Ex pediadtric Para clinic 57 qcm

1. You are evaluating a 15-year-old boy in your office. He tells you that he experiences chest pain at times while at home and at school. He describes it as sharp, located in the left chest, exacerbated by deep breathing, and resolving spontaneously.He does not feel palpitations or lightheadedness and has not had syncope. His 54-year-old father and grandfather both have had hypertension and myocardial infarctions.At this time, he has no pain, and results of physical examination are normal. Of the following, the MOST appropriate approach for this patient at this time is

2. A 5-year-old girl presents with a foul-smelling vaginal discharge of 2 weeks' duration. She has a previous history of one urinary tract infection at age 3 years. Of the following, the MOST appropriate next step is

3. You diagnose attention-deficit/hyperactivity disorder in a 10-year-old girl. She is growing well, and physical examination findings are normal. Of the following, the MOST appropriate test to confirm the diagnosis is

4. You are evaluating a 7-year-old boy for hematuria and proteinuria. As part of the evaluation, you measure serum electrolytes.The serum creatinine is 1.1mg/dL (97.2 mcmol/L). Of the following, the MOST accurate serum creatinine measurements for children of normal physical development are (All measurements mg/dL [mcmol/L])

5. A medical student who is rotating in your clinic has just evaluated a 12-month-old girl who presented with a history of recurrent bacterial and viral infections. As part of your discussion with the medical student, you review the different aspects of the immune system and the evaluation of the infant's host defense. Of the following, the test that is the BEST measure of cell-mediated immunity is

6. A 14-year-old overweight girl developed an episode of abdominal pain and jaundice 1week ago. At that time, total bilirubin measured 8 mg/dL (136.8 mcmol/L) and direct bilirubin measured 5 mg/dL (85.5 mcmol/L). She was admitted to the hospital, where ultrasonography demonstrated a dilated common bile duct and gallbladder stones. She underwent endoscopic retrograde cholangiopancreatography (ERCP), and a gallstone was extracted from her common bile duct. She presents to your office today for follow-up and is asymptomatic. Physical examination demonstrates a normal-size liver and spleen without tenderness. Repeat laboratory studies reveal a total bilirubin of 2.5 mg/dL (42.8 mcmol/L) and direct bilirubin of 1.5 mg/dL (25.7 mcmol/L). Transaminase measurements are normal. Of the following, the MOST appropriate next step is to

7. A 4-year-old girl presents to the emergency department with a 3-day history of left-sided weakness. On physical examination, she has a temperature of 99°F (37.2°C), pulse of 50 beats/min, respiratory rate of 24 breaths/min, and blood pressure of 118/78 mm Hg. She cannot abduct her right eye, but has normal funduscopic examination results. Strength on the left is 4/5 in the upper and lower extremity and on the right is normal. Of the following, the MOST appropriate next step in the evaluation of this child is

8. A 16-year-old girl who was treated successfully for leukemia that presented as a mediastinal mass at 2 years of age comes to your office complaining of a "lump" inher neck of 3 weeks' duration. On physical examination, you note a firm, hard, fixed mass that seems to be part of the left lobe of the thyroid and scattered shotty lymphadenopathy on the left. Of the following, the MOST informative laboratory study for this patient is

9. You have been the primary practitioner for a 15-year-old girl since she was 3 years old.She never has been hospitalized , and her history, vital signs, and physical examination findings on this health supervision visit are normal. At each of the past two yearly visits, urinalysis revealed no abnormalities except 2+ protein. Her urinalysis today again reveals 2+ protein with no other abnormalities. Her complete blood count, measurements of serum electrolytes and serum complements, and antinuclear antibody test results are all normal. Two successive 24-hour urine collections reveal 321 and 387 mg protein. You now refer the girl to a pediatric nephrologist. Of the following, the MOST important next step for the pediatric nephrologist is to

10. A 10-year-old boy presents with a 2-day history of a temperature to 102.5°F (39.2°C) and a maculopapular rash that began on his trunk and now has spread to his extremities and back. Several of the lesions appear to be vesicles, and he is starting to develop new lesions on his face. Of the following, the MOST rapid method to confirm the cause of this patient's infection is

11. A 10-year-old girl presents with progressive fatigue without pain.Physical examination reveals edema and a pink-to-violet discoloration of the upper eyelids and malar areas. Scaly, red papules are observed over the knuckles.Of the following, the MOST appropriate laboratory investigation to support the diagnosis is

12. A 4-week-old boy has been vomiting all of his feedings for the last 2 days.His mother reports decreased urine output but no fever. On physical examination, he is alert, appears hungry, and is moderately dehydrated. Abdominal examination reveals a small mass in the epigastrium. When he is offered a bottle, he takes it vigorously and then vomits forcefully. You order laboratory tests.Of the following, the MOST likely abnormality to expect is

13. A 7-year-old girl presents with a 4-week history of an erythematous rash that involves the eyelids and malar areas and now has occurred at the elbows and knees.Her mother reports that the girl has had a poor appetite, low-grade fevers, muscle aches, and weakness during the past week. Physical examination confirms the rash (Item Q102A). She has difficulty rising from a chair. Other findings on her physical examination are normal. Serum creatine kinase is 677 U/L. Of the following, the test MOST likely to lead to this child's diagnosis is

14. The pregnant mother of a 3-year-old girl in your practice is concerned because her obstetrician just told her that her serum aJpha-fetoprotein value is markedly increased. Of the following, the MOST appropriate advice to give to this woman is that she should consider

15. The parents of a 4-month-old bring the boy to you because of failure to thrive. The baby was born after a term gestation, and there were no complications at delivery. The mother reports that he has a weak suck, and his body seems limp. On physical examination, the child's weight is 4.1kg, length is 52 cm, and occipitofrontal circumference is 40.5 cm. His penis appears small for age, and the child exhibits diffuse hypotonia. Deep tendon reflexes are normal. Other findings on the physical examination are normal. Of the following, the test MOST likely to establish this child's diagnosis is

16. A 42-year-old primigravida is in her 16th week of pregnancy. She is concerned about the possibility of her child having myelomeningocele. Of the following, the MOST useful diagnostic evaluation is

17. A mother brings her 14-year-old son to your office complaining that she can never get him to clean his neck and asks you to talk with him. You note that he is overweight, with a body mass index of 32 mg/m2, and he has a Sexual Maturity Rating 3 for pubic hair, with testes that are about 10 mL.He has velvety dark pigmentation (Item Q122A) on the back of his neck and under his arms. On laboratory testing, the boy is most likely to have

18. A father brings in his 6-year-old boy who has chronic constipation because the child now has developed enuresis during both night and day. On physical examination, you discern a small, firm sacral dimple just to the right of the gluteal cleft.The remainder of the physical examination findings are normal. Of the following, the MOST appropriate next step in the evaluation of this child is

19. A 15-year-old previously healthy girl had an episode of syncope in gym class. She awoke after 1 minute and was taken to the emergency department where physical examination findings were normal. Of the following, the BEST assessment of the electrocardiographic result is

20. During the health supervision visit for a 1-month-old infant, you note mild jaundice, but no fever and clear lungs. Cardiac examination demonstrates a 2/6 systolic murmur at the left sternal border. Abdominal examination demonstrates a firm liver 3 cm below the costaJ margin and extending past the midline. The alanine aminotransferase is 140 U/L, aspartate aminotransferase is 130 U/L, total bilirubin is 5.5 mg/dL (94.1mcmol/L),and direct bilirubin is 3.0 mg/dL (51.3 mcmol/L). Of the following, the finding that MOST strongly suggests the need for referral to a surgeon for intraoperative cholangiography is

21. You are evaluating a very low-birthweight (VLBW) preterm infant who experienced polyuria in the first 72 hours after birth. No diuretics have been prescribed, and there is no glycosuria, hematuria , or obvious anasarca on examination. You collect a urine sample to measure electrolytes and creatinine and simultaneously obtain a blood sample to measure serum electrolytes and creatinine. Of the following, the MOST correct statement regarding sodium handling in the VLBW infant is that

22. You care for a 17-year-old boy who is overweight. He has gained 44 lb (20 kg) in the last year, especially in his abdominal area. On examination today, his blood pressure is 158/90 mm Hg using a large, appropriately sized cuff. His mother has a similar body habitus and is being treated for type 2 diabetes mellitus.Of the following, the MOST likely abnormalities to expect in this patient if his present condition continues into adulthood is

23. A newborn female has loose neck skin and nonpitting edema of the lower extremities.Of the following, the MOST appropriate evaluation for this infant is

24. A 16-year-old boy presents for his annual sports physical before wrestling season. He has been participating in a weight lifting program and proudly reports his increased muscle mass and strength. You are concerned that he may be using performance-enhancing substances (eg, creatine). Of the following, the use of creatine is MOST likely to be revealed by

25. A 15-year-old boy was camping with friends 1week ago. Over the last 4 days, he has developed fever, worsening headache, increasing sleepiness, and combativeness.You suspect arboviral meningoencephalitis .Of the following, the MOST frequently used method to confirm the diagnosis is

26. An 18-year-old girl who has asthma presents for an annual evaluation. She states that she has had asthma for the past 6 years. Her symptoms include cough, wheezing,and chest tightness, primarily triggered by upper respiratory tract infections, strenuous exercise, and pollen exposure.She never has been hospitalized for her asthma, but she had to visit the emergency department 2 years ago for an exacerbation. After reviewing her symptom frequency, medication use, and metered-dose inhaler technique, she performs a pulmonary function test. The prebronchodilator FEVl is 74% of expected and the FEVl /FVC is 79% of expected. Of the following, the BEST characterization of her asthma severity, based on results of her pulmonary function test, is

27. A 15-year-old girl is admitted to your facility with severe anorexia nervosa and amenorrhea. She weighs 35 kg and is 160 cm tall.She has bradycardia and orthostatic hypotension.You plan to stabilize her medically and begin nasogastric tube feeding.Of the following, the electrolyte abnormality that is MOST likely to occur during the first week of her treatment is

28. You are evaluating a 13-year-old boy who has a body mass index of 32 kg/m2 and a blood pressure of 140/80 mm Hg. Initial laboratory studies reveal fasting serum triglyceride levels of 180 mg/dL (2.0 mmol/L) (normal, 40 to 100 mg/dL [0.45 to 1.1mmol/L]). You diagnose metabolic syndrome.Of the following, the MOST appropriate evaluation in addition to fasting blood glucose is

29. A 16-month-old girl presents with the acute onset of difficulty breathing after attending a birthday party. She is in moderate distress, with a respiratory rate of 56 breaths/min. She has slightly diminished breath sounds on the right.You suspect foreign body aspiration. A plain anteroposterior chest radiograph appears normal. Of the following, the MOST appropriate radiographic study to confirm your suspicion of foreign body aspiration in this girl is

30. You are seeing a 10-year-old boy and his 13-year-old sister for the first time. When you review the medical records provided by their mother,you find normal medical histories, vital signs, and physical examination results for the children. However, the family history indicates that two of the children's uncles are receiving hemodialysis and are deaf and one grandfather died of kidney disease. You obtain a screening urinalysis (UA) in both children. The boy's UA reveals moderate blood, negative protein, and 20 to 30 red blood cells/high-power field (RBC/hpO; the girl's UA reveals trace blood with 5 to 10 RBC/hpf. Of the following, the MOST accurate statement regarding the prognosis for these children is that

31. You are called to evaluate a male infant at 50 hours of age because he has not voided. He was born at term and has breastfed poorly, but has passed stool. He appears uncomfortable on physical examination, with a large abdomen and seemingly palpable bladder. There is no respiratory distress. The external genitalia are normal, and both testes descended. Of the following, the MOST appropriate initial step in this infant's evaluation is

32. You receive a call from a teenage patient, who tells you that she is having palpitations and feels somewhat lightheaded. You refer her to your local emergency department, where no symptoms are discerned and physical examination findings are normal. The emergency department sends a copy of the patient's electrocardiogram by facsimile to your office for you to review. Of the following, the BEST interpretation of the girl's electrocardiogram is

33. A 14-year-old boy who had a sore throat and fever 2 weeks ago presents to the emergency department still dressed in his football gear from the practice field, where he complained of acute abdominal pain. He exhibits tachypnea, tachycardia, and mild hypotension and complains of intense pain in the left upper quadrant. Of the following, the MOST definitive study to diagnose this child's condition is

34. You are evaluating a 14-year-old boy who has a body mass index of 40 kg/m2. His mother and 25-year-old sister have type 2 diabetes. A fasting blood glucose concentration for the boy is 110 mg/dL (6.1mmol/L). Of the following, the MOST appropriate next step to screen for diabetes is to

35. A 12-month-old male infant presents for an ear re-evaluation 1month after being treated for his fourth episode of otitis media. His parents describe a normal birth history and normal development. The child is breastfed and does not attend child care. His immunizations are up to date through 6 months of age, including three doses of the conjugated pneumococcal vaccine. There is no history of sinusitis, pneumonia,sepsis, meningitis, or urinary tract infections.After the boy's last otitis media infection, your colleague measured the child's serum immunoglobulin (lg) concentrations, and results included a low IgG of 150 mg/dL (1.5 g/L), a normal lgM of 80 mg/dL (0.8 g/L), and a normal IgA of 40 mg/dL (0.4 g/L). Of the following, the next BEST laboratory test to evaluate this infant's antibody function is

36. You are admitting a 35-week gestation newborn to the neonatal intensive care unit for respiratory distress at 4 hours of age. She requires assisted ventilation. The resident working with you asks what test of pulmonary function is preferred in your initial assessment of this newborn. Of the following, the BEST response is

37. A 7-year-old boy comes to your office with complaints of daily bedwetting for 2 months.He was completely toilet trained by 4 years of age and had been dry at night except for occasional (about once per month) minor bedwetting until recently. He denies daytime enuresis, dysuria, frequency, urgency, fever, abdominal pain,or constipation. He has no history of urinary tract infections. His physical examination reveals weight and height at the 75th percentiles and no abnormalities. Of the following, the MOST important next step in this child's evaluation is to obtain:

38. A 17-year-old girl complains of clumsiness over the past 3 days.She has had moderate headaches for 1month and neck discomfort for 3 days. Physical examination reveals rightsided dysmetria and left upper and lower extremity numbness to pinprick and weakness, graded as 4/5.The remainder of her examination results are normal. Of the following, the MOST appropriate evaluation to establish this patient's diagnosis is:

39. You are supervising a pediatric resident in her continuity clinic. She is evaluating a 4-week-old male infant who has had projectile vomiting after feeding for the past week. After reviewing the patient's electrolyte levels, she obtains an electrocardiogram (ECG) and asks you to help interpret it. The ECG reveals flat T waves.Of the following, the MOST likely electrolyte abnormality suggested by the electrocardiographic findings is:

40. A 15-year-old postmenarcheal girl presents with persistent right lower quadrant discomfort of 6 weeks' duration and a feeling of abdominal fullness. Her last menstrual period was 3 weeks ago. Results of a urine pregnancy test are negative, and urinalysis results are normal. Ultrasonography reveals a well-defined right ovarian cyst fiJJed with multiple echoes. Of the following, the BEST next step for the management of this patient is

41. A 16-year-old girl is brought to the emergency department by ambulance after her mother found a suicide note on her bed. The girl claims that she took "20 or 30" ibuprofen tablets 4 hours ago and nothing else. Although she is tearful, her physical examination findings are normal. Of the following, the MOST appropriate next step in the management of this patient is to

42. A nurse asks you to examine a 26-hour-old infant who recently developed a rash. On physical examination, you note erythematous macules over the trunk, face, and proximal extremities. Most of the macules have tiny central pustules.The infant is breastfeeding well, and the remainder of the physical examination findings are normal. No lesions were present at birth.Of the following, analysis of the pustular contents is MOST likely to reveal

43. A 16-year-old girl is being seen in your clinic because of headaches for the past month that sometimes awaken her at night. At her last visit 2 years ago, she was well, 5 ft 2 in tall, and weighed 105 lb, with Sexual Maturity Rating (SMR) 4 breast development and SMR 4 pubic hair, but she had not reached menarche. On examination at this visit, she is 5 ft 2 in tall,weighs 110 lb, and still has not begun menstruating. On evaluation, you note bitemporal visual field deficits, perhaps worse on the left. In addition to magnetic resonance imaging and an ophthalmologic evaluation, the laboratory test that is MOST likely to be most diagnostically revealing is

44. An 8-year-old boy is inattentive at home and school, has difficulty completing his homework, and is failing reading. Physical examination findings are normal, he has friends at school, and the family has been living in their newly built home for the past 3 years. You begin to discuss a diagnosis of attention-deficit/hyperactivity disorder, and his mother asks you what tests you will perform to try to determine the cause of the problem. Of the following, your BEST response is that you will order

45. You are examining a 5-year-old girl who always has had significant daytime wetting and a history of recurrent urinary tract infections. Findings on physical examination are normal except for the presence of a sacral dimple above the gluteal cleft. Her urinalysis reveals a specific gravity of 1.005,pH of 5.5, no blood, no protein, and no white or red blood cells. Magnetic resonance imaging of the spine reveals spinal dysraphlsm. Of the following, the MOST important next step to determine the cause of this child's primary enuresis is to obtain

46. A 1-month-old infant presents with frecklelike macules (Item Q49A) over his face and extremities.The hospital record reveals that he had multiple papules and pustules distributed over his entire body, including palms and soles, at birth. The infant appears to be very healthy and thriving. Of the following, analysis of the pustular contents in the newborn period MOST likely would have revealed

47. A 17-year-old boy who has a 5-year history of Crohn disease comes in with a flare of his illness, characterized by fever, diarrhea, and a 15-lb weight loss.He admits he has "forgotten to take his medicines lately." Physical examination demonstrates a very thin patient who has a perianal fistula.Abdominal computed tomography scan demonstrates thickening of the ileum and ascending colon. You are trying to decide whether to administer enteral nutrition (through a nasogastric tube) or begin parenteral nutrition. Of the following findings associated with Crohn disease, the BEST indication for instituting parenteral nutrition is

48. A 12-month-old boy comes to the emergency department with a 3-day history of intractable vomiting and watery diarrhea. His mother reports decreased urine output for the past 24 hours. His heart rate is 180 beats/min , and his blood pressure is 85/40 mm Hg. He is lethargic but responds to stimulation. His mucous membranes are very dry, his skin turgor is decreased, and his capillary refill is 3 seconds.The remainder of his physical examination findings are unremarkable. Of the following, the laboratory data that are MOST consistent with this patient's clinical presentation are

49. A 4-year-old boy presents to your clinic for a second opinion. He has a 3-week history of diarrhea, abdominal pain, and tenesmus.The parents state that he seems to be getting worse, and nobody has been able to help them despite "a bunch of tests on his poop." His stool output has increased from four to five per day to eight to ten per day during the past week, and he now has a temperature of 102°F (38.9°C). They are starting to see what appears to be blood in the toilet after he goes to the bathroom. According to the parents, the boy was in good health until 1 week after they returned from a fishing trip on the Amazon river. Physical examination reveals a moderately ill-appearing boy who has diffuse abdominal pain. During your examination, he passes a very foul-smelling stool that appears to be a mixture of blood and pus, which you send to the laboratory for analysis. Of the following, the MOST appropriate next test is

50. A 12-year-old girl presents to the emergency department with nausea, vomiting, and abdominal pain of 1month's duration. Physical examination reveals a large, smooth mass encompassing almost the entire lower abdomen. Computed tomography scan confirms a mass, and biopsy documents Burkitt lymphoma.She immediately begins receiving chemotherapy, and 12 hours later she develops the classic electrolyte and urinary findings consistent with tumor lysis syndrome (TLS). Of the following, the laboratory findings MOST consistent with TLS are

51. A 5-year-old girl is brought to accident and emergency with a 24-hour history of vomiting and diarrhoea and now her eyes and skin have gone very yellow.She has been taking oral rehydration salts and is still passing urine. She is normally healthy and there is no family history of jaundice. On examination her heart rate is 130 and respiratory rate is 26.She is alert, warm and well perfused. The chest is clear, heart sounds are normal and the abdomen is soft with a 2cm liver edge. What should the management be?

52. A 5-week-old baby was admitted today to the chiJdren 's ward with bronchiolitis. The nasopharyngeal aspirate identified respiratory syncitial virus.He was saturating to 96 per cent in air this morning and was feeding two-thirds of his usual amount of formula milk. You are asked to review him as his work of breathing is worsening now it is night time. He has nasal flaring, intercostal and subcostal recession, tachypnoea and crepitations and wheeze heard bilaterally. What do you expect his capilJary blood gas to show?

53. Clara is a 14-year-old girl who was diagnosed with muscular dystrophy when she was younger. She now mobilizes in a wheelchair and other co-morbidities include a scoliosis and cardiomyopathy. She is being seen for her annual review in clinic. Which of these would best represent the respiratory complications of muscular dystrophy?

54. A 10-day-old baby boy was brought to accident and emergency with a distended abdomen.On questioning, he was born at term with no antenatal concerns. Until 2 days ago he had been feeding well and not vomiting, he had been wetting nappies, but mother has not witnessed a good urinary stream. On examining the child, you find a mass, dull to percussion, arising out of the pelvis, and he has had no wet nappies for the last day. You suspect he may have posterior urethral valves. Which one test will help to diagnose this underlying condition?

55. An 18-month-old boy presented to the GP with a history of eating soil. He had been in the garden this afternoon as his mother put the washing out. She found him eating the soil and took him straight inside. On examination, he is well and alert but has pale conjunctivae. He is not tachycardic or tachypnoeic. His diet consists of predominantly of breast milk. What is the most likely result of his haemoglobin and haematinics?

56. A 9-year-old girl presents to accident and emergency with fever, vomiting and dysuria. She is wearing a steroid bracelet and has a steroid card stating she is on daily prednisolone for severe asthma and eczema and is therefore at risk of adrenal suppression. She is tachycardic at 140 bpm and you are concerned that her blood pressure is low. Her capillary glucose is 3.0 mmol/L. What is the single most important investigation?

57. A 4-year-old boy was diagnosed with nephrotic syndrome 6 months ago and has required a long course of oral corticosteroids to maintain remission of the condition. He has developed truncal obesity and you are concerned he may be developing Cushing's syndrome. Which of the following is not a complication of Cushing's syndrome?