Pediatric Medicine Mastery Quiz
Pediatric Medicine Mastery Quiz
Test your knowledge in pediatric medicine with our comprehensive 101-question quiz designed for medical professionals and students. This quiz covers a wide range of topics, including common pediatric conditions, treatment protocols, and developmental milestones.
Whether you're studying for an exam or refreshing your knowledge, this quiz is a great way to challenge yourself:
- 101 multiple-choice questions
- Covers essential pediatric topics
- Ideal for medical students and professionals
301. You admitted to the hospital the previous evening a 1-year-old boy who presented with cough, fever, and mild hypoxia. At the time of his admission, he had evidence of a right upper lobe consolidation on his chest radiograph. A blood culture has become positive in less than 24 hours for Staphylococcus aureus. Approximately 20 hours into his hospitalization, the nurse calls you because the child has acutely worsened over the previous few minutes, with markedly increased work in breathing, increasing oxy- gen requirement, and hypotension. As you move swiftly to the child’s hospital room, you tell the nurse to order which of the following?
A second chest radiograph to evaluate for pneumatocele formation
A large-bore needle and chest tube kit for aspiration of a probable tension pneumothorax
A change in antibiotics to include gentamicin
A sedative to treat the child’s attack of severe anxiety
A thoracentesis kit to drain his probable pleural effusion
302. A 15-year-old boy has been immobilized in a double hip spica cast for 6 weeks after having fractured his femur in a skiing accident. He has become depressed and listless during the past few days and has complained of nausea and constipation. He is found to have microscopic hematuria and a blood pressure of 150/100 mm Hg. Which of the following is the most appropriate course of action?
Request a psychiatric evaluation
Check blood pressure every 2 hours for 2 days
Collect urine for measurement of the calcium to creatinine ratio
Order a renal sonogram and intravenous pyelogram (IVP)
Measure 24-hour urinary protein
303. An adolescent with type 1 diabetes returns for a follow-up visit after his annual checkup last week. You note that his serum glucose is elevated and his glycosylated hemoglobin (hemoglobin A1C) is 16.7%. This finding suggests poor control of his diabetes over at least which of the following time periods?
8 hours
1 week
1 month
2 months
6 months
304. A 6-year-old male presents to the physician with eyelid swelling. His mother noted an insect bite on his left cheek yesterday, and states that this morning his left eyelid was completely swollen shut and painful. He has not had a fever, fatigue, headache, or rhinorrhea. On examination, he is afebrile. The left eyelid is erythematous, tender to palpation, and swollen shut. When trying to clinically distinguish between preseptal and orbital cellulitis, which of the following findings is most likely to be seen with preseptal cellulitis?
Decreased eye movements
Decreased visual acuity
Proptosis
Eyelid discoloration
Fever
305. A 41-year-old woman who is 32-weeks pregnant presents to the emergency department in labor. Her pregnancy has been complicated by gestational hypertension. Her medical history is otherwise unremarkable. She does not abuse alcohol, tobacco, or illicit drugs. Despite medical interventions, her preterm labor cannot be arrested, and she delivers a 2 kg (41b, 5oz) female infant. Both she and the child do well after delivery. Which of the following is true regarding immunizations for this infant?
Immunizations should be given according to the chronologic age
Immunizations should be given according to the gestational age.
Toxoid and polysaccharide vaccines should be given according to chronologic age, but live attenuated vaccines should be given according to the gestational age.
Immunizations should be started after she reaches 3 kg.
Immunizations should be given when allergen testing confirms an immune response.
306. 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?
Ibuprofen as needed for pain or fever
Labetalol for her chronic hypertension
Amphetamines for her attention deficit disorder
Carbamazepine for her seizure disorder
Acyclovir for her HSV outbreak
307. A recovering premature infant who weighs 950 g (2 lb, 1 oz) is fed breast milk to provide 120 cal/kg/d. Over the ensuing weeks, the baby is most apt to develop which of the following?
Hypernatremia
Hypocalcemia
Blood in the stool
Hyperphosphatemia
Vitamin D toxicity
308. A 15-year-old female presents to your office with secondary amenorrhea. As part of your evaluation, you find that she is pregnant. After informing her of the pregnancy, you continue to explain that young mothers have a higher risk of several pregnancy-related complications, including which of the following?
Twin gestation
Low-birth weight infants
Hypotension
Excessive weight gain
Infants with genetic defects
309. A 16-year-old boy who is the backup quarterback for the local high school team is in your office complaining of worsening acne. For the last few months he has noted more acne and more oily hair. On his examination, you note gynecomastia and small testicular volume. He is SMR 5. Which of the following drugs of abuse is the likely explanation for all of his findings?
Cocaine
Oxandrolone
Marijuana
Toluene
Methylenedioxymethamphetamine
310. A 4-year-old Caucasian boy is brought to his physician's office for a health maintenance exam. He will be starting preschool soon, and his parents want to make sure that he is in optimal health. The child has no complaints, and is generally happy. His medical history is significant for pneumonia as a newborn, and three episodes of otitis media since birth. He does not take any medications on a regular basis. His newborn screening test results are normal. His developmental milestones are at par with his age. He lives with his parents in a middle-class, suburban house built in 1981. Which of the following is the most appropriate next step for this child's primary care?
Screen him for inguinal hernias
Serum lead level
Meningococcal vaccine
Vision exam
Rotavirus vaccine
311. 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?
Admission to the neonatal intensive care unit for close cardiovascular monitoring
HIV ELISA on the infant to determine if congenital infection has occurred
A course of zidovudine for the infant
Chest radiographs to evaluate for congenital Pneumocystis carinii
Administration of IVIG to the baby to decrease the risk of perinatal HIV infection
312. Initial examination of a full-term infant weighing less than 2500 g (5 lb, 8 oz) shows edema over the dorsum of her hands and feet. Which of the following findings would support a diagnosis of Turner syndrome?
A liver palpable to 2 cm below the costal margin
Tremulous movements and ankle clonus
Redundant skin folds at the nape of the neck
A transient, longitudinal division of the body into a red half and a pale half
Softness of the parietal bones at the vertex
313. 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?
He has attention deficit hyperactivity disorder and would benefit from methylphenidate
This could be autism and would benefit from antipsychotics
He has hearing problems and he needs ear, nose and throat evaluation
He has autism and will need special behavioral and educational programs
His diagnosis is Asperger syndrome
314. A father brings his 3-year-old daughter to the emergency center after noting her to be pale and tired and with a subjective fever for several days. Her past history is significant for an upper respiratory infection 4 weeks prior, but she had been otherwise healthy. The father denies emesis or diarrhea, but does report his daughter has had leg pain over the previous week, waking her from sleep. He also reports that she has been bleeding from her gums after brushing her teeth. Examination reveals a listless pale child. She has diffuse lymphadenopathy with splenomegaly but no hepatomegaly. She has a few petechiae scattered across her face and abdomen and is mildly tender over her shins, but does not have associated erythema or joint swelling. A CBC reveals a leukocyte count of 8,000/L with a hemoglobin of 4 g/dL and a platelet count of 7,000/L. The automated differential reports an elevated number of atypical lymphocytes. Which of the following diagnostic studies is the most appropriate next step in the management of this child?
Epstein-Barr virus titers
Serum haptoglobin
Antiplatelet antibody assay
Reticulocyte count
Bone marrow biopsy
315. While bathing her newly-received 2-year-old son, a foster mother feels a mass in his abdomen. A thorough medical evaluation of the child reveals aniridia, hypospadias, horseshoe kidney, and hemihypertrophy. Which of the following is the most likely diagnosis for this child?
Neuroblastoma
Wilms tumor
Hepatoblastoma
Rhabdomyosarcoma
Testicular cancer
316. A 7 -year-old Caucasian male with a history of peanut allergy develops sudden shortness of breath after lunch at school. On physical examination, his blood pressure is 70/50 mmHg and his heart rate is 130/min. Inspirations and expirations are labored and noisy. Which of the following is the best initial treatment?
Albuterol nebulizer
Subcutaneous epinephrine injection
Intravenous steroids
Intravenous diphenhydramine
Endotracheal intubation
317. A 1-year-old boy is brought to the pediatrician for a routine visit. While talking to his mother, she reports that they moved into an old house several months ago and are in the process of renovating. The child eats table food and drinks whole milk. His height, weight, and head circumference are all at the 50th percentile for his age. Physical examination is normal. The results of a fingerstick blood test are shown below: Hemoglobin 1 0.5 g/dL Hematocrit 30.0% Lead level 12 μg/dL (Normal < 10 μg/dL) Which of the following is the most appropriate next step in management?
Remove the child from the house
Check a serum lead level
Initiate chelation therapy with dimercaprol
Initiate chelation therapy with dimercaptosuccinic acid (DMSA, succimer)
Recheck lead level in one month
318. A 7-day-old boy is admitted to a hospital for evaluation of vomiting and dehydration. Physical examination is otherwise normal except for minimal hyperpigmentation of the nipples. Serum sodium and potassium concentrations are 120 mEq/L and 9 mEq/L (without hemolysis), respectively; serum glucose is 40 mg/dL. Which of the following is the most likely diagnosis?
Pyloric stenosis
Congenital adrenal hyperplasia
Secondary hypothyroidism
Panhypopituitarism
Hyperaldosteronism
319. 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?
CT scan of the pituitary
Measurement of serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
Measurement of serum testosterone
Reassurance of the normalcy of the condition
Chromosomes
320. A 12-week-old female infant is brought to the office by her mother due to a three- week history of weakness, poor appetite, and choking spells during feeding. Other accompanying symptoms include excessive sleeping, constipation and apathy. Her prenatal history is unremarkable. She was delivered vaginally at 38 weeks of gestation. Her weight and length at birth were within normal range. She is exclusively breastfed. Her mother's family history is unremarkable. The identity and family history of her father are unknown. The pertinent physical findings include apathy, weakness, hypotonia, large tongue, sluggish movement, abdominal bloating, and an umbilical hernia. Based on the given information, what is the most likely diagnosis?
Infant botulism
Werdnig-Hoffmann syndrome
Myotonic congenital myopathy
Congenital hypothyroidism
Myasthenia gravis
321. While making rounds in the newborn nursery, the nurses ask you to examine a 2-day- old infant who is not feeding well. The nurse reports that the infant is irritable, is not sleeping well, and has had several episodes of vomiting and loose stools today. A review of the maternal history reveals that she had poor prenatal care and the pregnancy was complicated by intrauterine growth restriction. On examination, the infant is diaphoretic and has a high- pitched cry. The infant is also noted to have occasional sneezing and is mildly tachypneic. No dysmorphic features are noted and the remainder of the examination is unremarkable. This infant's symptoms are most likely caused by prenatal exposure to which of the following?
Valproic acid
Phenytoin
Alcohol
Cocaine
Heroin
322. A 2-year-old boy is being followed for congenital cytomegalovirus (CMV) infection. He is deaf and developmentally delayed. The child’s mother informs you that she has just become pregnant and is concerned that the new baby will be infected and may develop serious consequences. Which of the following is true?
The mother has antibodies to CMV that are passed to the fetus.
The mother’s infection cannot become reactivated.
The likelihood that the new baby will become clinically ill is approximately 80%.
Termination of pregnancy is advised.
The new infant should be isolated from the older child.
323. A full-term infant is born after a normal pregnancy; delivery, however, is complicated by marginal placental separation. At 12 hours of age, the child, although appearing to be in good health, passes a bloody meconium stool. For determining the cause of the bleeding, which of the following diagnostic procedures should be performed first?
A barium enema
An Apt test
Gastric lavage with normal saline
An upper gastrointestinal series
A platelet count, prothrombin time, and partial thromboplastin time
324. A 1 0-year-old boy is brought to the emergency department due to abdominal pain and bloody diarrhea. The mother says that he was "fine" a few days ago, and then suddenly became ill. Physical examination shows a pale and jaundiced child. There is diffuse abdominal tenderness and 2+ pedal edema. Laboratory studies show anemia, thrombocytopenia and renal insufficiency. What is the most likely cause of the patient's symptoms?
Vibrio cholera
Escherichia coli
Crohn's disease
Lactose intolerance
Salmonella poisoning
325. A 2-year-old boy presents to the emergency department (ED) with severe wheezing. His symptoms have not improved even after three treatments with nebulizers. This is his third trip to the ED in the past two weeks. In the ED, he is given a dose of intravenous steroids, but continues to wheeze. On auscultation, there is no air entry bilaterally. His chest x-ray result is normal. His oxygen saturation is 91% on 6 liters of oxygen. What is the next best step in the management of this patient?
Start theophylline
Tracheostomy
Mechanical ventilation
Racemic epinephrine
Intravenous antibiotics
326. A 16-year-old girl is brought to the office due to abdominal pain and bloody diarrhea for the past two days. Her immunizations are up to date. Her past medical history is unremarkable. On examination, she appears lethargic and weak. Her skin turgor is poor, face and extremities are swollen, and skin appears yellow. Abdominal examination shows moderate non-localized, abdominal pain. Laboratory studies show: Hb 64 g/dl Hct 26.9% Platelets 45,000/mm3 Creatinine 2.3 mg/dl Total bilirubin 5.0 mg/dl What is the most common complication of the patient's condition?
Renal damage
Liver damage
Bone marrow failure
Pneumonia
Bowel obstruction
327. A fully immunized 2-year-old presents to the emergency room with several days of low-grade fever, barking cough, and noisy breathing. Over the past few hours he has developed a fever of 40°C (104°F) and looks toxic. He has inspiratory and expiratory stridor. The family has not noticed drooling, and he seems to be drinking without pain. Direct laryngoscopy reveals a normal epiglottis. The management of this disease process includes which of the following?
Intubation and intravenous antibiotics
Inhaled epinephrine and oral steroids
Inhaled steroids
Observation in a cool mist tent
Oral antibiotics and outpatient follow-up
328. An obese Caucasian father brings his 1 0-year-old obese son to your office. The father states that he was recently diagnosed with high cholesterol levels and coronary artery disease. Even though his son is asymptomatic, he is worried about the obesity. Which of the following best explains the next best step in management?
Get a fasting lipid profile
Get a screening test for total cholesterol level
Advise parents to start him on a low cholesterol diet
Evaluate him for coronary artery disease
Advise parents to start him on a regular physical exercise schedule
329. A 24-year-old woman arrives in the emergency center in active labor. She is at term, but received no prenatal care after 16 weeks of gestation when she lost her insurance coverage. The mother has an uncomplicated vaginal delivery. You are paged shortly after birth when the baby is noted to have respiratory distress. The infant has diminished breath sounds on the left, and the PMI is shifted toward the right. A chest radiograph is shown. The NG tube you placed earlier reveals the stomach to be below the diaphragm. Which of the following is the most likely diagnosis at this point?
Congenital cystic adenomatoid malformation
Congenital diaphragmatic hernia
Bronchogenic cysts
Congenital lobar emphysema
Congenital pneumonia
330. A 4-year-old boy, whose past medical history is positive for three urinary tract infections, presents with a blood pressure of 135/90 mm Hg. He is likely to exhibit which of the following symptoms or signs?
Multiple cranial nerve palsy
Headache
Hyporeflexia
Increased urine output
Right ventricular hypertrophy
331. The 1-year-old boy in the photograph below, who recently had a circumcision, requires an additional operation on his genitalia that will probably eliminate his risk of which of the following?
Testicular malignancy
Decreased sperm count
Torsion of testes
Urinary tract infection
Epididymitis
332. 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?
Increase fiber in his diet
Put him on the toilet at regularly scheduled times
Use a positive reward system
Stop potty training attempts for several months
Perform a urinalysis
333. A 6-year-old boy is brought to the ER with a two-day history of difficulty walking. He is dragging his right leg and seems to have weakness in his right arm. He also complains of headaches. The family just emigrated from Eastern Europe. According to his parents, the child suffers from delayed growth compared to his peers and does not like to engage in active play. His lips and fingers turn blue when he cries. His vital signs today are a blood pressure of 100/70 mmHg, pulse of 90/min, temperature of 38.3 0C (102.0 0F), and respiratory rate of 22/min. Which of the following is most likely responsible for his current complaints?
Glycogen storage disorder
Demyelinating disorder
Malignancy
Brain abscess
Malformation of the central nervous system
334. A 15-year-old is participating in high school football practice in August in Texas. He had complained of headache and nausea earlier in practice, but kept playing after a cup of water. He is now confused and combative. He is dizzy and sweating profusely. His temperature is 41°C (105.8°F). Therapy should consist of which of the following?
Provide oral rehydration solutions
Administer acetaminophen rectally
Order to rest on the bench until symptoms resolve
Initiate whole body cold water immersion
Tell him to go take a shower and rest until the next day’s practice
335. The term infant pictured below weighs 2200 g (4 lb, 14 oz). He is found to have a ventricular septal defect on cardiac evaluation. This infant appears to have features consistent with which of the following?
Perinatal phenytoin exposure
Trisomy 21
Alport syndrome
Fetal alcohol syndrome
Infant of diabetic mother
336. A previously healthy 4-year-old child is brought to the physician for a school physical for kindergarten. His mother has brought in his immunization record and reports that received all his immunizations prior to age 2. He has received only a yearly influenza vaccine since age 2. His physical examination is unremarkable. Which of the following immunizations should he be given during this visit?
Haemophilus influenza type B #4
Pneumococcal #3
Inactivated polio #4
Measles-mumps-rubella #1
Hepatitis B #3
337. A 6-week-old child is being evaluated for a fever of unknown etiology. As part of the laboratory evaluation, a urine specimen was obtained that grew E coli with a colony count of 2000/L. These findings would be definite evidence of a urinary tract infection if which of the following is true about the sampled urine?
It has a specific gravity of 1.008.
It is from a bag attached to the perineum of an uncircumcised boy.
It is from an ileal-loop bag.
It is from a suprapubic tap.
It is the first morning sample.
338. 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?
Obtain an EEG
Refer to a child psychiatrist
Begin -blocker therapy
Encourage adequate fluid and salt intake
Obtain serum and urine drug screens
339. 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?
Cryosurgery
Pulsed dye laser
Radiation therapy with gamma particles
Skin grafting
Topical corticosteroid therapy
340. A 4-year-old, apparently healthy child is examined by a pediatrician. The pediatrician hears a loud systolic ejection murmur with a prominent systolic ejection click. He also hears a soft, early diastolic murmur. Both murmurs are heard best at the upper right sternal border. ECG shows left ventricular hypertrophy. Which of the following is the most likely diagnosis?
Aortic valve stenosis
Atrial septal defect
Tetralogy of Fallot
Transposition of great arteries
Ventricular septal defect
341. A 19-year-old primiparous woman develops toxemia in her last trimester of pregnancy and during the course of her labor is treated with magnesium sulfate. At 38 weeks’ gestation, she delivers a 2100-g (4-lb, 10-oz) infant with Apgar scores of 1 at 1 minute and 5 at 5 minutes. Laboratory studies at 18 hours of age reveal a hematocrit of 79%, platelet count of 100,000/μL, glucose 41 mg/dL, magnesium 2.5 mEq/L, and calcium 8.7 mg/dL. Soon after, the infant has a generalized convulsion. Which of the following is the most likely cause of the infant’s seizure?
Polycythemia
Hypoglycemia
Hypocalcemia
Hypermagnesemia
Thrombocytopenia
342. An infant who appears to be of normal size is noted to be lethargic and somewhat limp after birth. The mother is 28 years old, and this is her fourth delivery. The pregnancy was uncomplicated, with normal fetal monitoring prior to delivery. Labor was rapid, with local anesthesia and intravenous meperidine (Demerol) administered for maternal pain control. Which of the following therapeutic maneuvers is likely to improve this infant’s condition most rapidly?
Intravenous infusion of 10% dextrose in water
Administration of naloxone (Narcan)
Administration of vitamin K
Measurement of electrolytes and magnesium levels
Neurologic consultation
343. At 43 weeks’ gestation, a long, thin infant is delivered. The infant is apneic, limp, pale, and covered with ―pea soup‖ amniotic fluid. Which of the following is the best first step in the resuscitation of this infant at delivery?
Intubation and suction of the trachea; provision of oxygen
Artificial ventilation with bag and mask
Chest compressions
Administration of 100% oxygen by mask
Catheterization of the umbilical vein
344. A 4-year-old child presents with an enlarged submandibular node that is 4 cm in diameter, nontender, and not fluctuant. The node has been enlarged for about 4 weeks, and there is no history of fever or contact with any person who was ill. A CBC is normal, and a Mantoux test with 5 tuberculin units of PPD shows 6 mm of induration. Which of the following is the most likely diagnosis?
Cat-scratch fever
Acute pyogenic lymphadenitis
Acute lymphoblastic leukemia
Tuberculous lymphadenitis
Atypical mycobacteria lymphadenitis
345. 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?
IV antibiotic treatment for 2 weeks
Repeat renal scan
Renal arteriogram
antireflux surgery
Addition of vitamin C (ascorbic acid) to the treatment regimen
346. A 2-week-old infant presents with hepatosplenomegaly and a thick, purulent, bloody nasal discharge. Coppery, oval, maculopapular skin lesions are present in an acral distribution. The neurologic examination is normal, including head circumference. Which of the following is the most likely cause of this congenital infection?
Cytomegalovirus (CMV)
HSV
GBS
T. gondii
T. pallidum
347. A 7-month-old patient presents with a history of 3 days of fever to 104°F, which resolved the same day that an exanthem erupted. The exanthem is prominent on the neck and trunk. It is macular, with discrete lesions 3–5 mm in diameter. Which of the following is the most likely diagnosis?
Erythema infectiosum
Measles
Roseola infantum
Rubella
Scarlet fever
348. A newborn infant has respiratory distress and trouble feeding in the nursery. The mother has no significant medical history, but the pregnancy was complicated by decreased fetal movement. On physical examination, you note that aside from shallow respirations and some twitching of the fingers and toes, the infant is not moving, and is very hypotonic. In the mouth there is pooled saliva and you note tongue fasciculations. Deep tendon reflexes are absent. Spinal fluid is normal. Appropriate statements about this condition include which of the following statements?
The condition is caused by the absence of the muscle cytoskeletal protein dystrophin.
The condition is caused by the degeneration of anterior horn cells in the spinal cord.
The condition is caused by the antibodies that bind the acetylcholine receptor at the postsynaptic muscle membrane.
The condition is caused by progressive autoimmune demyelination.
The condition is caused by birth trauma.
349. A 3-year-old boy’s parents complain that their child has difficulty walking. The child rolled, sat, and first stood at essentially normal ages and first walked at 13 months of age. Over the past several months, however, the family has noticed an increased inward curvature of the lower spine as he walks and that his gait has become more “waddling” in nature. On examination, you confirm these findings and also notice that he has enlargement of his calves. Which of the following is the most likely diagnosis?
Occult spina bifida
Muscular dystrophy
Brain tumor
Guillain-Barrésyndrome
Botulism
350. Your 6-year-old son awakens at 1:00 AM screaming. You note that he is hyperventilating, is tachycardic, and has dilated pupils. He cannot be consoled, does not respond, and is unaware of his environment. After a few minutes, he returns to normal sleep. He recalls nothing the following morning. Which of the following is the most likely diagnosis?
Seizure disorder
Night terrors
Drug ingestion
Psychiatric disorder
Migraine headache
351. A 5-year-old febrile child presents with swelling of the right eyelid. Proptosis and limitation of ocular movements is noted. Which of the following is the most likely diagnosis?
Retinoblastoma
orbital cellulitis
Periorbital cellulitis
Neuroblastoma
Hyphema
352. 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?
Amoxicillin
Amoxicillin-clavulanic acid
Cephalexin
Ceftriaxone
Erythromycin
353. A 10-year-old boy is brought in with a chief complaint of multiple colds. On further questioning, you elicit a history of chronic, clear nasal discharge with no seasonal variation. Other symptoms include sneezing, itching of the nose and eyes, as well as tearing and occasional eye redness. Some relief is obtained with an over-the-counter cold medicine containing antihistamine and a decongestant. His history suggests which of the following?
Nasal foreign body
Immunologic deficiency
Rhinitis medicamentosa
Chronic sinusitis
Allergic rhinitis
354. A 15-year-old boy comes to the physician with left shoulder joint pain and swelling. He has had these symptoms for the past 3 months and they are getting progressively worse. He has no fever, weight loss, or night sweats. The patient lifts weights and plays baseball 5 days a week. He has taken acetaminophen and ibuprofen with little relief. Examination shows a tender mass at the left proximal humerus. Range of motion is normal. Laboratory evaluation shows elevated alkaline phosphatase, erythrocyte sedimentation rate, and lactate dehydrogenase. X-ray of the shoulder is shown in the photograph below. Which of the following is the most likely diagnosis?
Ewing sarcoma
Osteoid osteoma
Osteomyelitis
Osteosarcoma
Stress fracture
355. 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?
Throat culture
Monospot test
Antistreptolysin O antibodies
Oral penicillin V
Oral azithromycin
356. A 4-day-old infant presents with yellow discoloration of the skin and sclera. The baby was born at term by a normal vaginal delivery. Pregnancy was uncomplicated; there were no risk factors for sepsis and no history of maternal alcohol or drug use. The baby is breast-fed and has been nursing every 2 hours, about 10 minutes at each breast. The bilirubin level is 15 mg/dL (all unconjugated), the hematocrit is 45%, and the Coombs test is negative. Which of the following is the most likely diagnosis?
Congenital biliary atresia
Isoimmune hemolytic disease
Crigler-Najjar syndrome
Breast milk jaundice
breast-feeding jaundice
357. A previously healthy, active, 18-month-old African American child presents with unilateral nasal obstruction and foul-smelling discharge. The child’s examination is otherwise unremarkable. Which of the following is the most likely diagnosis?
Foreign body
Nasal polyps
Frontal sinusitis
Deviated septum
Choanal atresia
358. 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?
Try steroids to decrease tonsillar and adenoid hypertrophy.
Refer to an otolaryngologist for tonsillectomy and adenoidectomy.
Arrange for continuous positive airway pressure (CPAP) at home.
Arrange for home oxygen therapy for use at night.
Arrange for polysomnography.
359. A 3-year-old boy is brought to the emergency department three hours after having a seizure. He has been having severe diarrhea for the last three days. His mother recently read about the importance of maintaining adequate hydration during diarrhea, so she had been giving him a lot of milk mixed with water. On examination, his vital signs are stable and mucus membranes are moist. Initial lab results are:
Hb 13 g/dl
WBC 6,000/mm3
Platelets 300,000/mm3
Blood Glucose 98 mg/dl
Serum Na 120 mEq/L
Serum K 34 mEq/L
Chloride 92 mEq/L
BUN 22 mg/dl
Creatinine 1.2 mg/dl
What is the most likely cause of this patient's seizure?
SIADH
Water intoxication
Severe dehydration
Acute renal failure
Sepsis
360. The state laboratory calls your office telling you that a newborn infant, now 8 days old, has an elevated thyroid stimulating hormone (TSH), and low thyroxin (T4) on his newborn screen. If this condition is left untreated, the infant is likely to demonstrate which of the following in the first few months of life?
Hyperreflexia
Hyperirritability
Diarrhea
Prolonged jaundice
Hyperphagia
361. A 1-year-old boy presents with the complaint from his parents of “not developing normally.” He was the product of an uneventful term pregnancy and delivery, and reportedly was normal at birth. His previous health-care provider noted his developmental delay, and also noted that the child seemed to have an enlarged spleen and liver. On your examination, you confirm the developmental delay and the hepatosplenomegaly, and also notice that the child has short stature, macrocephaly, hirsutism, a coarse facies, and decreased joint mobility. Which of the following is the most likely etiology of his condition?
Beckwith-Wiedemann syndrome
Crouzon syndrome
Trisomy 18 (Edwards syndrome)
Jeune syndrome
Hurler syndrome
362. A 22-year-old Caucasian female who has received no prenatal care experiences a stillbirth. This is her first pregnancy. The baby has multiple fractures, blue sclerae and short, bent extremities. Her past medical history is significant for a seizure disorder. She has been taking phenytoin regularly and had no seizure episodes during the pregnancy. She admits to eating poorly and occasionally drinking alcohol during the first trimester. She lives with her boyfriend who abuses her physically. She recalls several episodes of abuse during the pregnancy. Which of the following is most likely responsible for fetal abnormalities?
Folic acid deficiency
Collagen synthesis defect
Prenatal abuse
Phenytoin use
Alcohol abuse
363. 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?
Short-acting bronchodilators and a 5-day course of steroids
Intubation and antibiotics
Observation for hypoxia and dehydration alone
Inhaled epinephrine and a dose of steroids
Rigid bronchoscopy
364. 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?
Prescribe aspirin and ask her to call back if the fever does not respond.
Make an office appointment for the next available opening.
Make an office appointment for the next day.
Refer the child to the laboratory for an immediate hematocrit, white blood cell count, and differential.
Admit the child to the hospital.
365. A 7-month-old baby presents with a history of constipation for 1 month. He has one hard stool every week. He has been well otherwise. His physical examination is normal. Which of the following is the most likely cause of his problem?
Hypothyroidism
Lead poisoning
Functional constipation
Hirschsprung disease
Hypocalcemia
366. A specific pattern of abnormalities has been identified among infants born to mothers who consume moderate-to-large amounts of alcohol during their pregnancies. Which of the following abnormalities is characteristic of these infants?
Cataracts
Developmental dysplasia of the hip
Gonadal dysgenesis
Neural tube defects
Mental retardation
367. A 1-week-old black infant presents to you for the first time with a large, fairly well- defined, purple lesion over the buttocks bilaterally, as shown in the photograph. The lesion is not palpable, and it is not warm nor tender. The mother denies trauma and reports that the lesion has been present since birth. This otherwise well-appearing infant is growing and developing normally and appears normal upon physical examination. Which of the following is the most appropriate course of action in this infant?
Report the family to child protective services
Reassurance of the normalcy of the condition
Soft tissues films of the buttocks to identify calcifications
Administration of vitamin K
Measurement of bleeding time as well as factor VII and XI levels
368. A newborn infant develops respiratory distress immediately after birth. His abdomen is scaphoid. No breath sounds are heard on the left side of his chest, but they are audible on the right. Immediate intubation is successful with little or no improvement in clinical status. Emergency chest x-ray is shown (A) along with an x-ray 2 hours later (B). Which of the following is the most likely explanation for this infant’s condition?
Pneumonia
Cystic adenomatoid malformation
Diaphragmatic hernia
Choanal atresia
Pneumothorax
369. A 9-month-old infant is brought to the pediatrician's office because his weight is persistently below the 10th percentile. His mother states that the infant seems to be hungry all the time and usually consumes 8-12 oz of formula every 2-3 hours in addition to some table food. He also has frequent, bulky, and malodorous stools. A malabsorption syndrome is suspected. The results of which of the following tests will most likely be abnormal?
Abdominal radiography
Fecal fat quantification
Serum albumin
Stool culture for Clostridium difficile toxins
Stool smear for leukocytes and eosinophils
370. The parents of a previously healthy 2-year-old child note her to be pale and bring her to your clinic for evaluation. She currently has no fever, nausea, emesis, bone pain, or other complaints. Her examination is significant for pallor, tachycardia, and a systolic ejection murmur, but she has no organomegaly. Her complete blood count (CBC) reveals a hemoglobin of 4 g/dL, normal indices for age, a WBC count of 6.5/L, and a platelet count of 750,000/L. Her reticulocyte count is 0%. Coombs test is negative. Her peripheral blood smear shows no blast forms and no fragments. Red blood cell (RBC) adenosine deaminase levels are normal. A bone marrow reveals markedly decreased erythroid precursors. Which of the following is this child’s likely diagnosis?
Diamond-Blackfan anemia
Sickle-cell anemia
Pearson marrow-pancreas syndrome
Iron deficiency anemia
Transient erythroblastopenia of childhood
371. On a routine-screening CBC, a 1-year-old is noted to have a microcytic anemia. A follow-up hemoglobin electrophoresis demonstrates an increased concentration of hemoglobin A2. The child is most likely to have which of the following?
Iron deficiency
ϝ�-Thalassemia trait
Sickle-cell anemia
Chronic systemic illness
Lead poisoning
372. A 2-year-old child is brought to the office by his parents for the evaluation of failure to thrive and chronic diarrhea. His diarrhea is "almost continuous", and he also has recurrent episodes of fever. He was initially quite well and was on the 60th percentile for weight; however, for the past seven months, he didn't seem to grow and failed to gain weight. Over the past three months, he fell to the 3rd percentile for weight. His parents deny any use of drugs, but they drink occasionally. His mother mentions that her former boyfriend was a heroin addict. Physical examination reveals oral thrush, generalized lymphadenopathy and eczema. What is the most likely diagnosis in this patient?
Congenital Toxoplasmosis
Non-Hodgkin lymphoma infiltrating small intestine
HIV infection
Miliary tuberculosis
Malabsorptive disease
373. A 3-year-old girl is brought to the emergency department because she became partially unconscious, lethargic and febrile. Her mother claims that "she suddenly took a turn for the worse" 24 hours ago after an upper respiratory tract infection. She has no allergies, and was not taking oral antibiotics. Her blood pressure is 60/45mm Hg and pulse is 120/min. On examination, she appears emaciated and lethargic. Despite numerous attempts, it is impossible to start a peripheral intravenous line, and the child's condition continues to deteriorate. What is the best next step to obtain IV access in this patient?
Subclavian central line
Lntraosseous
Jugular cut down
Femoral vein
Fluids down endotracheal tube
374. After being delivered following a benign gestation, a newborn infant is noted to have a platelet count of 35,000/L, decreased fibrinogen, and elevated fibrin spilt products. On examination you note a large cutaneous hemangioma on the abdomen that is purple and firm. Which of the following anomalies might also be expected in this infant?
Kaposiform hemangioendothelioma
Nevus simplex
Nevus flammeus
PHACE(S) syndrome
Infantile fibrosarcoma
375. A 4-year-old previously well African American boy is brought to the office by his aunt. She reports that he developed pallor, dark urine, and jaundice over the past few days. He stays with her, has not traveled, and has not been exposed to a jaundiced person, but he is taking trimethoprim sulfamethoxazole for otitis media. The CBC in the office shows a low hemoglobin and hematocrit, while his “stat” serum electrolytes, blood urea nitrogen (BUN), and chemistries are remarkable only for an elevation of his bilirubin levels. His aunt seems to recall his 8-year-old brother having had an “allergic reaction” to aspirin, which also caused a short-lived period of anemia and jaundice. Which of the following is the most likely cause of this patient’s symptoms?
Hepatitis B
Hepatitis A
Hemolytic-uremic syndrome
Gilbert syndrome
Glucose-6-phosphate dehydrogenase deficiency
376. A 24-month-old child is seen in the pediatrician's office for a regular health supervision visit. He has no history of developmental delay. He was born by an uncomplicated normal vaginal delivery at term, and he has not had any significant illness or injury prior to this visit. Which of the following motor milestones is most consistent with his age?
Building a tower of two cubes
Copying a circle
Scribbling
Throwing a ball overhead
Walking backward
377. A 2-year-old girl has severe dental caries of the upper and lower incisors. Her teeth are brushed twice daily with a small amount of fluoride-containing toothpaste. What is the feeding practice most likely to result in this pattern of dental caries?
Drinking juice from a cup at snack time
Drinking juice from a bottle at snack time
Drinking milk from a bottle at meal time
Prolonged breast-feeding beyond the first year
Drinking a bottle of juice in bed
378. A 6-year-old girl has a low-grade fever, headache, and nasal congestion. She has a flushed face and has developed a lacy reticular rash on the trunk and extensor surface of her arms and legs. Palms and soles are spared. Her mother has been ill with a low-grade fever and some joint stiffness and pain. Which of the following is the most likely diagnosis?
Rubella
Measles
Scarlet fever
Roseola infantum
Erythema infectiosum (fifth disease)
379. A 3-year-old boy has had fever for 4 days. On physical examination he has bilateral cervical lymphadenopathy, injected pharynx, and dry cracked lips. A throat swab is done and the rapid strep test is negative. The child is sent home and advised to follow-up if symptoms worsen. The child is brought back 2 days later with all previous findings including a maculopapular rash, swollen hands, and conjunctivitis. Which of the following is the most likely diagnosis?
Scarlett fever
Kawasaki disease
Toxic shock syndrome
Infectious mononucleosis
Erythema infectiosum
380. An 8-year-old girl is brought to the emergency department with fever for the past 6 days. Her parents report that she has been very "cranky" and has developed a new rash. Six weeks ago, she completed a 10-day course of amoxicillin for streptococcal pharyngitis. She has no other medical problems and takes no medications. Her temperature is 39.4° C (103° F), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 24/min. Physical examination shows injected lips and pharynx. Bilateral conjunctivae are also injected, with no exudates. A 1.7-cm mobile lymph node is palpated on the left neck. A blanching erythematous rash is present across her face, trunk, and extremities, including the palms and soles. Her mouth is shown below. What is the most appropriate next step in management of this patient?
Amoxicillin
Aspirin and intravenous immunoglobulin
Doxycycline
Lymph node biopsy
Reassurance and close follow-up
381.A 6-year-old African-American child is brought in by his father for complaints of easy fatigability and pallor. These symptoms occurred after the son was treated with "some medication" for a recent diarrhea. Physical examination is normal except for pallor and multiple petechiae. Laboratory values are as follows:
Hb 8.0 g/dL
WBC 12,000/cmm
Platelets 50,000/cmm
Blood glucose 118 mg/dL
Serum Na 135 mEq/L
Serum K 5.3 mEq/L
Chloride 110 mEq/L
Bicarbonate 18 mEq/L
BUN 38 mg/dL
Serum creatinine 2.5 mg/dL
Total bilirubin 3 mg/dL
Direct bilirubin 0.5 mg/dL
PT 12 seconds
APTT 30 seconds
LDH 900 IU/L
Reticulocyte count 6%
A peripheral blood smear reveals giant platelets and multiple schistocytes. What is the most likely underlying pathophysiology for this boy's pallor?
Sickle cell anemia
Thalassemia
Vitamin B12 deficiency
Folate deficiency
Microangiopathic hemolytic anemia
382. A 13-year-old boy’s scrotum is shown below. He complains of several months of swelling but no pain just above his left testicle. He is sexually active but states that he uses condoms. On physical examination, the area in question feels like a “bag of worms.” Which of the following is the most appropriate management for this condition?
Doppler flow study of testes
Radionuclide scan of testes
Urinalysis and culture
Ceftriaxone intramuscularly and doxycycline orally
Reassurance and education only at this time
383. A 3-day-old infant’s scrotum is shown below. Palpation reveals a tense, fluid-filled area surrounding the right testicle. The scrotum transil luminates well, and the amount of fluid does not vary with mild pressure. Which of the following is the most appropriate approach to this condition?
Request a surgical consultation
Incision and drainage
Administer prophylactic antibiotics
Observe only
Perform a chromosome determination
384.A 1-week-old infant is brought to the emergency department due to vomiting and poor feeding. The prenatal and birth histories are unremarkable. The infant's pulse is 140/min, temperature is 37 C (98.7 F), and capillary refill is 2 sec. He has sunken eyes, depressed anterior fontanel, and dry mucus membranes; skin elasticity is reduced. Heart and lungs are clear. There is no abdominal mass. Genital examination shows enlarged clitoris, and fusion of the labioscrotal folds. The initial laboratory work-up reveals the following:
Sodium 128 mEq/L
Potassium 5.8 mEq/L
BUN 25 mg/dl
If this patient's karyotype is 46 XX, which of the following is most likely to be increased in this patient's serum?
17 -alpha-hydroxyprogesterone
18-hydroxycorticosterone
11-deoxycorticosterone
11-deoxycortisol
Corticosterone
385. An 8-year-old Caucasian boy is brought to the office for the evaluation of high-grade fever, flank pain and burning micturition for the last two days. He has had two previous episodes of acute pyelonephritis. Physical examination reveals costovertebral angle tenderness. Urinalysis shows pyuria, significant bacteriuria, WBC casts, positive nitrite and esterase. The voiding cystourethrogram (VCUG) reveals vesicoureteral reflux. What is the most likely complication of this condition, if left untreated?
Hydronephrosis
Renal stones
Renal scarring
Renal abscess
Renal cell carcinoma
386. A woman comes to an emergency department because she is in labor. She has had no prenatal care. Her baby is delivered and appears to be of about 32 weeks' gestation. The newborn is very pale and shows severe, generalized edema. Cord-blood hematocrit is 22%, and cord-blood bilirubin is 7 mg/dl. Ultrasound examination demonstrates pleural effusions, ascites, cardiomegaly, and hepatomegaly. Which of the following is the most likely diagnosis?
ABO incompatibility
Beta thalassemia
Congenital spherocytosis
Sickle cell anemia
Rh incompatibility
387. A neonate is examined following a protracted breech delivery. One of the infant's arms is partially paralyzed. The affected arm is adducted and internally rotated at the shoulder, and the forearm is pronated. Which of the following is the most likely diagnosis?
Bell palsy
Erb palsy
Klumpke palsy
Pseudobulbar palsy
Supranuclear palsy
388. A 2-year-old boy presents with refusal to use his right arm for 1 day. He is otherwise well. His mother states she pulled upward on his arm the previous evening to keep him from tripping down the stairs. Which of the following is the most likely diagnosis?
Colles fracture
Fractured clavicle
Greenstick fracture of the humerus
Rotator cuff injury
Subluxation of the radial head
389. 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?
The child will need hospitalization, a lumbar puncture, and antibiotics.
An EEG and CNS imaging must be done.
Anticonvulsants must be stated and continued for 6 months.
There is a slight increase in risk for development of epilepsy.
The child must be monitored carefully for long-term neurologic damage.
390. A 1-day-old infant who received silver nitrate eye drops in the delivery room is suffering from bilateral purulent conjunctival discharge. Which of the following is the most likely cause of this child’s condition?
N. Gonorrhoeae infection
Herpes simplex infection
Nasolacrimal duct obstruction
Chemical irritation
Pseudomonas infection
391. 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?
Dietary advice and oral iron treatment
Hemoglobin electrophoresis
Intravenous pyelogram
Skeletal survey with x-rays
Bone marrow biopsy
392. A 2-year-old boy is brought to the clinic because of a swelling at the base of his neck on the left side. The family indicates that since he was born, they suspected he had some kind of a mass in his left supraclavicular area and behind the sternomastoid on that same side, but the area felt soft and mushy, was not always evident, and seemed to be painless, so they did nothing about it. Two weeks ago the child had an upper respiratory infection, and within a day or two the mass became larger and quite obvious. On physical examination he indeed has a soft, mushy, ill-defined mass occupying the entire left supraclavicular area and extending into the posterior triangle of the neck. He has no enlarged lymph nodes anywhere, and his spleen and liver are not palpable. Which of the following is the most appropriate next step in the evaluation?
Bone marrow biopsy
MRI of the neck and chest
Multiple percutaneous needle biopsies
Open surgical excisional biopsy
Panendoscopy under general anesthesia
393. A 14-year-old girl has a history of red eyes with clear discharge that she suffers from in a seasonal pattern. Together with these symptoms, she reports itching, which is her most bothersome complaint. Physical examination shows conjunctival redness, tearing, and swelling, but there is no purulent discharge. This clinical picture is most compatible with a diagnosis of which of the following conditions?
Allergic conjunctivitis
Bacterial conjunctivitis
Blepharitis
Corneal abrasion
Trachoma
394.A 4-day-old boy is brought to the physician for an outpatient follow-up visit. His mother's pregnancy and delivery were uncomplicated. The patient weighed 3.4 kg (7.5 lb) and was 48.2 cm (1'7") long at birth. He did well in the newborn nursery and was discharged from the hospital on day 2 of life. His mother reports that he is now exclusively breastfed and nurses for 10 minutes on each breast every 3 hours. He has two wet diapers/day and has not had a bowel movement for 2 days. He weighs 2.95 kg (6.5 lb) and is 48.2 cm (1'7'') long. He appears jaundiced on the face and chest. The remainder of the physical examination shows no abnormalities. Laboratory studies reveal:
Total bilirubin 15 mg/dl
Direct bilirubin 1 mg/dl
Infant's blood type 0 positive
Mother's blood type A positive
Which of the following is the most likely cause of this infant's hyperbilirubinemia?
Biliary atresia
Breast milk jaundice
Breastfeeding failure jaundice
Galactosemia
ABO incompatibility
395.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°C (101°F), pulse 85/min, and respiratory rate 20/min. On examination, there is pain and stiffness during manipulation of the wrists and ankles. A faint, ery1hematous, 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?
Juvenile rheumatoid arthritis
Rheumatic fever
Acute lymphoblastic leukemia
Systemic lupus ery1hematosus
Fibromyalgia
396. A young Hispanic couple brings their first child to their physician for a well-child examination. The child is a 3-month-old healthy-appearing infant, whose weight is at the 45th percentile of the normal growth curve. During examination, the physician observes an area of blue-black pigmentation over the buttocks. The parents say that it was present from the time of birth. Which of the following is the most appropriate next step in management?
Tell parents that this is a normal finding
Tell parents that this is a bruise caused by trauma
Order CT/MRI scans to rule out dysraphism
File a report of suspected child abuse
Tell parents that this is a severe condition finding
397. A 14-year-old boy presents with decreased exercise tolerance. He is noted to have a grade III/VI systolic ejection murmur best heard at the left upper sternal border and a grade II/VI mid-diastolic murmur at the lower left sternal border. The first heart sound is normal. The second heart sound is widely split and fixed. A right ventricular impulse is palpated. On a chest roentgenogram, the pulmonary artery segment is enlarged, and pulmonary vascular markings are increased. An ECG shows right axis deviation. Which of the following congenital heart diseases does this boy most likely have?
Aortic stenosis
Atrial septal defect
Coarctation of the aorta
Patent ductus arteriosus
Ventricular septal defect
398. A 7-year-old boy presents with a rash. His mother states that he was well until 3 days ago when he developed fever and malaise. The next day, the rash started as papules on the trunk, which rapidly changed to vesicles. The lesions have spread all over the body. On physical examination, he has no fever and seems well. You note numerous vesicles all over the body, some of which have crusted over. Which of the following is the most likely diagnosis?
Chicken pox
Kawasaki disease
Measles
Rubella
Staphylococcal scalded skin syndrome
399. 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?
Avoids contact with other children
Discontinues antibiotics 72 hour before surgery
Avoids aspirin and antihistamines for 2 weeks before surgery
Does not drink from siblings’ cups
Eats iron-laden foods for 3 weeks before surgery
400. A 4-month-old baby is in for a well-child check and routine immunizations. The baby had a fever of 39°C the day he received his 2-month immunizations. The parents have read about the vaccine on the Internet and express their concerns. Which of the following is an absolute contraindication to giving the diphtheria and tetanus toxoids and acellular pertussis (DTaP)?
History of fever >38C after previous vaccination
History of local reaction after previous vaccination (redness, soreness, swelling)
Family history of seizures
Encephalopathy within 7 days of administration of previous dose of vaccine
Current antibiotic therapy
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