DES 2016. Final (Part 52)

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 bed-wetting 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 disk-shaped 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 well-appearing 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?