and the ears are low set and malformed. Each hand has six fingers and a simian crease. Which of the following congenital abnormalities of the brain is particularly likely to be present in this infant?

A 4-year-old boy, recently adopted through an international adoption service, is noted to have intermittent watery diarrhea, nausea, belching, and abdominal pain. His weight is less than the fifth percentile for his age. Which of the following studies would be most helpful in making the diagnosis?

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?

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?

A 21-year-old female, G1P0, who recently emigrated from Zimbabwe presents for prenatal counseling 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?

A 4 week old infant present with tachycardie 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?

A 12-year-old child is brought to his pediatrician for a routine health maintenance visit. He has been well except for occasional attacks of asthma and has met all development milestones. His immunizations are up to date. He occasionally uses theophylline for his asthma. Physical examination is remarkable for a blood pressure of 150/90 mm Hg in both arms. Which of the following is the most likely cause of his hypertension?

One of your asthmatic patients arrives for a checkup. 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?

An infant is brought to the office for health maintenance visit. On examination, the infant turns when her name is called. She is able to say "mama." Her mother mentions that she also says "dada" at home. She is able to look for her mother when she gets frightened. She also waves bye-bye to the doctor when the doctor steps out of the examination room. What age of this child is most consistent with these developmental milestones?

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?

A 5-year-old boy is brought to the emergency department due to general malaise and a swollen scrotum. His mother noticed the swollen scrotum today, and is sure that "it was not there yesterday." He had a low-grade fever and a cough two weeks ago, and "hasn't been himself ever since." He has no significant past medical history. On examination, he looks ill and lethargic. He has palpable purpura on his buttocks and lower legs. He has a swollen right scrotum which is slightly tender to palpation, and his abdomen is moderately tender to palpation. Urinalysis reveals the presence of a small amount of blood and protein. He is subsequently admitted for observation. Which of the following adverse outcomes is he most likely to develop?

A term neonate develop apnea tachypnea and seizures in the first 2 hour of life. The infant is large for gestational age and appears obese. Physical examination is otherwise unremarkable. Serum studies demonstrate a blood glucose level of 30 mg/dL. The mother most likely has which of the following conditions?

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?

A 4-year-old child was brought in for evaluation of sleep problems. He cried and screamed within an hour of falling asleep. He seemed disoriented and confused; he did not seem aware of his parents’ presence. They were unable to arouse him to comfort him. This resolved spontaneously, and he had no recollection of the event the next morning. You informed the parents that he was most likely experiencing which of the following?

Varicella vaccination is a live virus vaccine. It is generally not recommended in immunocompromised patients. Which of the following is an exception to this rule?

A male infant was found to be jaundiced 12 hours after birth. At 36 hours of age, his serum bilirubin was 18 mg/dL, hemoglobin concentration was 12.5 g/dL, and reticulocyte count 9%. Many nucleated RBCs and some spherocytes were seen in the peripheral blood smear. The differential diagnosis should include which of the following?

On a routine well-child examination, a 1-year-old boy is noted to be pale. He is in the 75th percentile for weight and the 25th percentile for length. Results of physical examination are otherwise normal. His hematocrit is 24%. The answer to which of the following questions is most likely to be helpful in making a diagnosis?

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?

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?

A 4-year-old boy is seen in the office for a general check-up. The child appears well nourished and has normal developmental milestones. His temperature is 36.6 C (98 F), pulse rate is 80/min, and blood pressure is 110/70 mmHg. On abdominal palpation, there is a lobular right-sided flank mass, and the kidneys are palpable bilaterally. What is the most likely cause of the flank mass in this child?

A 12 year old boy is bought 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?

A 10-year-old boy is admitted to the hospital because of bleeding. Pertinent laboratory findings include a platelet count of 50,000/ L, prothrombin time (PT) of 15 seconds (control 11.5 seconds), activated partial thromboplastin time (aPTT) of 51 seconds (control 36 seconds), thrombin time (TT) of 13.7 seconds (control 10.5 seconds), and factor VIII level of 14% (normal 38%-178%). Which of the following is the most likely cause of his bleeding?

A 5-month-old boy is brought to the office for a mass in his left groin area. The infant is on the examination table, quietly sucking on his pacifier. On examination, there is a fluid- filled sac that does not reach the inguinal ring and transilluminates well. Which of the following is the most likely diagnosis

A 9-year-old girl is brought to the clinic with complaints of fatigue, abdominal pain and low grade fever. Four days ago her mother noticed a red rash on the tops of her daughter's feet, which has now spread to her thighs and buttocks. The rash was initially small red dots, but has now become patches. Her daughter subsequently developed periumbilical, cramping, abdominal pain. Review of systems is positive only for a respiratory viral illness three weeks ago. Her temperature is 37.7 C (99.8 F), pulse is 96/min, and respirations are 18/min. Abdominal examination is remarkable for tenderness to palpation near the umbilicus, but the abdomen is otherwise soft, with no rebound or guarding, and no organomegaly. Raised, palpable purpuric lesions are present on the buttocks and thighs. The ankles are tender and edematous bilaterally. Complete blood count reveals a leukocyte count of 9,000/mm3. Her hemoglobin 12. 6 g/dL, and platelets are 325,000/mm3. Serum electrolytes are normal. Which of the following is her urinalysis most likely to reveal?

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/ L. 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?

A 6-month-old infant is taken to the emergency department because he had a seizure. Physical examination demonstrates premature closure of cranial sutures and markedly bowed legs. Laboratory studies demonstrate low serum phosphate levels, with normal vitamin D and parathyroid hormone levels. Urinalysis shows high phosphate levels, but no increased excretion of glucose, amino acids, or protein. The child's maternal grandfather had crippling bone disease, and his mother has mild bowing of the legs. Which of the following is most likely diagnosis?

A 2-year-old girl is brought to the emergency department with a fever, chills, poor appetite, and vomiting. On examination, she is irritable and diaphoretic. Her temperature is 39.2 C (102.5 F), blood pressure is 80/48 mm Hg, pulse is 88/min, and respirations are 17/min. She is tender at the left costovertebral angle. Initial laboratory tests show the following: Leukocyte count 16,300/mm3 Hemoglobin 12.5 g/dL Platelet count 245,000/mm3 Blood urea nitrogen 6 mg/dL Creatinine 0.5 mg/dl Urinalysis is positive for leukocyte esterase and nitrite, with 150 white blood cells/hpf. After TV antibiotic administration and stabilization, what is the most appropriate diagnostic study?

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?

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?

A 6 year old girl brought to the office for the evaluation of ''passing smoky urine''. She recently had a sore throat. Her blood pressure is 150/100 mmHg. There is swelling of the face and extremities. Urinalysis reveals many red blood cells, red blood cell casts and 1 + proteinuria. Her serum C3 level and CH 50 are low. Her C4 1evel is normal. Her antistreptolysin-a (ASO) titer is 1,024 Todd units (normal ≤ 166 Todd units). In this patient, which of the following abnormal findings is most likely to become normal within 8 to 12 weeks?

A 3-year-old child is taken to a pediatrician because he develops burning pain, erythema, and swelling minutes after being exposed to the sun. Physical examination demonstrates erythema with swelling of the hands and arms. The skin is thickened on the backs of the hands but does not show blistering or scarring. Which of the following is the most likely diagnosis?

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?

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?

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?

A previously healthy one year old child is bought to the physician for 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?

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?

A 7 -year-old male child is brought to the office due to decreased urine output and lethargy for the past week. His birth and past medical histories are insignificant. His immunizations are up-to-date. Examination reveals no abnormalities. His BUN and creatinine levels are elevated. What is the most appropriate next step in the management of this patient?

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 best appropriate management ?

An infant born at 35 weeks gestational to Mother with no prenatal care is noted to be jittery and irritable, and is having difficulty feeding. You note coarse tremors on examination. The nurses report a high-pitched cry and note several episodes of diarrhea and emesis. You suspect which of the following?

A previously healthy full-term infant has several episodes of duskiness and apnea during the second day of life. Diagnostic considerations should include which of the

A 3-year-old girl is brought to the pediatrician with complaints of abdominal pain and fever. Her mother states that the fever started 2 days ago, with the highest temperature being 39.0 C (102.2 F). She has had no vomiting or diarrhea. The mother states that her daughter has been complaining of pain on urination. On examination, she is tender in her lower abdomen, and there is some right-sided costovertebral angle tenderness. A urinalysis confirms the suspicion of a urinary tract infection. Which of the following would be the most appropriate diagnostic procedure ?

A very concerned mother brings a 2-year-old child to your office because of two episodes of a brief, shrill cry followed by a prolonged expiration and apnea. You have been following this child in your practice since birth and know the child to be a product of a normal pregnancy and delivery, to be growing and developing normally, and to have no chronic medical problems. The first episode occurred immediately after the mother refused to give the child some juice; the child became cyanotic, unconscious, and had generalized clonic jerks. A few moments later the child awakened and had no residual effects. The most recent episode (identical in nature) occurred at the grocery store when the child’s father refused to purchase a toy for her. Your physical examination reveals a delightful child without unexpected physical examination findings. Which of the following is the most likely diagnosis?

You are called to examine a 2 day old male infant due difficulty in feeding. He becomes cyanotic and short of breath when he feeds, but turns pink when he cries. His prenatal, birth and family histories are unremarkable. His vital signs are normal. Chest auscultation is normal. His peripheral pulses are full and symmetric. What is the most likely diagnosis?

A 3-week-old female is brought into the emergency department with a fever and irritability. She was born after a normal pregnancy and delivery. Her mother had routine prenatal care and has no history of sexually transmitted infections. The infant's mother is 14 years old and the father is 17 years old. They are not married, and the father is not involved in the care of the infant. The infant lives with her mother and maternal grandparents at the maternal grandparents' home. You are concerned about meningitis and decide to do a lumbar puncture. The mother and maternal grandparents are present in the emergency department. Informed consent should be obtained from which of the following individuals?

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

A child can walk well holding on to furniture but is slightly wobbly when walking alone. She uses a neat pincer grasp to pick up a pellet, and she can release a cube into a cup after it has been demonstrated to her. She tries to build a tower of two cubes with variable success. She is most likely at which of the following age?

A neonate has an obviously abnormal foot. The foot is in a markedly plantar flexed position, with the sole facing the adjacent leg in a position of marked adduction. No other anomalies are noted on physical examination. Which of the following is the most likely diagnosis?

A mentally retarded 10-year-old boy presents with arthritis, nephrolithiasis, and progressive renal failure. Since his first years of life, he manifested peculiar neurologic abnormalities consisting of self-mutilative biting of the lips and fingers, choreoathetosis, and spasticity. Two male relatives on his mother's side presented with a similar condition and died in their teens. Which of the following is the most likely diagnosis?

A previously healthy 7-year-old girl comes to the office with complaints of episodic abdominal pain over the past several months. The pain is periumbilical and sharp but does not wake her from sleep or interfere with play. She has no fever, joint complaints, or constipation or diarrhea. Growth and development have been normal. The physical examination is within normal limits. Which of the following is the most likely diagnosis?

A 4-month-old male infant is brought to the office by his parents due to progressive lethargy, poor feeding, fatigue and increasing pallor for the past four weeks. His antenatal and birth histories are unremarkable. His diet consists mainly of breast milk. His immunizations are up-to-date. His mother's blood type is O+. Physical examination reveals a webbed neck, cleft lip, shielded chest, triphalangeal thumbs, and pale mucous membranes and conjunctivae. Cardiac auscultation reveals mild tachycardia and a systolic ejection murmur over the left upper sternal border. The initial investigations reveal the following: Hb 8 g/dl Ht 26% WBCs 7,000/mm3 Platelets 300,000 /mm3 Reticulocytes 04% MCV 104 fl Blood type A - Bilirubin direct 0.1 mg/dl Bilirubin total 1.0 mg/dl What is the most likely diagnosis?

A 15-year-old Caucasian male is brought to the office by his mother for the evaluation of a six-month history of unstable gait and speech difficulty which are getting worse over time. His past medical history is insignificant. He is not taking any medications, and denies smoking or alcohol consumption. His blood pressure is 120/70 mmHg and pulse is 80/min. Musculoskeletal examination showed scoliosis and feet deformity with 'hammer toes.' The neurologic examination showed dysarthria, dysmetria, nystagmus, and absence of deep plantar reflexes on lower extremities. What is the most common cause of death in this patient population?

An 18-month-old child is brought to the emergency department by his mother due to a one-day history of lethargy and anorexia. He had a fever the whole day yesterday, which responded to Tylenol (Acetaminophen). He then developed a petechial rash over his entire body, which worsened in the last few hours. He is up-to-date with his immunizations, and is an otherwise healthy baby. On examination, he is drowsy and lethargic. He has neck stiffness and appears septic. He flexes his hips when his neck is flexed. What is the most likely organism responsible for the patient's symptoms?

You are called to examine a one day old male neonate who gradually developed cyanosis over the past few hours. The infant was delivered vaginally at full term, assisted with forceps, and weighed 9 lbs. The Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Oxygen administration by mask does not relieve the cyanosis. Further examination reveals tachypnea, subcostal retractions, a normal S 1, single and loud S2, and no murmur. Which of the following is the most probable cause of the infant's cyanosis?

A 9 month old chubby healthy appearing boy is brought to 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?

A 29-year-old woman presents to the delivery room in labor at 35 weeks' gestation with a temperature of 40 C (104 F). She lives on a dairy farm and is in the habit of drinking unpasteurized milk from her cows before sending it to the dairy. For the past 3 days she has been unable to attend to her chores because of fever, headache, mild diarrhea, and a general feeling of illness. When her amniotic membranes rupture, the fluid is dark, cloudy, and brownish-green. At birth, the infant has no malformations or edema, but is in severe respiratory distress. Which of the following is the most likely diagnosis?

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?