A 7-year-old boy presents with a 3-year history of seasonal rhinorrhea and nasal congestion. He states that "as soon as the weather warms up," he experiences daily nasal symptoms that are often severe enough to limit his outdoor activity. On physical examination, you note infraorbital swelling, a transverse nasal crease, boggy turbinates, and clear rhinorrhea. A nasal smear demonstrates numerous eosinophils. You decide to treat him with a nasal spray. Of the following, the MOST effective long-term treatment for this boy is a nasal spray containing a(n)
Corticosteroid
Anticholinergic
Decongestant
Mast cell stabilizer
Saline solution
You diagnose tinea capitis in a 7-year-old girl. She is otherwise healthy and has no known allergies to medications. You plan to prescribe oral griseofulvin. Of the following, it is MOST appropriate to prescribe the drug
With clinical follow-up only at 4 to 6 weeks
After obtaining a baseline complete blood count
After obtaining baseline liver function tests
With serial complete blood counts during therapy
With serial liver function tests during therapy
A 16-year-old boy comes to your office with a 6-month history of abdominal cramping. He states that the cramps immediately precede a bowel movement and that passage of stool results in pain relief. There is no clear association with any type of food group. The patient's bowel movements are variable, ranging from hard stools every other day to loose stools several times a day. Weight and height are normal, as are physical examination findings and measurements of stool guaiac, complete blood count, erythrocyte sedimentation rate, albumin, aspartate aminotransferase, alanine aminotransferase, immunoglobulin A, and tissue transglutaminase. Stool studies are negative for Giardia sp, Clostridium difficile, and enteric pathogens. Of the following, the MOST appropriate next step is
Fiber supplementation
Colonoscopy and biopsy
Observation
Oral tegaserod
Referral to a psychiatrist
A 13-month-old boy presents to your office after his mother called for an urgent appointment because he had a bad cough and noisy breathing. He has been previously healthy and is fully immunized. On physical examination, his temperature is 100.9°F (38.3°C), pulse rate is 142 beats/min, respiratory rate is 36 breaths/min (crying), and pulse oximetry reading is 98% on room air. The mother states that he went to sleep normally with only mild symptoms of an upper respiratory tract infection and awakened at 4 am with noisy breathing. He tolerated sips of juice this morning and has had no vomiting, diarrhea, or high fever. After the boy settles down from having his vital signs measured, he has a "barking cough," and on auscultation, you notice stridor with every breath. Mild suprasternal retractions are visible on examination of the chest. He prefers to sit up and looks slightly anxious. Of the following, the treatment MOST likely to provide improvement is
Dexamethasone oraUy or intramuscularly
Ceftriaxone intramuscularly
Humidjfied oxygen by face mask
Nebulized albuterol
Nebulized budesonide
You are evaluating a 6-hour-old male infant who was born after a term pregnancy and normal delivery and weighs 4 kg. The infant is comfortable but exhibits mild tachypnea, with a respiratory rate of 50 breaths/min. His heart rate is regular at 150 beats/min. His oxygen saturation is 60% in all extremities and does not increase significantly with the administration of oxygen by face mask. His lungs are clear, and there are no murmurs, gallops, or rub. You suspect transposition of the great arteries. Of the following, the BEST management strategy is
Increasing the left-to-right (aorta-to-pulmonary artery) shunt at the ductus arteriosus
Diuretic therapy intravenously for pulmonary edema
Increasing the right-to-left shunt at the foramen ovate
Increasi ng the right-to-left (pulmonary artery-to-aorta) shunt at the ductus arteriosus
Intubation and mechanical ventilation with an Fio2 of 1.0
A 2-month-old exclusively breast-fed infant presents to your office because his mother thinks that he is irritable. His mother reports that the infant has been passing loose stools and cries when he has a bowel movement. He is generally happy at other times. Physical examination demonstrates a healthy, afebrile, vigorous infant who has normal skin color. Cardiac, pulmonary, and abdominal examination findings are all normal. Anal inspection demonstrates no fissures. A stool specimen has reddish flecks, and the guaiac test is positive. Of the following, the BEST next step is to
Remove milk products from the maternal diet
Begin therapy with oral amoxicillin
Institute a tli al of lansoprazole
Obtain an upper gastrointestinal radiography series
Send stool for Clostridium difficile toxin testing
Just before clinic starts, you find your two visiting medical students talking about a movie they saw over the weekend in which some of the characters suffered from the "black death" or bubonic plague. They involve you in the conversation and ask you what you know about this disease of antiquity. They are astounded to hear that plague still exists in the world today. You decide to use this time to make a teaching point and query them about the appropriate antimicrobial therapy for plague. Of the following, the MOST appropriate antimicrobial agent is
Gentamicin
Ampicillin
Aztreonam
Ceftriaxone
Meropenem
A 9-year-old girl is stung on the left leg by a hornet while playing outside. Within 10 minutes, she experiences diffuse pruritus, and a large area of erythema develops at the sting site. Five minutes later, extensive raised welts appear on her trunk and extremities. Her parents rush her to the emergency department, where intravenous antihistamines and steroids are administered. During this episode, she denies difficulty breathing or swallowing. No tongue or uvula edema is evident during examination, and her symptoms gradually resolve over 4 hours. Of the following, the NEXT recommended step in her management is to
Discharge the girl to home
Admit the girl to the hospital for 24 hours
Perform skin testing to hornet and other stinging insects within the next 72 hours
Prescribe a daily oral antihistamine for the girl to take when playing outside
Start allergy shots to hornet
You are evaluating a 12-year-old boy who recently moved to your community. His family history reveals that his father, who is 36 years old, suffers from extremely high blood cholesterol levels (>500 mg/dL [12.9 mmol/L]). The boy's mother states that her husband's brother has the "same problem." Findings on the boy's physical examination are normal. Of the following, the BEST next step for your patient is to
Measure cholesterol and triglyceride concentrations
Begin therapy with a lipid-lowering medication
Institute a low-fat diet plan and follow up in 3 months
Obtain a blood sample for genetic testing
Order a baseline electrocardiogram
You are called to evaluate an 18-month-old infant who was found playing with a medication bottle. The top was open, and many of the pills were on the floor. The prescription was for a tricyclic antidepressant used by the patient's older brother. On physical examination, the boy appears clumsy but awake and flushed. He has a heart rate of 150 beats/min, a respiratory rate of 28 breaths/min, and dilated pupils. He is breathing easily and has strong pulses. Of the following, the MOST important next step in this patient's management is
Electrocardiography and continuous cardiac monitoring
Administration of syrup of ipecac
Lidocaine therapy to prevent ventricular arrhythmias
Measurement of serum drug levels for tricyclic antidepressants
Measurement of serum electrolyte levels
A 14-year-old girl presents with complaints of lower abdominal cramps that have occurred on days 1 and 2 of her menstrual cycle for the past year. The cramps usually are associated with bloating and loose bowel movements. The symptoms have caused school absences on the first day of the past three periods. Use of acetaminophen has provided no relief. Menarche was at age 12 years. Her menstrual cycle is regular; menses last 5 days and are characterized by moderate flow. Of the following, the MOST appropriate management of these symptoms is the use of
Naproxen sodium
Acetaminophen with codeine
Fluoxetine
Montelukast
Tramadol hydrochloride
A 2-year-old boy presents with a 3-day history of diarrhea and vomiting. He has been able to tolerate small amounts of fluids. He is moderately dehydrated, with dry mucous membranes and a heart rate of 145 beats/min. Of the following, the BEST management for this patient's fluid status is:
Oral rehydration therapy at home followed by a diet of fruits, vegetables, and meats
Hospitalization with intravenous fluids and a restrictive bland diet
Hospitalization with intravenous fluids and gut rest for 24 hours
Oral rehydration therapy at home followed by a clear liquid diet for 24 hours
Oral rehydration therapy at home followed by a restrictive bland diet
A worried grandmother brings her 2-year-old grandchild to the emergency department immediately upon finding the boy with an open bottle of 81-mg chewable aspirin (which is used by the grandfather for coronary artery disease prophylaxis). She is unsure of the number of tablets in the bottle prior to ingestion, but the original number was 30, and there are now three remaining. The child has vomited once and is fussy and lethargic. Physical evaluation reveals a 12-kg child who has tachypnea and tachycardia. Laboratory results include a pH of7.45, carbon dioxide of 25 mEq/L (25 mmol!L), and bicarbonate of 18 mEq/L (18 mmol/L). A salicylate measurement result is pending. Of the following, the next BEST step in the management of this child is to:
Administer activated charcoal
Administer sodium bicarbonate intravenously
Administer syrup of ipecac
Observe the child clinically in the emergency department
Remeasure the salicylate level in 6 hours
A mother brings her 10-month-old son to the emergency department because he has been vomiting for the past 10 days. The child has not experienced any diarrhea. On physical examination, he is lethargic and has dry mucous membranes, reduced tears, a full anterior fontanelle, and 2-second capillary refill. After a second intravenous bolus of 20 mL/kg of normal saline, the boy extends his arms and legs forcefully for 10 seconds. Of the following, the MOST appropriate next step in the management of this child is administration of:
Intravenous dexamethasone of l mg/kg
Additional intravenous normal saline bolus of 20 mL/kg
Intravenous fosphenytoin bolus at 20 mg/kg phenytoin equi valents over 10 minutes
Intravenous prochlorperazine of 5 mg
Rapid intravenous lorazepam of 0.05 mg/kg
An 18-month-old child has been brought to your urgent care clinic for evaluation. He and his mother are in town visiting his grandmother. His mother tells you that she found him playing with an open bottle of his grandmother's medication. On physical examination, he is sleepy but arousable, pale, mildly diaphoretic, and afebrile. His respiratory rate is 20 breaths/min, heart rate is 60 beats/min, and blood pressure is 65/40 mm Hg. His lungs are clear, there are no murmurs, and his pulses are weak. Of the following, the MOST likely cause for this patient's presentation is ingestion of
Beta blocker
Captoptil
Hydralazine
Pseudoephedrine
Tricyclic antidepressant
A 7-year-old girl presents to your clinic with a 2- to 3-day history of a nonproductive cough, malaise, and temperature to 101 °F (38.3°C). On physical examination, you note that the girl does not appear ill and are surprised to hear widespread crackles in the lungs bilaterally. Chest radiography demonstrates bilateral diffuse infiltrates. Of the following, the MOST appropriate antimicrobial agent to treat this girl's infection is:
Azithromycin
Amoxicillin
Doxycycline
Levofloxacin
Trimethoprim-sulfamethoxazole
You are speaking to the mother of a child who attends a junior high school where one of the students was diagnosed with meningococcal disease 24 hours ago. Her child does not have any classes with the index patient and, except for passing him in the hall during lunch 3 days ago, has had no other contact with the patient. The child's mother is frantic because the school sent home a notice asking parents to bring their children to the public health department or their private physician to receive antibiotic prophylaxis. Of the following, the MOST appropriate advice for this parent is that her child:
Does not require anti biotic prophylaxis and does not need to be seen
Does not require antibiotic prophylaxis but needs to be evaluated to determine if she is developing symptoms of meningococcal disease
Needs to be seen to obtain nasopharyngeal cultures for meningococcal organisms and if the cultures are positive, may require antibiotic prophylaxis
Requires antibiotic prophylaxis and should be seen immediately
Should be seen immediately to detennine if she needs to be hospitalized and treated for possible meningococcal disease
An 18-year-old boy presents to the emergency department 30 minutes after eating at a seafood restaurant. He states that approximately 10 minutes into his meal he developed generalized hives, pruritus, and difficulty breathing. He has a history of shellfish food allergy, although he had ordered steak and denies eating any crab, lobster, or shrimp. On physical examination, the patient appears to have labored breathing, audible wheezing, and diffuse raised erythematous lesions (Item Q15A) on his trunk and extremities. His vital signs include a temperature of 98.5°F (37°C), heart rate of 100 beats/min, respiratory rate of 22 breaths/min, blood pressure of 110/60 mm Hg, and pulse oximetry of92% on room air. Of the following, the MOST appropriate immediate action is:
Adminisu·ation of inu·amuscular epinephrine
Administration of I 00% oxygen
Adminisu·ation of 1 L intravenous normal saline
Administration of beta-2 agonist nebulization
Observation
A 3-year-old child is rushed to the emergency department after the mother found her with an open and empty bottle of acetaminophen. The mother has no idea how many tablets were in the bottle. She estimates that no more than 1 hour has passed since the child ingested the tablets. The child began to vomit during the trip to the emergency department, and has vomited three times more since her arrival. The child is awake and alert but clearly unhappy, crying even in her mother's arms. She appears pale and diaphoretic. Her heart rate is 110 beats/min, respiratory rate is 26 breaths/min, temperature is 98.6°F (37°C), and blood pressure is 90/60 mm Hg. Of the following, the MOST appropriate statement about acetaminophen toxicity is that:
An antidote is available, but its use can be defen·ed until further information is gathered
Given the short duration since the ingestion, it will be helpful to administer syrup of ipecac
Multiple episodes of vomiting indicate that irreversible liver damage already has occurred
The administration of activated charcoal is contraindicated in acetaminophen toxicity
The contents of one bottle of acetaminophen are not s ufficient to cause life-threatening toxicity in a child
The pediatric resident at the emergency department notifies you that one of your patients, an 18- month-old boy, has been admitted to the hospital for observation after being found with an open bottle of lemon-scented furniture polish. On arrival at the emergency department, the child had lemon-scented polish on his clothing, and his breath smelled of the substance. His mother stated that he had vomited once, but there has been no choking, gagging, or coughing since the ingestion. Of the following, the MOST appropriate management includes:
Observation for 6 hours for signs of disu·ess
Administration of activated charcoal
Consultation for urgent bronchoscopy
Gastric lavage
Serial chest radiographs
A female infant is born with unilateral cleft lip and palate. Findings on the remainder of the physical examination are normal, and you inform the parents that this apparently is an isolated birth defect. During counseling of the family about their risk for having another similarly affected child, the statement that you are MOST likely to include is tha
Cleft lip with/without cleft palate is a multifactori al u·ait that has a 4% risk of recurrence
Because the defect is isolated, their risk is no greater than that of any other couple
The recurrence risk can be estimated only after a chromosome analysis has been obtained
The risk is increased for future females, but not males
The risk is increased only if one of the paTents had cleft lip with/without cleft palate
A 16-year-old boy is brought to your office by his parents because he wants medicine to help him grow and develop muscles. He has been working out for 1 year without much effect. On physical examination, his height is 63 in (adjusted mid-parental height, 73 in), he weighs 106lb, and he has testes that are 8 mL in volume. He appears healthy but very young. His father says that he was very small as a boy but was given three injections of growth hormone when he was 16 and grew to his present height of 71 in during late high school and college. Laboratory test results for the boy are normal, including a complete blood count, erythrocyte sedimentation rate, electrolytes, blood urea nitrogen, creatinine, prolactin, insulin-like growth factor-1, tissue transglutaminase antibody, quantitative immunoglobulin A, free thyroxine, and thyroidstimulating hormone. A bone age radiograph is reported to resemble that of a 13-year-old. Of the following, your BEST approach is to
Counsel that thjs is delayed puberty and that he wiU grow over the next few years
Obtain brain magnetic resonance imaging and refer the boy to an endocrinologist for growth hormone studies
Offer an endocrinologic referral for a 1- to 2-year course of growth hormone therapy
Offer an endocrinologic referral for a 1- to 2-year course of testosterone therapy
Suggest that rugh-calorie food supplements be taken daily to enhance growth
A 9-year-old girl develops daily daytime enuresis for 3 weeks. You notice her sitting in a chair in your office waiting room with her legs crossed and squirming. About 20 minutes later, upon entering the examination room, she runs to the bathroom to urinate. You are able to obtain a urine sample, and results of analysis are normal. Her vital signs and findings on history and physical examination are all unremarkable. Of the following, the MOST appropriate next step in her management is to
Design a voiding routine
Consult a urologist
Lirrut njghttime flu ids
Obtai n renal ul trasonography
Prescribe oxybutynin
A 7-month-old male infant adopted from a Somalian orphanage has been in the United States for 3 weeks. Ten days after arrival, the infant is hospitalized with a fever to 104°F (40°C), increased irritability, and decreased oral intake and activity. Results of a blood culture are positive for Haemophilus influenzae type b. Since arriving in the United States, he has been attending the home child care that his adoptive mother operates, which includes six other children between 12 and 18 months of age, each of whom has been fully immunized. Of the following, the MOST appropriate recommendation for chemoprophylaxis for child care attendees and staff is
No prophylaxjs for attendees and supervisory personnel
ProphyJaxjs for all attendees
Prophylaxis for all attendees and supervisory personnel
Prophylaxis only for attendees between 12 and 15 months of age
Prophylaxis only for supervisory personnel
You are performing a presedation physical examination in a 3-year-old female who is scheduled to have a repeat computed tomography (CT) scan with contrast. The mother mentions that her daughter experienced diffuse hives and facial swelling 10 minutes after the contrast administration during her first CT. Of the following, the BEST way to prevent future contrast reactions is to:
Provide pretreatment with oral antihistamines and steroids
Administer 1 L intravenous normal saline prior to the procedure
Perform desensitization to contrast
Use a high-osmolar contrast agent
Use a contrast agent with low iodine content
A 16-year-old Caucasian girl from the northeastern United States presents for a health supervision visit. She drinks three to four diet sodas a day and describes herself as "a couch potato.'' She has a history of asthma and had been hospitalized for administration of intravenous methylprednisolone twice in the past year. Physical examination findings are normal. She is at Sexual Maturity Rating 4 and has had normal menses for 3 years. A year ago, she fell while walking and fractured her ulna. You are considering therapy for suspected osteopenia. Of the following, the MOST appropriate therapy for this patient at this time is
Oral calcium and vitamin D supplement
Intranasal calcitonin
Oral alendronate
Oral estrogen
Oral phosphorus supplement
A term male infant is born to a woman who has known multiple drug abuse problems. Her urine drug screen was positive for barbiturates, benzodiazepines, and opioids upon admission to the labor and delivery unit. The infant is delivered vaginally without complications. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. His birth weight is 3,500 g. You are asked to evaluate the infant for early discharge at 23 hours of age. Findings on physical examination are normal, with the exception of jitteriness, and the infant is not breastfeeding well. Of the following, the BEST reason to keep this infant in the hospital is that
Neonatal abstinence syndrome may not be fully evident for 5 days or more
A negative urine drug screen for the infant is required
Breastfeeding fai lure requires a lactation consultation
Foster care placement must be arranged
Jitteriness is most likely due to hypoglycemia that requires treatment
A 15-month-old boy presents to the emergency department following the acute onset of nausea, vomiting, and abdominal pain. He appears agitated. His heart rate is 160 beats/min, but other vital signs are normal. His mother, who has asthma, reports fmding her theophylline bottle lying empty on the floor in her bedroom. His capillary blood gas measurement is normal, and his blood glucose concentration is 190 mg/dL (10.5 mmoVL). Of the following, the MOST appropriate management of this patient is
Administration of activated charcoal
Administration of beta-adrenergic receptor antagonists
Administration of ipecac
Gasttic lavage
Whole-bowel irrigation
Upon entering your examination room, you fmd a father who is visibly upset. He has brought his 1-month-old and 2-year-old daughters to see you today because his wife was recently diagnosed with tuberculosis. As you question him further, he tells you that his wife's physician told him that his wife's chest radiograph was abnormal and she was "smear-positive." He hands you results from the health department stating that he and his daughters all had negative skin tests and chest radiographs. His wife is at the health department today to start medicines against tuberculosis, and he wants to know if there is anything that should be done for the children. Of the following, the MOST appropriate treatment is to
Begin isoniazid therapy
Administer the bacille Calmette-Guerin vaccine
Provide reassurance
Remove the children from the home for 3 months
Repeat the skin test in 1 month
A 2,700-g male infant born at 36 weeks' gestation is being treated for suspected neonatal sepsis following the development of respiratory distress shortly after birth. His mother had a fever to 102°F (38.9°C) during labor and delivery but reports that she had no illnesses during pregnancy. Of the following, the MOST appropriate antibiotic regimen for this infant is
Ampicillin and an aminoglycoside
Clindamycin and a third-generation cephalosporin
Meropenem and an aminoglycoside
Piperacillin and an aminoglycoside
Vancomycin and a third-generation cephalosporin
You are notified by the newborn screening program that a 2-week-old infant in your practice has an elevated phenylalanine level, which is confirmed by repeat testing. The mother reports that the baby is healthy and breastfeeding well. Of the following, the MOST important first step in management of this infant is to
Consult with a metabolic geneticist or nuttitionist
Admit the baby to the hospital for further evaluation
Instruct the mother that she no longer should breastfeed
Place the baby immediately on phenylalanine-free formula
Send urine for organic acid analysis
A 10-year-old child is brought to your office for evaluation of a 1-day history of fever, vomiting, diarrhea, and abdominal pain. His mother states that he has vomited five times, and the emesis has been clear. He has had four episodes of non bloody diarrhea. He describes his abdominal pain as crampy but cannot localize it to any specific part of his abdomen. He denies any symptoms of dysuria. On physical examination, the child is in no acute distress, his temperature is 99.2°F (37.3°C), heart rate is 102 beats/min, respiratory rate is 26 breaths/min, and blood pressure is 105/70 mm Hg. Results of examination of the head, neck, chest, and heart are normal. His abdomen is soft, and there is no guarding. There is no rebound tenderness. He complains of mild discomfort on deep palpation of his entire abdomen. He has hyperactive bowel sounds on auscultation, and he has no flank tenderness. Of the following, the MOST appropriate next step in the management of this patient is to
Send the patient home with instructions for supportive care
Administer intravenous fluids
Obtain blood for a complete blood count
Obtain serum for electrolyte analysis
Order frontal supine and upright abdomen radiographs
A 12-year-old girl presents with her third headache in the last 2 months. She describes the pain as pounding, sharp, and severe. The pain is bifrontal and has been present for 1 hour. Past history is notable for motion sickness at age 4 years. Physical examination results are normal, but the girl draws a picture of dots when asked if she sees anything prior to pain. Of the following, the MOST appropriate treatment for this child is
Oral ibuprofen
Intramuscular mepetidine
Intranasal butorphanol
Oral zolmitriptan
Subcutaneous sumatriptan
A 2-year-old boy presents with a history of vomiting and diarrhea for several days. Physical examination reveals lethargy, poor oral intake, tachycardia, dry mucous membranes, and poor skin turgor. He refuses to take oral fluids, so you decide to begin intravenous fluid administration. Of the following, the BEST next step in fluid management is to
Administer a bolus of isotonic fluid at 20 mL/kg
Administer a bolus of hypotonic fluids at 20 mL/kg
Administer a bolus of 3% saline at 10 mL/kg
Administer 5% dextrose and 0.25 normal saline with 20 mEg potassium chloride at maintenance rate
Await laboratory results before starting fluid therapy
A 12-year-old boy presents to his GP with left-sided unilateral breast development stage III. He is very upset as he is being bullied at school. His mother is worried as her friend's sister has just been diagnosed with breast cancer and wants to know if he could have breast cancer? What is the management?
Reassure and explain this is a normal part of puberty; it will resolve but the other breast may enlarge transiently as well
Refer for a breast ultrasound
Test sex hormone levels
Test alpha fetoprotein
Do a fine needle aspirate on his left breast
A mother comes to see you with her 2-year-old daughter, Stacey, out of frustration that her daughter is so ill behaved. She does not know how to make her listen and is worried that she is going to get hurt. Yesterday she ran ahead and did not stop when her mother called to her. She ran into the street and was hit by a cyclist, but fortunately he was OK and Stacey had only had a few cuts and scrapes and seems alright! On questioning you hear other stories of a naughty child. She is active and eats weiJ, feeding herself a lot now, but her mother does say she gets frequent coughs and colds. Her mother says that Stacey only says about 5-10 words and only she can understand what Stacey says. What is the best next management?
Refer for a hearing test
Ask the health visitor to visit mum for parenting advice and support
Order blood tests for full blood count to check for leukaemia as she has recurrent coughs and colds
Give Stacey a tetanus shot to cover her after her fall the day before
Tell Stacey that she needs to listen to her mother and not have any more accidents
An older mother books in to see you after attending the health visitor for a weight check at 2 months for her first child. She and her husband have had a hard time coming to terms with their daughter's diagnosis of Down's syndrome. She is relieved that the appointment with the cardiologists went well and the heart is normal. However they have a lot of trouble getting her to take the whole bottle, she was slow to regain her birth weight and looking at the plotted weight yesterday she is not growing along her birth centile and the mother is worried she is not doing a good enough job. She is not vomiting except for small possets after feeds, is passing urine and opening her bowels. The red book growth chart shows the weight to be falling off centiles. What is the most appropriate management?
Replace the growth chart in their red book with a Down's syndrome growth chart, reassure mum by re-plotting her growth and explain she is normal but arrange to review again
Contact the cardiologists in light of the poor feeding and slow weight gain for a second opinion as baby's with Down's syndrome are at high risk of heart problems and they may have missed it
Refer to the dietician for nuttitional support
Tell the mother to try a different milk and come back in 2 weeks
Advise the mother to change to a faster flow teat for their bottles so that she takes her feed faster
A 4-year-old child has been losing weight recently and has been vomiting for the past 24 hours, unable to eat anything. His mother has brought him into accident and emergency out of concern as he seems confused. The triage nurse has taken him to the resuscitation room and asked for your help. On examination he is drowsy, has a heart rate of 150, respiratory rate of 60 and a central capillary refill of 5 seconds. He has subcostal recessions and good air entry bilaterally with no added sounds. He moans when you examine his abdomen but there are no masses. You put in a canula and take bloods. The venous blood gas shows: pH 7.12, PC02 2.3 kPa, P02 6.7 kPa, HC03-15.3 mmoVL, BE -8.6, Glucose 32.4 mmoVL. What is the most likely diagnosis and what is the first management step?
Diabetic ketoacidosis, give a fluid bolus
Diabetic ketoacidosis, start an insulin infusion
Pneumonia, start IV co-amoxiclav
Ruptured appendix, give a fluid bolus and book the emergency operating theatre
Gastroenteritis with severe dehydration, give a fluid bolus
The accident and emergency triage nurse asks you to look at a 3-year-old child with a short history of waking up this morning unwell with a cough and fever. She looks unwell, heart rate is 165, respiratory rate 56, saturations of 96 per cent in air, temperature of 39.3°C and central capillary refill of 4 seconds. She has a mild headache but no photophobia or neck stiffness and you notice a faint macular rash on her torso and wonder if one spot is non-blanching. You ask the triage nurse to move her to the resuscitation area and call your senior to review her. Fifteen minutes later your senior arrives and the spot you saw on the abdomen is now non-blanching and there is another spot on her knee. What are the three most important things to give her immediately?
High flow oxygen, IV fluid bolus, IV ceftriaxone
IV fluid bolus, IV ceftriaxone, IV methylprednisolone
High flow oxygen, IV ceftriaxone, IV fresh frozen plasma
IV fluid bolus, IV ceftriaxone, IV fresh frozen plasma
High flow oxygen, IV ceftriaxone, IV methylprednisolone
A 13 month old is brought in having had a blue floppy episode at home lasting 1 minute. While you are taking a history from the mother, you notice the baby has gone blue again and seems to be unconscious in her arms. You call for help and place the baby on the examination table. There is no obvious work of breathing. The nurses bring the crash trolley and give you a bag valve mask, which they are connecting to the oxygen. You give two inflation breaths but do not see the chest rise. You reposition the air way and this time the breaths go in. You feel for a pulse and there is none. When asked to do CPR the nurse asks for direction on how many breaths and compressions you both need to do.
Two inflation breaths per 15 compressions
Two inflation breaths per 30 compressions
Continuous inflation breaths about 10- 12 per minute and compressions 100-120 per minute
One inflation breath per five compressions
Two inflation breaths per five compressions
A 10-year-old child is brought in by ambulance with seizure activity. His mother reports it starting 30 minutes ago in his right arm and quickly became generalized tonic clonic jerking. She gave him his buccal midazolam after the first 5 minutes and called an ambulance when he did not respond after another 5 minutes. The ambulance crew gave him rectal diazepam on arrival at 15 minutes into the seizure. He is receiving high flow oxygen via a face mask and continues to convulse. The mother tells you that he was weaned from his long-term seizure medication, phenytoin, 2 weeks ago and that he has had a cold for the past 2 days. What is the next step in management?
Gain intravenous or intraosseous access and start a phenytoin infusion
Gain intravenous or intraosseous access and administer lorazepam
Gain intravenous or intraosseous access and administer ceftri axone
Repeat the rectal diazepam
Gain intravenous or intraosseous access and start a phenobarbital infusion
A 3-year-old boy is brought in by ambulance fitting. You are assigned to get the history from the father. Harry is normally fit and well with no significant past medical history or allergies. He is up to date with his immunizations and has been growing and developing normally. His behaviour has been difficult for the past 2 weeks since the birth of his little sister. Mum has been unwell as she developed HELLP syndrome and was in hospital for a week following the delivery. Yesterday, he was quite unwell with a tummy bug, vomiting and had black diarrhoea. That evening they found a mess he had made in the bathroom with all of his mum's things strewn over the floor including her tablets from the hospital. By that time, Harry was getting better so they did not think anything of it. Today he has been acting strangely and has been difficult to understand, he then became lethargic at about 4 pm and started fitting 15 minutes ago. What is the most likely diagnosis?
Iron overdose
Paracetamol overdose
Aspili n overdose
Tricyclic antidepressant overdose
Bleach intoxication
A 6-year-old boy with a history of asthma and eczema is brought in to accident and emergency from a local restaurant. He is on high flow facial oxygen with significant facial oedema and generalized erythema. On auscultation there is widespread wheeze for which the ambulance crew gave a salbutamol nebulizer. What is the next step in management?
Give intramuscular 1:1000 adrenaline, 250 !lg
Insert an IV line and give lO mg slow intravenous antihistamine
Insert an IV line and give 100 mg slow intravenous hydrocortisone
Insert an IV line and give 200 Jlg of 1: 10 000 intravenous adrenaline
Repeat the salbutamol nebulizer and call for an anesthetist for intubation
A pregnant woman seeks advice from you regarding her condition and its impact on the pregnancy and risk to the baby. She has phenylketonuria (PKU) and has been on a phenylalanine-free diet for life. She was told that it was very important during her pregnancy to be compliant with this diet. She would like to know how the baby will be tested for the condition as she is aware that is an inherited condition. What is the initial investigation you will advise?
Newborn blood spot screening
Serum tyrosine levels
Genetic screening
Serum phenylalanine levels
Urine phenylketones
You are asked to see a 3-day-old baby on the post-natal ward. The baby was born at term and is the first child of consanguineous parents. The baby is drowsy and vomiting, with no fever, rash or diarrhoea. On examination, the baby is noted to have ambiguous genitalia. You do some blood tests: white cell count 5 x 109/L, C-reactive protein 2 mg!L, Na+ 125 mmoVL, K+ 8 mmoVL, glucose 1.7 mmoVL. 17-0H level progesterone is low. You make a diagnosis of congenital adrenal hyperplasia. What is the best initial management plan?
IV dextrose and IV hydrocortisone
IV hydrocorti sone
IV dextrose
IV 0.9 per cent saline
IV 3 per cent saline and IV hydrocortisone
A preterm baby is now 25 + 7 weeks corrected gestation. He is on the neonatal unit being cared for while his mother recovers on ITU after he was born secondary to an eclamptic seizure. He has been receiving formula milk as the parents have not consented to donor breast milk. He has been having bilious aspirates from his nasogastric tube and today his abdomen in very distended and tense. He has had one episode of bloody stools. You are going to treat him for nectrotizing enterocolitis (NEC). What is the best initial management plan?
NBM, IV fluids, abdominal X-ray and surgical review
Conservative management, observe and reassess
Nil by mouth (NBM), IV antibiotics and emergency exploratory laparotomy
IV fluids, emergency laparotomy and bowel resection
IV fluids and IV antibiotics
You are on elective in Uganda and spending the day on the paediatric ward. You are told that it is the rainy season and malaria is now becoming increasingly problematic. Almost all the children on the ward are suffering with the effects of malaria. The first child is a 5-year-old boy with a cyclical fever, abdominal pain and a 4cm splenomegaly. He has 2 per cent parasitaemia on blood film. You are asked how you would treat this child. What is the best initial management step?
IV fluids and IV quinine
IM quinine
IV fluids and prophylactic splenectomy
Emergency splenectomy
Oral atovaquone
You have been treating a 2-year-old girl for pneumococcal meningitis for the past 5 days. Of the following, the MOST likely complication of her disease is
Hearing impairment
Brain abscess
Cerebral infarct
Cranial nerve palsy
Sagittal sinus thrombosis
A frail 6-year-old child who has cystic fibrosis is transported by ambulance to the emergency department. She has had hemoptysis for the past 4 hours, yielding approximately 10 mL of bright red blood. She has had increased cough over the past 3 days. Physical examination fmdings include a respiratory rate of 38 breaths/min, heart rate of 90 beats/min, oxygen saturation of 92% on room air, blood pressure of 100/70 mm Hg, and temperature of 98.6°F (37°C). She is awake and alert but seems breathless when she tries to speak. On auscultation, you note diffuse crackles throughout her lung fields. Of the following, the BEST next step in the management of this patient is to
Obtain blood for determination of prothrombin and partial thromboplastin time
Administer methylprednisolone
Begin therapy with ceftriaxone
Insert an endotracheal tube and begin positive pressure ventilation
Transfuse with 0-negative blood
A 1-month-old infant was born with an extensive erythematous patch on the right side of his face that has grown at a rate matching his somatic growth. Of the following, the child is at GREATEST risk for
Glaucoma
Congestive herut failure
Consumptive coagulopathy
Ocular axis occlusion
Tethered spinal cord
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