USMLE Pediatry For Student Diagnostic Pédiatrie P2 190 QCM
201) A 2-year-old patient arrives late to your office with his father and a sign-language translator. They are very apologetic, but the father communicates that he had car trouble at his dialysis center and thus was late picking up the child from day care. The father is concerned about his child’s having intermittent red, bloody-looking urine. A gross inspection of the child’s urine in your office looks normal, but the dipstick demonstrates 3+ blood. Which of the following is the most likely cause of this child’s hematuria?
. Alport syndrome
. Berger nephropathy (IgA nephropathy)
. Idiopathic hypercalciuria
. Membranousglomerulopathy
. Goodpasture syndrome
202) A 2-year-old boy is brought to the clinic by his mother because he is lethargic and not as active as the other kids on their block. He has difficulty walking and getting up, and he always appears tired. His mother thinks that she has a relative with a disorder that causes weakness. On examination, the child is alert but quiet. His calves appear hypertrophied. His reflexes are depressed. When he gets up from the floor, he uses his hands to climb on his legs to assume an upright position. What is the most likely diagnosis of this child?
Myasthenia gravis
Dermatomyositis
Duchenne muscular dystrophy
Polio myelitis
Fragile X syndrome
203) A 2-month-old male infant is rushed to the emergency department by his baby sitter. She says that the baby became unresponsive and blue while feeding. The whole episode lasted 45-60 seconds, but the baby still appears pale. She denies any history of coughing or choking. On examination, the infant appears cyanotic and tachypneic. His blood pressure is 90/60 mm of Hg; his pulse rate is 155/min and regular. On auscultation, a harsh pansystolic murmur is noted at the left sternal border, along with a single S2. Hepatomegaly is noted. Pulse oximetry shows an oxygen saturation of 80%. Based on this history and physical examination, what is the most likely diagnosis?
Truncus arteriosus
Ventricular septal defect
Tetralogy of Fallot
Patent ductus arteriosus
Transposition of great vessels
204) A 13-year-old asymptomatic girl is shown below. She states that the findings demonstrated began more than a year ago. Which of the following is the most likely diagnosis?
. Iodine deficiency
. Congenital hypothyroidism
. Graves’ disease
. Exogenous ingestion of Synthroid
. Lymphocytic (Hashimoto) thyroiditis
205) During a routine well-child examination a 10-year-old girl reports that she has occasional headache, “racing heart,” abdominal pain, and dizziness. Her mother states that she has witnessed one of the episodes, which occurred during an outing at the mall, and reported the child to be pale and to have sweating as well. Other than some hypertension, she has a normal physical examination. Evaluation of this child is most likely to result in which of the following diagnoses?
. Hysterical fainting spells
. Pregnancy
. Diabetesmellitus
. Pheochromocytoma
. Migraine headache
206) A 4-year-old boy presents to the physician with fever and a sore throat. His illness began with rhinorrhea, cough, and congestion one week ago, but in the last 24 hours he has developed fever, a sore throat, and neck pain. His mother also reports that he sounds hoarse. His appetite is decreased and he complains of dysphagia. His temperature is 39.7 C (103.5F), pulse is 100/min, and respiratory rate is 25/min. On examination, the child appears sick. He has cervical lymphadenopathy on the right and decreased range of motion of his neck. His voice is muffled and sounds hoarse. His oropharynx is erythematous and a bulge is noted in the posterior pharyngeal wall. A lateral radiograph of the neck is shown below. Which of the following is the most likely diagnosis?
. Diphtheria
. Viral pharyngitis
. Epiglottitis
. Infectious mononucleosis
. Retropharyngeal abscess
207) A 10-year-old obese child (shown below) has central fat distribution, arrested growth, hypertension, plethora, and osteoporosis. Which of the following disorders is most likely responsible for the clinical picture that this boy presents?
. Bilateral adrenal hyperplasia
. Adrenaladenoma
. Adrenal carcinoma
. Craniopharyngioma
. Ectopic adrenocorticotropin-producing tumor
208) A 6-year-old boy is brought to your practice by his paternal grandmother for his first visit. She has recently received custody of him after his mother entered the penal system in another state; she does not have much information about him. You note that the child is short for his age, has downslanting palpebral fissures, ptosis, low-set and malformed ears, a broad and webbed neck, shield chest, and cryptorchidism. You hear a systolic ejection murmur in the pulmonic region. His grandmother reports that he does well in regular classes, but has been diagnosed with learning disabilities and receives speech therapy for language delay. His constellation of symptoms is suggestive of which of the following?
. Noonan syndrome
. Congenital hypothyroidism
. Turner syndrome
. Congenital rubella
. Down syndrome
209) A 2-week-old infant is noted to be jaundiced. The baby's stools are pale, and his urine darkly colored. Physical examination demonstrates hepatomegaly. Serum studies show elevations of AST, ALT, conjugated bilirubin, and unconjugated bilirubin. By 2 months of age, the baby is notably irritated by pruritus, has retarded growth, and has visible dilated veins in the periumbilical area. Ultrasound fails to demonstrate a gallbladder. Which of the following is the most likely diagnosis?
Alpha-1-antitrypsin deficiency
Biliary atresia
Cystic fibrosis
Hepatitis B
Hepatitis C
210) A mother brings her 7-year-old son to the clinic because, over the past several days, his urine has become pink and bis eyes have looked puffy. About 2 weeks ago, he missed school because of fever and a sore throat. On examination, the boy's blood pressure is 130/85 mm Hg, his eyelids and scrotum appear puffy, and he has 1+ tibial edema. No rashes are noted. Which of the following is the most likely diagnosis?
Acute poststreptococcal glomerulonephritis
Hemolytic-uremic syndrome
Henoch-Schonlein purpura
Nephrotic syndrome
Vesicoureteral reflux
211) The examination of a child’s back is shown below. Evaluation with ultrasound of this lesion may demonstrate which of the following?
. Epsteinpearl
. Mongolian spot
. Cephalohematoma
. Omphalocele
. Occult spina bifida
212) An otherwise healthy 7-year-old child is brought to you to be evaluated because he is the shortest child in his class. Careful measurements of his upper and lower body segments demonstrate normal body proportions for his age. Which of the following disorders of growth should remain in your differential?
. Achondroplasia
. Morquio disease
. Hypothyroidism
. Growth hormone deficiency
. Marfan syndrome
213) A 4-year-old immigrant boy is brought by his mother to a Medical Camp for the Uninsured for the evaluation of his inflamed right eye. He has had a nasal discharge for the past 10 days. His brother has similar symptoms. His vital signs are stable. There are follicles and inflammatory changes in the conjunctiva of his right eye. The cornea shows neovascularization. What is the most likely diagnosis?
. Herpes simplex keratitis
. Orbital cellulitis
. Trachoma
. Gonococcal conjunctivitis
. Viral conjunctivitis
214) A previously healthy 7-year-old child suddenly complains of a headache and falls to the floor. When examined in the emergency room (ER), he is lethargic and has a left central facial weakness and left hemiparesis with conjugate ocular deviation to the right. Which of the following is the most likely diagnosis?
. Hemiplegic migraine
. Supratentorial tumor
. Todd paralysis
. Acute subdural hematoma
. Acute infantile hemiplegia
215) An irritable 6-year-old child has a somewhat unsteady but nonspecific gait. Physical examination reveals a very mild left facial weakness, brisk stretch reflexes in all four extremities, bilateral extensor plantar responses (Babinski reflex), and mild hypertonicity of the left upper and lower extremities; there is no muscular weakness. Which of the following is the most likely diagnosis?
. Pontineglioma
. Cerebellar astrocytoma
. Tumor of the right cerebral hemisphere
. Subacute sclerosing panencephalitis
. Progressive multi focal leukoencephalopathy
216) A previously healthy 4-year-old boy is brought to the physician for evaluation of fever and respiratory distress. The patient developed fever three days ago. Since then, he has had increasing fatigue, irritability, and respiratory distress. His temperature is 100 F (38.2C), pulse is 144/min, respiratory rate is 45/min, and blood pressure is 95/60 mm Hg. On examination, the child appears to be in moderate respiratory distress with tachypnea and subcostal retractions. He is tachycardic with an III/IV holosystolic murmur best heard at the cardiac apex. Peripheral pulses are present and capillary refill is three seconds. His liver is palpated three centimeters below the costal margin. A chest radiograph is shown below. Which of the following is the most likely cause of this patient's symptoms?
Community-acquired pneumonia
Viral hepatitis
Kawasaki disease
Rheumatic fever
Myocarditis
217) A 6-year-old boy presents in clinic for a routine visit. Examination reveals coarse, dark pubic hair, an enlarged penis and testes, and acne of the face and upper back. His mother notes that he has a body odor similar to that of her teenage son after playing sports. The child is in file 99th percentile of height for his age group. Which of the following is the most likely diagnosis?
Congenital adrenal hyperplasia
Hypothalamic tumor
Klinefelter syndrome
Male pseudohermaphroditism
XYY syndrome
218) A 10-year-old girl is brought to a pediatrician because her mother notices that she stumbles frequency at night, even with adequate lighting. Visual field testing demonstrates a relatively narrow mid-peripheral ring scotoma. Ophthalmoscopy demonstrates dark pigmentation in a bone spicule configuration involving the equatorial retina. Additional findings include a waxy yellow appearance to the disk and narrowed retinal arteries. Which of the following is the most likely diagnosis?
Cataract
Central retinal artery occlusion
Retinal detachment
Retinitis pigmentosa
Uveitis
219) A 6-week-old boy is brought to the physician because of a rash involving the diaper area. On examination, there are erythematous, slightly scaly patches covering the buttocks and the lower abdomen. Skin creases appear spared. The baby is otherwise healthy. Physical examination reveals no lymphadenopathy, fever, or other signs of organic illness. Which of the following is the most common cause of this condition?
. Candidiasis
. Irritant contact dermatitis
. Langerhans cell histiocytosis
. Psoriasis
. Seborrheic dermatitis
220) A 3-year-old boy was bitten while teasing a neighborhood cat. On examination, there are two puncture wounds on the right hand and some superficial scratch marks. There is erythema, warmth, and induration around the puncture sites. Which of the following organisms most likely caused the infection?
Pasturella multicoda
Bartonella henselae
Eikenella corrodens
Peptostreptococcus species
Alpha Streptococci
221) A 2-year-old boy has had a purulent drainage from the right nostril for a week. He is afebrile and has had no associated symptoms, such as cough. Which of the following is the most likely diagnosis?
Sinusitis
Nasal polyps
An upper respiratory infection
A foreign body in the right nostril
Allergic rhinitis
222) You are called to examine a male newborn because his first feeding caused him to choke, cough and regurgitate. He was born at term via normal vaginal delivery. On examination, he has excessive salivation, fine, frothy bubbles in the mouth, abdominal distention and rattling breath sounds. Radiographs of the chest and abdomen reveal bilateral atelectasis and gastric distension. Which of the following can best explain the above findings?
Diaphragmatic hernia
Unilateral choanal atresia
Vascular ring
Duodenal atresia
Esophageal atresia
223) A 9-year-old boy is brought to the office by his parents due to headaches, vomiting and visual disturbances. One week ago, he began to experience headaches that were most prominent in the morning. He also became lethargic, and had a decreased appetite and decline in school performance. The pertinent physical findings include an unbalanced gait, trunk dystaxia, horizontal nystagmus, and papilledema. If this child had a medulloblastoma, which structure would most likely be affected?
Cerebellar hemispheres
Cerebellar vermis
Spinocerebellar tracts
Cerebellar peduncles
Frontal lobe
224) A 7 -year-old girl is brought to the clinic by her mother due to a persistent postnasal drip and repeated episodes of a runny nose. In the winter, she experiences several episodes of upper respiratory tract infections, which last for two to three weeks at a time. She snores, and is unable to smell her favorite food. Her immunizations are up-to-date. On examination, she is mildly underweight for her age. She has a runny nose, and her nasal drainage is colorless and stringy. Nasal inspection reveals bilateral nasal polyps, and auscultation of the chest reveals coarse rales. What is the one condition that you would like to rule out in this child?
Leukemia
Cystic fibrosis
Foreign body aspiration
Nasal septal deviation
Allergic rhinitis
225) A 2-year-old boy is brought by his mother to the emergency department because of a high-grade fever which "does not go away" with acetaminophen. For the last four days, the child has been very irritable and is crying a lot. He is also pulling his ear and not eating well. He has been generally well, other than the occasional sore throat this season. His temperature is 38.8° C (102.2° F), blood pressure is 90/60 mm Hg, pulse is 119/min, and respirations are 24/min. He appears well nourished, but is irritable. Physical examination reveals enlarged cervical lymph nodes and splenomegaly. The tympanic membranes are inflamed. CBC shows: WBC 81,100mm3, Hemoglobin 8.0 g/dL, Hematocrit 25%, Platelets 16,000 mm3, Blast forms 80%, Prolymphocytes 10%, Lymphocytes 10%. The blast cells have condensed nuclear chromatin, small nucleoli and scant agranular cytoplasm. Subsequent histochemical staining reveals strongly positive periodic acid Schiff (PAS) reaction. No Auer rods were seen. Which of the following is the most likely diagnosis?
. Burkitt lymphoma
. Acute myelocytic leukemia
. Prolymphocytic leukemia
. Acute lymphoblastic leukemia
. Myelodysplastic syndrome
226) A young infant is noted to have developed constipation over the past week, and then facial diplegia and difficulty sucking and swallowing. The child has been colicky, and the maternal grandmother has been treating the child with a mixture of weak tea, rice water, and honey. Which of the following disorders is the most likely culprit in this child?
. Infantile spinal muscular atrophy
. Myastheniagravis
. Congenital myotonic dystrophy
. Duchenne muscular dystrophy
. Botulism
227) About 12 days after a mild upper respiratory infection, a 12-year-old boy complains of weakness in his lower extremities. Over several days, the weakness progresses to include his trunk. On physical examination, he has the weakness described and no lower extremity deep tendon reflexes, muscle atrophy, or pain. Spinal fluid studies are notable for elevated protein only. Which of the following is the most likely diagnosis in this patient?
. Bell palsy
. Muscular dystrophy
. Guillain-Barré syndrome
. Charcot-Marie-Tooth disease
. Werdnig-Hoffmann disease
228) A premature neonate develops respiratory distress syndrome several hours after birth. The infant is placed on a respirator and given other appropriate care. However, when the infant reaches a corrected gestational age of 36 weeks, he does not tolerate weaning from the ventilator. A chest x-ray film demonstrates alternating areas of hyperaeration and pulmonary scarring, resulting in parenchymal streaks and hyperexpanded areas. Which of the following is the most likely diagnosis?
Apnea of prematurity
Bronchopulmonary dysplasia
Cystic fibrosis
Persistent pulmonary hypertension of the newborn
Transient tachypnea of the newborn
229) A neonate has Down syndrome. Maternal hydrammos had been noted prenatally. After the first feeding, the infant has projectile vomiting with bile-stained vomitus. An x-ray film demonstrates a "double-bubble sign" in the abdomen. Which of the following is the most likely diagnosis?
Duodenal atresia
Esophageal atresia
Hirschsprung disease
Hypertrophic pyloric stenosis
Meconium plug syndrome
230) A 10-year-old boy is brought to the office by his parents because he is developing dark facial hair, deepening of the voice and a rapid height increase. He also complains of persistent headaches which are resistant to over-the-counter analgesics for the past 2 weeks. He denies nausea, vomiting or visual disturbances. His medical history is unremarkable. Physical examination reveals coarse pubic and axillary hair. Other pertinent findings include lid retraction, paralysis of upward and downward gaze, and poor pupillary reaction to light. His deep tendon reflexes are normal, Babinski sign is negative, and there are no focal neurologic signs. What tumor is most likely responsible for this child's symptoms?
Medulloblastoma
Neuroblastoma
Oligodendroglioma
Craniopharyngioma
Pinealoma
231) A 17-year-old girl comes to the clinic with several weeks of joint pain and rash. The joint pain is most prominent in the hands. She states that the pain is most severe in the morning and tends to improve over the day. She has noted some swelling of her fingers. She has also had a rash on her face that becomes more prominent when she is outdoors. She states that sunlight tends to bother her eyes. On further questioning, she states that she has not felt well for several months. She has had intermittent fever, has been more tired than usual, and has lost weight although she has not been restricting her diet. On physical examination, she looks tired. She has lost 5 lbs since her last visit 1 year ago. She has an erythematous rash on her cheeks. She has several shallow ulcers in her mouth. She has fusiform swelling of her fingers and pain with movement of her fingers. Which of the following is the most likely diagnosis?
Systemic lupus erythematosus (SLE)
Dermatomyositis
Juvenile rheumatoid arthritis
Rheumatic fever
Lyme disease
232) A full-term newborn develops cyanosis a few hours after birth. Oxygen administration does not improve color or oxygen saturations. Which of the following is the most likely diagnosis?
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Aortic stenosis
Pulmonary stenosis
233) 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
234) 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
235) 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
236) 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
237) 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
238) 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
239) 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
240) A 10-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
241) 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
242) 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
243) 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
244) 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
245) 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
246) 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
247) 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
248) 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
249) 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
250) 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
251) 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
252) 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
253) 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
254) 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
255) 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
256) 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
Breast milk jaundice
Crigler-Najjar syndrome
Breast-feeding jaundice
257) 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
258) 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
259) 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
260) 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 (Image A) along with an x-ray 2 hours later (Image B). Which of the following is the most likely explanation for this infant’s condition?
Pneumonia
Cystic adenomatoid malformation
Diaphragmatic hernia
Choanal atresia
Pneumothorax
261) 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/μL, and a platelet count of 750,000/μL. 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
262) 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
. β-Thalassemia trait
. Sickle-cell anemia
. Chronic systemic illness
. Lead poisoning
263) 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
264) After being delivered following a benign gestation, a newborn infant is noted to have a platelet count of 35,000/μL, 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
265) 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)
266) 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
267) 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
268) 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
269) 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
270) 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
271) 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
272) 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
273) 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, erythematous, centrifugal rash on her trunk and proximal limbs is present. Laboratory studies show: Complete blood count: Hemoglobin 12.5 g/dL, MCHC 32%, MCV 85 fl, Reticulocyte count 0.1%, Platelet count 200,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%, C-reactive protein 3.5 mg/dL, Erythrocyte sedimentation rate 38 mm/hr. Which of the following is the most likely diagnosis?
. Juvenile rheumatoid arthritis
. Rheumatic fever
. Acute lymphoblastic leukemia
. Systemic lupus ery1hematosus
. Fibromyalgia
274) 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
275) 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
276) A 4-year-old boy presents to the emergency department with generalized tonic-clonic seizures. On physical examination, the child is noted to be lethargic. His temperature is 37.4 C (99.3 F), blood pressure is 100/60 mm Hg, pulse is 72/min, and respirations are 16/min. His oral mucosa is moist, and there is no peripheral edema. Laboratory tests show: Blood: Sodium 120 mEq/L, Potassium 4.2 mEq/L, Chloride 96 mEq/L, Bicarbonate 20 mEq/L, Blood urea nitrogen 9.6 mg/dL, Creatinine 0.4 mg/dL, Glucose 88 mg/dL, Urine: Sodium 55 mEq/L, Potassium 16 mEq/L, Osmolality 530 mOsmol/kg. Which of the following is the most likely diagnosis?
Acute renal failure
Addison disease
Congestive heart failure
Hyponatreraic dehydration
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
277) A 1-month-old, previously healthy infant develops forceful projectile vomiting. No bile is seen in the vomitus. After the infant feeds, gastric peristaltic waves are visible crossing the epigastrium from left to right. Several minutes later, the projectile vomiting occurs. Which of the following is the most likely diagnosis?
Diaphragmatic hernia
Duodenal atresia
Esophageal atresia
Hypertrophic pyloric stenosis
Meconium plug syndrome
278) A 5-month-old girl is brought to the office by her mother, who states that the girl had an episode following feeding during which she began to breathe deeply, became blue, and then lost consciousness. The mother states that she picked her up and held her, and the infant regained her usual color and became alert. Physical examination reveals a harsh systolic murmur. Which of the following is the most likely diagnosis?
. Aortic stenosis
. Coarctation of the aorta
. Patent ductus arteriosus
. Tetralogy of Fallot
. Ventricular septal defect
279) Physical examination of an infant delivered to a 42-year-old, gravida 3, para 2, woman, is remarkable for slight hypotonia and a poor Moro reflex. Further examination reveals upslanting palpebral fissures, epicanthal folds, excess nuchal skin, an enlarged tongue, clinodactyly of the fifth fingers, and a single transverse palmar crease. Which of the following is the most likely diagnosis?
. Down syndrome
. Edwards syndrome
. Fetal alcohol syndrome
. Marfan syndrome
. Turner syndrome
280) You are called to the newborn nursery to evaluate a term infant with bilious emesis. Although the mother had poor prenatal care, she had a normal vaginal delivery with no complications. The infant began having bilious vomiting several hours after birth. The infant has urinated, but has not had a bowel movement. Vital signs are temperature 36.9 0C (98.4 0F), pulse 150/min, and respiratory rate 40/min. On examination, the abdomen is distended and there are decreased bowel sounds. The remainder of the physical examination is unremarkable. An abdominal radiograph is shown below. Which of the following is the most likely diagnosis?
Pyloric stenosis
Intestinal atresia
Hirschsprung disease
Necrotizing enterocolitis
Gastroesophageal reflux
281) A 10-month-old infant on long-term aspirin therapy for Kawasaki disease develops sudden onset of high fever, chills, diarrhea, and irritability. A rapid swab in your office identifies influenza A, adding her to the long list of influenza patients you have seen this December. Over the next few days, she slowly improves and becomes afebrile. However, 5 days after your last encounter you hear from the hospital that she has presented to the emergency center obtunded and posturing with evidence of liver dysfunction. Which of the following statements about her current condition is correct?
. With proper supportive care, the overall mortality rate is low.
. With her progressiveliver dysfunction, increased total serum bilirubin is anticipated.
. Administration of N-acetylcysteine is first-line therapy.
. Seizures are uncommon with this condition.
. Death is usually associated with increased intracranial pressures and herniation.
282) The parents of a 7-month-old boy arrive in your office with the child and a stack of medical records for a second opinion. The boy first started having problems after his circumcision in the nursery when he had prolonged bleeding. Studies were sent at the time for hemophilia, but factor VIII and IX activity were normal. At 2 months he developed bloody diarrhea, which his doctor assumed was a milk protein allergy and changed him to soy; his parents note he still has occasional bloody diarrhea. He has seen a dermatologist several times for eczema, and he has been admitted to the hospital twice for pneumococcal bacteremia. During both admissions, the parents were told that the infant’s platelet count was low, but they have yet to attend the hematology appointment arranged for them. The child’s WBC count and differential were normal. Which of the following is the most likely diagnosis in this child?
. Idiopathic thrombocytopenic purpura
. Wiskott-Aldrich syndrome
. Acute lymphocytic leukemia
. Adenosine deaminase deficiency
. Partial thymic hypoplasia
283) A one-day-old infant with Down syndrome has developed persistent vomiting. He was delivered vaginally at 34 weeks without any complications. On examination, he appears dehydrated and slightly tachypneic. His abdomen is soft and not distended. Abdominal x-ray reveals two large distinct air bubbles, but there are no dilated bowel loops or air fluid levels. What is the most likely diagnosis of this patient?
Pyloric stenosis
Reflux disorder
Tracheoesophageal fistula
Bowel obstruction
Duodenal atresia
284) A 10-year-old boy from the Connecticut coast is seen because of discomfort in his right knee. He had a large, annular, erythematous lesion on his back that disappeared 4 weeks prior to the present visit. His mother recalls pulling a small tick off his back. Which of the following is a correct statement about this child’s likely illness?
. The tick was probably a Dermacentor andersoni
. The disease is caused by a rickettsial agent that is transmitted by the bite of a tick
. In addition to skin and joint involvement, CNS and cardiac abnormalities may be present
. Therapy with antibiotics has little effect on the resolution of symptoms
. The pathognomonic skin lesion is required for diagnosis
285) Two weeks ago, a 5-year-old boy developed diarrhea, which has persisted to the present time despite dietary management. His stools have been watery, pale, and frothy. He has been afebrile. Microscopic examination of his stools is likely to show which of the following?
. Salmonella sonnei
. Enterobius vermicularis
. Sporothrix schenckii
. Toxoplasmagondii
. Cryptosporidium
286) The rash and mucous membrane lesions shown in the photograph below develop in an infant 5 days into the course of an upper respiratory infection with otitis media; the child is being treated with amoxicillin. The child’s condition is likely which of the following?
. Urticaria
. Rubeola
. Stevens-Johnson syndrome
. Kawasaki disease
. Scarlet fever
287) A 6-year-old boy is brought to the physician for evaluation of behavior problems. His parents report he is "hyperactive all the time." They cannot get him to sit still. When he does sit, he fidgets and tries to get out of his seat. He is easily distracted and frequently changes from one activity to another. He does not seem to listen when his parents talk to him, and often forgets to do his chores. He talks excessively and often interrupts other people. His parents state that he has been like this for a few years, but they had originally assumed his behavior was normal for his age. His physical examination is unremarkable. Which of the following will be of most help in establishing the diagnosis?
. Family history of similar behavior
. Educational testing
. Teacher evaluations
. Sleep history
. Symptoms of an anxiety disorder
288) An 8-year-old boy is brought to the office due to headaches and impaired walking. These symptoms started seven days ago, and progressed gradually. He just recently recovered from otitis media that was superimposed on an acute respiratory infection. His past medical history is significant for three episodes of otitis media and one episode of pneumonia. His temperature is 36.7C (98F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 20/min. Physical examination reveals mild right-sided hemiparesis and a slightly dilated left pupil. The funduscopic examination is normal. Which of the following is the most likely diagnosis?
Brain abscess
Bacterial meningitis
Toxoplasmosis
Venous thrombosis
Arterial thrombosis
289) A 1-day-old male infant has bilious vomiting after every feeding. He hasn't passed any stools yet. He had no prenatal care, and was delivered vaginally at term. He weighs 3kg (6.61b), and his APGAR scores were 6 and 7 at 1 min and 5 min, respectively. On examination, the neonate is hypotonic, he has a flat facial profile, short ears with downfolding ear lobes, a single palmar crease, and a depressed fontanel. There is abdominal distention which is most prominent in the upper abdomen. His abdominal x-rays show gastric and duodenal gas distension with no air distally. What other anomaly can also be expected in this infant?
Sigmoid volvulus
Meconium plug syndrome
Hirschsprung's disease
Intussusception
Meckel's diverticulum
290) A 14-year-old boy is brought to the emergency room because of persistent midepigastric pain for two days. The pain is getting no better, yet it is no worse, and radiates to his back. The boy also has had fever, as well as nausea and vomiting that is worse when his temperature rises in the afternoon. On examination, his temperature is 39.2C (102.5F) and there is marked upper abdominal tenderness with guarding. Mild abdominal distention is present with no audible bowel sounds. A complete blood count reveals an elevated leukocyte count and a normal serum amylase. Which of the following is the most likely diagnosis?
. Fitz-Hugh-Curtis syndrome
. Intussusception
. Wilms tumor
. Pancreatitis
. Pyelonephritis
291) A baby is born at 34 weeks gestation. The amniotic fluid is brown and murky. The baby has low APGAR scores and appears to be septic, with lethargy, apnea, bradycardia, and temperature instability. The mother lives on a farm and gives a history of a flu-like illness one month before delivery. Gram's stain of a smear from the mother's cervix demonstrates abundant, pleomorphic, gram-variable coccobacillary forms. Which of the following is the most likely diagnosis?
. Congenital cytomegalovirus infection
. Congenital rubella
. Congenital syphilis
. Neonatal herpes simplex infection
. Neonatal listeriosis
292) A 14-year-old black male comes to the office for the evaluation of pain in his right hip that started several weeks ago. The pain has gradually progressed, and now it limits his daily activities. He has sickle cell disease and was hospitalized three months ago due to a painful crisis that was successfully treated with hydration, oxygen, and analgesics. His temperature is 37.2C (99F), blood pressure is 100/70 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals no local tenderness, but there is restriction of abduction and internal rotation of the hip What is the most likely diagnosis?
Osteomyelitis caused by Salmonella
Osteomyelitis caused by Staphylococcus
Joint effusion from septic arthritis
Avascular necrosis
Femoral fracture
293) A 6-year-old Caucasian male is brought to your office with a two-week history of right shoulder pain. Physical examination reveals localized swelling below the shoulder joint, and x-ray shows a single lytic lesion in the right humeral head. Laboratory analyses show mild hypercalcemia but are otherwise within normal limits. Which of the following is the most likely diagnosis?
Osteoporosis
Sarcoidosis
Langerhans histiocytosis
Primary hyperparathyroidism
Osteogenesis imperfect
294) An infant is born prematurely and is small for gestational age. At birth, the infant is obviously ill with jaundice, fever, hepatosplenomegaly, myocarditis, and rashes. Neurologic involvement is prominent, with hydrocephalus, intracranial calcifications, and seizures. The mother has a cat and continued to clean the cat's litter box during the pregnancy. Which of the following is the most likely causative agent?
. Cytomegalovirus
. Herpes simplex
. Rubella virus
. Toxoplasma
. Treponema pallidum
295) A beekeeper’s previously healthy 6-month-old son develops gradual onset of lethargy, poor feeding, constipation, and generalized weakness. On taking a history, you determine that the child has recently been placed on a homemade formula consisting of evaporated milk, water, and honey. Which of the following is the most likely explanation for this symptom complex?
Sodium intoxication
Hirschsprung disease
Hypothyroidism
Spinal cord tumor
Botulism
296) A 12-year-old girl is taken to a pediatrician complaining of a sore mouth. On questioning, the child states that she has been feeling poorly, with fatigue and weakness. She began menstruating briefly and then stopped. Physical examination is notable for focal white crusting of the oral cavity; biopsy of one of these areas later shows candidiasis, Laboratory studies show the following: Sodium 127 mEq/L, Potassium 5.3 mEq/L, Bicarbonate 24 mEq/L, Calcium 7.5 mEq/dL, Phosphorus 5.5 mg/dL, Glucose 87 mg/dL. Which of the following is the most likely diagnosis?
Multiple endocrine neoplasia, type I
Multiple endocrine neoplasia, type IIA
Polyglandular deficiency syndrome, type I
Polyglandular deficiency syndrome, type II
Polyglandular deficiency syndrome, type III
297) A 15-year-old girl presents with a 2-day history of pain and swelling in her left knee. She plays soccer regularly on her school team. There is no history of trauma. On physical examination, there is marked swelling and tenderness over her anterior tibial tuberosity. A radiograph of her left knee reveals irregularities of the tubercle contour and haziness of the adjacent metaphyseal border. Which of the following is the most likely explanation for her symptoms?
. Avascular necrosis of the hip
. Legg-Calve-Perthes disease
. Osgood-Schlatter disease
. Septic arthritis
. Slipped capital femoral epiphysis
298) A 7-year-old male is brought to the emergency department for a suspected femur fracture. He has had multiple fractures in the past after minor trauma. Today, his mother states that he was running and fell. He complained of pain in his thigh after he fell. His examination is remarkable for tenderness to palpation and slight deformity of his right proximal thigh. He has decreased muscle tone throughout. His eye examination is shown below. Which of the following is the most likely associated finding?
Aortic root dilatation
Horseshoe kidney
Opalescent teeth
Mental retardation
Ash leaf macules
299) A 2-day-old male infant presents with multiple episodes of bilious vomiting over the past 24 hours. He has a prominent tongue, flat occiput and slanting eyes. His hands are short, and there are wide gaps between his first and second digits. His abdomen is soft and without any distention, guarding or rigidity. On auscultation of the chest, there is a systolic ejection murmur along the left sternal border, with a wide and fixed splitting of S2. Abdominal x- rays show air trapped in the first portion of the duodenum and stomach. What is the most likely cause of the child's symptoms?
Pyloric stenosis
Gastroesophageal reflux
Duodenal atresia
Mesenteric adenitis
Acute appendicitis
300) A 2-year-old girl presents to the office with a dry cough and a low-grade fever. Over the last two days, she has become very irritable and difficult to feed. She has also had a runny nose. On examination, there is significant wheezing and tachycardia. Evaluation of the nasal discharge confirms the diagnosis of respiratory syncytial virus infection. In the future, which of the following does this child have a slight risk of developing?
Pneumonia
Lung abscess
Cystic fibrosis
Asthma
Aspergillosis
301) A 10-month-old boy develops an upper respiratory tract infection 2 days before presentation. On the day of presentation, he has a generalized tonic-clonic seizure lasting 30 seconds. His temperature is 40.0 C (104 F), blood pressure is 90/60 mm Hg, and respirations are 22/min. He is alert and smiling. He has rhinorrhea, and his neck is supple. He has bruises below his knees. Which of the following is the most likely diagnosis?
Child abuse
Idiopathic epilepsy
Infantile spasms
Meningitis
Simple febrile seizure
302) A 4-month-old child presents with a 2-day history of vomiting and intermittent irritability. On examination, “currant jelly” stool is noted in the diaper, and a sausage-shaped mass is palpated in the right upper quadrant of the abdomen. Which of the following conditions is most likely to cause this?
Appendicitis
Diaphragmatic hernia
Giardiasis
Intussusception
Rotavirus gastroenteritis
303) A 2-hour-old full-term newborn infant is noted by the nursing staff to be having episodes of cyanosis and apnea. Per nursery protocol they place an oxygen saturation monitor on him. When they attempted to feed him, his oxygen levels drop into the 60s. When he is stimulated and cries, his oxygen levels increase into the 90s. Which of the following is the most important next step to quickly establish the diagnosis?
Echocardiogram
Ventilation perfusion scan
Passage of catheter into nose
Hemoglobin electrophoresis
Bronchoscopic evaluation of palate and larynx
304) The police bring a 14-year-old boy to the clinic after he was found setting fire to the neighbor's house. He has been previously arrested and warned by the cops twice. The first time was 15 months ago for stealing his neighbor's motorcycle. The second occasion was 6 months ago for a fight with his peers on the roadside. His parents arrive and tell you that he has been behaving this way for the past 3 years, and often argues at home. He steals money from them and tries to hurt the pets. Although they have not seen him using any drugs, they suspect that his behavior could be due to drugs. What is the most likely diagnosis?
Conduct disorder
Antisocial personality disorder
Oppositional defiant disorder
Attention deficit hyperactivity disorder
Substance abuse
305) A 14-year-old girl presents to the emergency room for severe lower mid-abdominal pain that has been increasing over the past 12 hours. She describes it as crampy and sharp. Her last menstrual period was about 2 weeks ago. It was regular with no pain and lasted 4 to 5 days. She has had menstrual periods for nearly 2 years, and over the past 6 months she has noticed some cramping pain the first day or two of her menses. She denies sexual activity and has not had any vaginal discharge. Her bowel movements have been normal and she reports no urinary frequency, urgency, or burning with urination. Which of the following is the most likely diagnosis?
. Dysmenorrhea
. Ectopic pregnancy
. Ovarian cyst
. Pelvic inflammatory disease
. Mittelschmertz
306) A 9-month-old boy is taken to the emergency room because of high fever. Breath sounds are diminished in the lungs, and a chest x-ray film shows lobar pneumonia. Probable streptococcal pneumonia is demonstrated in Gram's stain of sputum and then later confirmed by culture. The child responds to antibiotic therapy. A detailed history is taken during the admission, which reveals that this is the third episode of pneumonia in this young child; the two previous episodes occurred at 6 and 7.5 months of age. One of the mother's brothers had died of infection at age 9. Immunoglobulin studies demonstrate the following: IgG 80 mg/dL [normal 723-1685 mg/dL], IgA 60 mg/dL [normal 81-463 mg/dL], IgM 20 mg/dL [normal 48-271 mg/dL]. Studies of the lymphocyte population demonstrate normal numbers of T cells and markedly decreased B cells. Which of the following is the most likely diagnosis?
. Bruton agammaglobulinemia
. Common variable immunodeficiency
. DiGeorge syndrome
. Transient hypogammaglobulinemia of infancy
. Wiskott-Aldrich syndrome
307) A newborn baby is noted to have abnormal facies with low-set ears; a small receding jaw; and widely separated eyes. At 30 hours of age, the baby develops multiple muscle spasms. Serum studies are notable for calcium of 4.5 mg/dL. Which of the following is the most likely diagnosis?
. Bruton's agammaglobulinemia
. Common variable immunodeficiency
. DiGeorge syndrome
. Selective IgA deficiency
. Transient hypogammaglobulinemia of infancy
308) A 5-year-old girl is being evaluated for generalized swelling. Her blood pressure is 98/60 mm Hg. Her laboratory results show: Creatinine 0.7 mg/dl, Albumin 1.6 g/dL, Cholesterol 360 mg/dL, Triglycerides 400 mg/dL, C3 complement 120 mg/dL (normal, >80 mg/dL), Antinuclear antibody Negative, Urinalysis 1 RBC/hpf, protein 400 mg/dL. Which of the following is the most likely diagnosis?
Membranoproliferative glomerulonephritis
Membranous glomerulopathy
Minimal change disease
Postinfectious acute glomerulonephritis
Systemic lupus erythematosus
309) A 10-year-old girl is evaluated by a pediatrician. She is already 5'8" tall and is taller than other members of her family were at this age. Her arms are disproportionately long compared with her trunk, and her sternum is outwardly displaced. Her joints are hyperextensible, particularly at the knees. Ocular examination demonstrates dislocation of one lens. Which of the following is the most likely diagnosis?
Achondroplasia
Cutis laxa
Ehlers-Danlos syndrome
Marfan syndrome
Osteogenesis imperfect
310) An 8-year-old boy is brought to the clinic by his mother, who states that he has been complaining of pain in both knees. The mother also states that he had a rash on his leg 3 weeks ago. She said it was there for almost 2 weeks and then went away. She describes the rash as reddish and circular, with a small clear area in the center. She said the rash was not itchy or painful. The child has also complained of headaches and muscle aches over the past several weeks. On questioning, the mother states that they were vacationing in Wisconsin about 1 month ago and the boy was hiking in the woods when he was bitten by a tick. Which of the following is the most likely diagnosis?
. Babesiosis
. Colorado tick fever
. Lyme disease
. Rocky Mountain spotted fever
. Tularemia
311) A male child born to a 25-year-old Caucasian mother by normal vaginal delivery at 36 weeks of gestation is found to have a small face, a small jaw, and a prominence on the back of his head. There are no skin creases on the palmar aspect of his digits. There is overlapping of his fingers bilaterally, along with rocker bottom feet and limited hip abduction. Heart murmur is present. Which of the following cardiovascular abnormality is most likely seen in this patient?
Atrial septal defect
Ventricular septal defect
Supravalvular aortic stenosis
Conotruncal abnormality
Congenital heart block
312) The newborn nursery calls to notify you that a 1-day-old baby boy has developed abdominal distension and bilious emesis. Prenatal history was significant for areas of echogenic bowel seen on ultrasound. You order an abdominal radiograph; based on the results you order a contrast enema. Both are shown here. This infant is most likely to have which of the following?
. Duodenal atresia
. Cystic fibrosis
. Gastroenteritis
. Malrotation with volvulus
. Hirschsprung disease
313) A 15-year-old girl is admitted to the hospital with a 6-kg weight loss, bloody diarrhea, and fever that have occurred intermittently over the previous 6 months. She reports cramping abdominal pain with bowel movements. She also reports secondary amenorrhea during this time. Stool cultures in her physician’s office have shown only normal intestinal flora. A urine pregnancy test was negative, while an erythrocyte sedimentation rate (ESR) was elevated. Her examination is significant for the lack of oral mucosal ulcerations and a normal perianal examination. Anti-Saccharomyces cerevisiae antibodies (ASCA) are negative, while anti-neutrophil cytoplasm antibodies (p-ANCA) are positive. You confirm your presumptive diagnosis with a rectal biopsy. In counseling her about her disease, which of the following statements would be true?
. Inheritance is autosomal dominant
. Her risk of colon cancer is minimally elevated over the general population
. Intestinal strictures are common
. The most serious complication of her disease is toxic megacolon
. The intestinal involvement is separated by areas of normal bowel
314) A 6-year-old boy is brought to the physician by his mother with complaints of "inattentivity." His school teacher frequently complains about him, saying that he, "cannot sit still and just does not listen." He rarely completes his classroom assignments in time. When asked to run errands at home, he appears not to listen and continues to do whatever he is engaged in. He makes poor eye contact and has limited language skills compared to his peers. He usually prefers to play by himself. Which of these is the most likely diagnosis in this case?
Selective mutism
Attention deficit hyperactivity disorder
Undetected hearing impairment
Autism
Oppositional defiant disorder
315) At the time of delivery, a woman is noted to have a large volume of amniotic fluid. At 6 hours of age, her baby begins regurgitating small amounts of mucus and bile-stained fluid. Physical examination of the infant is normal, and an abdominal x-ray is obtained (see below). Which of the following is the most likely diagnosis of this infant’s disorder?
Gastric duplication
Pyloric stenosis
Esophageal atresia
Duodenal atresia
Midgut volvulus
316) A 15-month-old Asian girl is brought to the physician's office because of persistent non-productive cough and skin rash. Other accompanying symptoms are a runny nose, sneezing and intermittent nasal obstruction. She has had these symptoms for the past four days. Her parents report that she seems to have lost interest in her usual activities and is irritable all the time. Her pulse is 130/min, temperature is 38.8C (102F), and respirations are 24/min. Her eyes are red and have a watery discharge; there is congestion that is more marked over the canthi; the inner conjunctiva has bluish white lesions on an erythematous background. Throat examination reveals erythema of the posterior pharyngeal wall and tonsillar pillars, and yellowish exudates on the tonsils. The buccal mucous membranes are red with bluish-white lesions. The face has blanching, erythematous "brick-red" maculopapular rash. No rash is present over the extremities. Cervical lymphadenopathy is noted. The lab results are as follows: Hct 46%, WBC count 3,000/mm3, Platelet 160,000/mm3, Urine Dipstick ++ for proteins. What is the most likely diagnosis?
Atypical measles
Human herpes virus 8
Kawasaki disease
Rubeola
Scarlet fever
317) A 17-year-old teenage girl presents to your office after having problems during sex with her boyfriend. She also states that she has been developing facial hair, which she has constantly been removing. She started her menstruations at the age of 13 and her cycles have always been regular. On examination she is obese but appears a little masculine and has an enlarged clitoris. Initial lab values are as follows: Serum LH 20 IU/L, Serum FSH 10 IU/L, 17 -hydroxyprogesterone 600ng/ml (Normal is 15ng/ml), Serum testosterone Normal, Serum DHEA 4.0ng/ml (Normal is 4.2ng/ml). What is the most likely diagnosis?
Polycystic ovarian disease
Cushing's syndrome
Cushing's disease
Adrenal carcinoma
Congenital adrenal hyperplasia
318) A 2-week-old male infant is brought to the office by his 28-year-old primiparous mother for the evaluation of jaundice that was noted two days ago. The infant's stool has a lighter color. He is exclusively breastfed. The pregnancy was uncomplicated, and prenatal screening tests for TORCH organisms were all negative. The infant was delivered vaginally with no complications. His temperature is 37.2 C (99F), pulse is 140/min, respirations are 50/min, and capillary refill is < 2 sec. Examination reveals jaundiced skin and mucous membranes. Abdominal palpation reveals hepatomegaly. The initial investigations show the following: Hb 18.0 g/dl, Hct 52%, Bilirubin, Total 5 mg/dl, Bilirubin, Direct 4 mg/dl, Blood type 0 + (The mother's blood type is B-), Coombs' test Negative. What is the most likely diagnosis?
. Breast milk jaundice
. Biliary atresia
. Physiologic jaundice
. Gilbert syndrome
. Crigler-Najjar syndrome
319) The infant in the following picture presents with hepatosplenomegaly, anemia, persistent rhinitis, and a maculopapular rash. Which of the following is the most likely diagnosis for this child?
Toxoplasmosis
Glycogen storage disease
Congenital hypothyroidism
Congenital syphilis
Cytomegalovirus disease
320) A premature infant develops respiratory distress several hours after birth. The infant is placed in an incubator with supplemental oxygen. The physician instructs the nurse to cover the infant's eyes to minimize the chance of damage by the high oxygen tension. Which of the following is characteristic of eye damage produced by exposure to high oxygen tensions in premature infants with respiratory distress?
Blood vessels in the vitreous
Cotton wool exudates in the retina
Microaneurysms of the retinal arterioles
Papilledema of the optic nerve head
Ulcers on the cornea
321) A 7-year-old boy is brought to the clinic by his mother, who states that he has been complaining of abdominal pain for 2-3 days. He has been afebrile, with no vomiting or diarrhea. His mother states she brought him to the office today because she noticed a rash on his legs that is getting worse, and he is now complaining of knee pain. On examination, there are palpable purpuric lesions on both legs and buttocks. He has pain around his ankle and knee joints with minimal swelling, and no warmth or erythema. Which of the following is the most likely diagnosis?
Dermatomyositis
Gastroenteritis
Henoch-Schonlein purpura
Juvenile rheumatoid arthritis
Kawasaki disease
322) A 7-year-old boy who has had pain in his right leg for 4 months is being evaluated. The pain is worse at night and is unrelenting, but it can usually be relieved with ibuprofen. On physical examination, there is localized tenderness over the anterior aspect of the right thigh. There is also mild atrophy of the affected limb. A radiograph of the femur reveals a radiolucent nidus with surrounding reactive sclerotic bone. Which of the following is the most likely diagnosis?
. Brodie's abscess
. Ewing sarcoma
. Osteosarcoma
. Osteoid osteoma
. Stress fracture
323) A 2-year-old boy is brought to the emergency department due to a cough and a "whistling" sound with breathing. Two days ago, he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh, "barky" cough. His immunizations are up-to-date. His 6-year-old brother also has cold symptoms. His temperature is 37.5C (99.5F), pulse is 140/min, and respirations are 36/min. On examination, he is alert, in mild respiratory distress, has a dry barking cough, hoarse cry, and some clear mucoid rhinorrhea. His pharynx is slightly injected, but without enlargement or asymmetry. The lungs are clear on auscultation. Lateral neck x-rays reveal a mildly narrowed subglottic region. What is the most likely diagnosis?
Epiglottitis
Croup
Laryngotracheobronchopneumonitis
Foreign body aspiration
Laryngeal diphtheria
324) A 2-year-old child is brought to the physician for a routine visit. He is growing and developing appropriately. He eats a variety of foods including meat, vegetables, and fruits, and drinks 3-4 glasses of whole milk each day. He is starting to put words together into short sentences. His mother has no concerns. Physical examination is unremarkable. Routine laboratory studies show the following: Hemoglobin 9.5 g/dl, RDW 14%, MCV 65 fl, Reticulocyte count 3.0%, Platelet count 212,000/mm3, Leukocyte count 6,500/mm3, TIBC 300 mcg/dl (240-450 mcg/dl), Ferritin 100 ng/ml (7 -140 ng/ml). What is the most likely cause for this child's anemia?
Iron deficiency
Anemia of chronic disease
Thalassemia trait
Cyanocobalamin deficiency
Spherocytosis
325) A previously healthy 5-year-old girl is brought to the physician for evaluation of night awakenings. She has woken up screaming in each of the past three nights about one hour after going to sleep. When her parents go to her room, she is crying, sweating, and looks frightened. She does not respond to her parents and does not seem fully awake. When her parents hold her, she calms down and goes back to sleep. The next morning, she does not recall the incident. She started kindergarten this week and has just begun going all day without taking a nap. On examination, she is afebrile and her vital signs are within normal limits. A complete physical examination is unremarkable. What is the most likely diagnosis?
. Nightmare
. Somnambulism
. Epilepsy
. Night terrors
. Benign paroxysmal vertigo
326) A 17-year-old boy comes to medical attention because of recurrent sinusitis and pneumonia, and persistent watery diarrhea due to Giardia lamblia. His parents and a sister are in excellent health. Physical examination reveals enlarged lymph nodes in cervical, axillary and inguinal regions. A lymph node biopsy shows hyperplastic follicles with an absence of plasma cells. Laboratory investigations show: Hematocrit44%, Leukocyte count9, 800/mm3, Neutrophils55%, Lymphocytes30%, Monocytes5%, CD4 T-cell count1000 cells/mm3, Proteins, serum6.2 g/dL, Albumin5.0 g/dL, Globulin1.2 g/dL. Additional studies demonstrate severely depressed levels of serum IgG, with slightly below-normal levels of IgM and IgA. Which of the following is the most likely diagnosis?
. Acquired immunodeficiency syndrome (AIDS)
. Common variable immunodeficiency
. Hodgkin disease
. Isolated IgA deficiency
. X-linked agammaglobulinemia of Bruton
327) An 8-year-old boy presents with a 2-day history of rash. The rash started on the head and spread downward to his trunk and extremities. He also complains of a fever, cough, and a runny nose for the past 5 days. On physical examination, his temperature is 38.2 C (100.7 F), blood pressure is 88/56 mm Hg, pulse is 76/min, and respirations are 16/min. There is a small, irregular red spot with a central gray color on his buccal mucosa. The rash on his body is erythematous and maculopapular in quality. Which of the following is the most likely diagnosis?
. Erythema infectiosum
. Hand-foot-mouth disease
. Measles
. Roseola infantum
. Rubella
328) A 3-year-old child presents in clinic with marked erythema of the cheeks, with no prior symptoms. The rash soon involves the arms and has a reticular erythematous maculopapular appearance. The patient has been previously healthy and is not on any medications. He has not been exposed to any other ill individual. Which of the following is the most likely diagnosis?
Fifth disease (erythema infectiosum)
Measles
Roseola
Rubella
Varicella
329) The mother of a 6-month-old infant is concerned that her baby may be teething. You explain to her that the first teeth to erupt in most children are which of the following?
. Mandibular central incisors
. Maxillary lateral incisors
. Maxillary first molars
. Mandibular cuspids (canines)
. First premolars (bicuspids)
330) A 6-month-old previously health child is brought to the doctor's office because of sudden onset of lethargy, constipation, generalized weakness and poor feeding. He has been meeting all development milestones and his immunization schedule is up to date. On further questioning, his parents mention that his diet was recently advanced to a homemade formula of evaporated milk and honey. On physical examination, he has stable vital signs, clear lungs, normal skin turgor and full fontanelles. Which of the following is the most likely explanation for the patient's presentation?
. Botulism
. Hirschsprung disease
. Hypernatremia
. Hyponatremia
. Hypothyroidism
331) A 15-year-old girl presents to the emergency department with the sudden onset of watery diarrhea tinged with blood. The girl was previously healthy. Her only medications are topical benzoyl peroxide and oral clindamycin for acne vulgaris. Physical examination reveals a slightly distended abdomen that is diffusely tender. Her temperature is 38.1 C (100.5 F). She has not been exposed to any uncooked meat and has not eaten any unusual foods. Which of the following is the most likely diagnosis?
. Gastroenteritis
. Irritable bowel syndrome
. Pseudomembranous enterocolitis
. Salmonella infection
. Ulcerative colitis
332) A 22-year-old woman has just delivered a male infant at 41 weeks of gestation. Her medical history is normal and her pregnancy was uncomplicated. She is an assistant in a veterinary clinic. Examination of the infant reveals jaundice, hepatosplenomegaly, and generalized lymphadenopathy. During the examination, he suddenly begins to have tonic-clonic seizures. The CT scan reveals active inflammatory lesions, hydrocephalus and intracranial calcifications. What is the most likely diagnosis of this patient?
Congenital syphilis
Congenital rubella
Congenital toxoplasmosis
Congenital herpes simplex
Congenital hepatitis B
333) A 5-year-old girl is brought to the physician's office for a follow-up visit after recovering from an episode of acute bacterial meningitis. Five weeks ago, she developed pneumococcal meningitis, and was admitted to the hospital, where she underwent lumbar puncture, CT scan of the head, and ceftriaxone therapy. She was discharged in a stable condition. According to the mother, the child has not been performing well in school since her illness. She also noticed that the child has forgotten how to copy figures such as triangles and squares, and is unable to identify colours accurately. What is the most likely cause for the regression of milestones in this patient?
Drug reaction
Lumbar puncture
Meningitis
Alexia
Amnesia
334) You are seeing a 2-year-old boy for the first time. His father denies any past medical or surgical history, but does note that the child’s day care recently sent a note home asking about several episodes, usually after the child does not get what he wants, when he “breathes funny” and sits in a corner with his knees under his chin for a few minutes. The day-care staffers think this “self-imposed time-out” is a good thing, but they worry about the breathing. One teacher even though he once looked blue, but decided that it was probably because of the finger paints he had been using. On examination, you identify a right ventricular impulse, a systolic thrill along the left sternal border, and a harsh systolic murmur (loudest at the left sternal border but radiating through the lung fields). His chest radio- graph and ECG are shown. Which of the following congenital cardiac lesions would you expect to find in this child?
Patent ductus arteriosus
Right ventricular outflow obstruction
Atrial septal defect (ASD)
Transposition of the great vessels with a patent foramen ovale
Hypoplastic left heart
335) A 5-year-old boy is brought to the physician because of a malodorous discharge coming from his right nostril. His parents report that the child developed frequent sneezing and mucus discharge for one week. They thought it was a common cold. The child is afebrile and in apparent good health. There is no history of allergic diseases or recurrent infections. Examination reveals obstruction of the right nasal fossa with associated purulent discharge from the right nostril. Which of the following is the most likely diagnosis?
. Allergic rhinitis
. Juvenile angiofibroma
. Nasal foreign body
. Nasal polyp
. Rhinitis medicamentosa
336) A 4-year-old girl is brought to your office by her mother for recent onset of fever and rash. For the past 4 days, she has had headaches, fever, and sore throat. She was apparently normal 4 days ago, and upon presentation of the symptoms, her mother thought that she was having a simple viral fever which would go away with time; however, she then developed a pale pink maculo-papular rash, first on the face and neck, and then it rapidly spread onto the trunk and limbs. On examination, the child is afebrile and doesn't appear ill, but there are few palpable suboccipital and posterior auricular lymph nodes. What is the most likely cause of this patient's condition?
Group A beta- hemolytic streptococci
Measles virus
Rubella virus
Varicella virus
Human parvovirus
337) For the past year, a 12-year-old boy has had recurrent episodes of swelling of his hands and feet, which has been getting worse recently. These episodes occur following exercise and emotional stress, last for 2 to 3 days, and resolve spontaneously. The last episode was accompanied by abdominal pain, vomiting, and diarrhea. The results of routine laboratory workup are normal. An older sister and a maternal uncle have had similar episodes, but they were not given a diagnosis. He presents today with another episode as shown in the photographs on the next page. Which of the following is the most likely diagnosis?
Systemic lupus erythematosus
Focal glomerulosclerosis
Congenital nephrotic syndrome
Hereditary angioedema
Henoch-Schönlein purpura
338) During a regular checkup of an 8-year-old child, you note a loud first heart sound with a fixed and widely split second heart sound at the upper left sternal border that does not change with respirations. The patient is otherwise active and healthy. Which of the following heart lesions most likely explains these findings?
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Isolated tricuspid regurgitation
Tetralogy of Fallot
Mitral valve prolapse
339) A 2-year-old child with minimal cyanosis has an S3 and S4 (a quadruple rhythm), a systolic murmur in the pulmonic area, and a middiastolic murmur along the lower left sternal border. An ECG shows right atrial hypertrophy and a ventricular block pattern in the right chest leads. Which of the following is the most likely diagnosis?
Tricuspid regurgitation and pulmonic stenosis
Pulmonic stenosis and a VSD (tetralogy of Fallot)
Atrioventricular canal
Ebstein anomaly
Wolff-Parkinson-White syndrome
340) An 18-year-old male undergoes elective hernia repair. During the operation, he suffers considerable blood loss, and receives a blood transfusion. He then experiences an anaphylactic transfusion reaction. He is resuscitated and further hospital course is uncomplicated. His past medical history is significant for recurrent sinopulmonary infections and intermittent episodes of diarrhea since childhood. Which of the following is the most likely cause of his symptoms?
. IgA deficiency
. DiGeorge Syndrome
. X linked agammaglobulinemia
. Wiskott-Aldrich syndrome
. Cystic fibrosis
341) A 2-hour-old male neonate has developed worsening cyanosis over the past few minutes. The infant was vaginally delivered (assisted with forceps) at full term and weighed 4.1 kg (9 lb). The Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Oxygen is administered by mask but does not relieve the cyanosis. Further examination reveals tachypnea, subcostal retractions, a normal first heart sound, a single and loud second heart sound (S2), and no murmur. Which of the following is the most likely cause of the infant's cyanosis?
. Transposition of the great vessels
. Atrial septaI defect
. Coarctation of the aorta
. Ventricular septal defect
. Patent ductus arteriosus
342) A 5-year-old girl presents to the emergency department with acute onset of muscle weakness. The mother carried the girl to the examination room and states that the muscle weakness started in her daughter's legs yesterday. The weakness became worse today and progressed to the trunk and both arms. She was also complaining difficulty of breathing earlier today. She has been otherwise healthy but had a common cold about 10 days ago. On examination, her respirations are 26/min and shallow. She has profound muscle weakness in her lower extremities, and moderate weakness in her upper extremities. Her deep tendon reflexes are absent. A lumbar puncture is performed, which shows increased protein concentration but no pleocytosis. Which of the following is the most likely diagnosis?
. Botulism
. Dermatomyositis
. Guillain-Barré syndrome
. Myasthenia gravis
. Toxic neuropathy
343) A 4-year-old previously healthy but unimmunized boy presents with sudden onset of high fever, inspiratory stridor, and refusal to drink. Of the following causes of inspiratory stridor, which best fits this clinical scenario?
Epiglottitis
Vascular ring
Croup
Foreign body aspiration
Laryngeal tumor
344) A week-old infant presents blood in his stools. He was born at home, with the father assisting in the delivery; no physician or midwife was present. He has been breast-fed and has been nursing well. On examination, you also note some blood in his nose. He is not jaundiced; a rectal examination and guaic test of the stool confirms that blood is present. His examination is otherwise normal. He is on no medications. Which of the following is the most likely diagnosis?
Child abuse
Vitamin K deficiency
Breast milk allergy
Sepsis
Liver disease
345) A 12-year-old American boy comes to you with the complaints of abdominal pain and dark urine. On examination he has normal vitals, icteric sclerae, and abdominal tenderness with a mass palpable in right upper quadrant. His laboratory report shows bilirubin: 6.5 mg/di, negative viral serologies and mild elevations of amylase and lipase. Ultrasonography shows a cystic extra hepatic mass and a gall bladder separated from the mass. What is the most likely diagnosis in this patient?
. Caroli's syndrome
. Choledochal cyst
. Biliary abscess
. Biliary atresia
. Pseudo pancreatic cyst
346) A 10-year-old boy has been having “bellyaches” for about 2 years. They occur at night as well as during the day. Occasionally, he vomits after the onset of pain. Occult blood has been found in his stool. His father also gets frequent, nonspecific stomachaches. Which of the following is the most likely diagnosis?
. Peptic ulcer
. Appendicitis
. Meckel diverticulum
. Functional abdominal pain
. Pinworm infestation
347) During a well-child visit, the grandmother of an 18-month-old patient is concerned because the child’s feet turn inward. She first noticed this when her grandson began to walk. It does not seem to bother the child. On examining his gait, his knees point forward and his feet turn inward. Which of the following is the most likely cause of this condition?
Adducted great toe
Femoral anteversion
Legg-Calvé-Perthes disease
Medial tibial torsion
Metatarsus adductus
348) Two weeks after a viral syndrome, a 9-year-old boy presents to your clinic with a complaint of several days of weakness of his mouth. In addition to the drooping of the left side of his mouth, you note that he is unable to completely shut his left eye. His smile is asymmetric, but his examination is otherwise normal. Which of the following is the most likely diagnosis?
Guillain-Barré syndrome
Botulism
Brainstem tumor
Cerebral vascular accident
Bell palsy
349) A 4-year-old girl is noticed by her grandmother to have a limp and a some-what swollen left knee. The parents report that the patient occasionally com- plains of pain in that knee. An ophthalmologic examination reveals findings as depicted in the photograph. Which of the following conditions is most likely to be associated with these findings?
Juvenile rheumatoid arthritis
Slipped capital femoral epiphysis
Henoch-Schönlein purpura
Legg-Calvé-Perthes disease
Osgood-Schlatter disease
350) A 1-month old boy is brought to the emergency department by his mother, who states that he has been having what she describes as "projectile vomiting" for the past several days. She states that he vomits every time she feeds him, and the situation seems to be getting worse, although he does not seem to be in pain. She describes the vomitus as non-bilious, and he has had normal stools with no blood in them. On examination, the infant appears to be mildly dehydrated, his abdomen is soft, and there is a palpable, olive-sized, firm moveable mass in the right upper quadrant. Which of the following is the most likely diagnosis?
. Duodenal atresia
. Intussusception
. Hirschsprung disease
. Midgut volvulus
. Pyloric stenosis
351) A pediatrician examines a 2-month-old infant who had been born at term. The pediatrician hears a continuous murmur at the upper left sternal border. The peripheral pulses in all extremities are full and show widened pulse pressure. Which of the following is the most likely diagnosis?
. Coarctation of the aorta
. Patent ductus arteriosus
. Peripheral pulmonic stenosis
. Persistent truncus arteriosus
. Ventricular septal defect
352) A 3-week-old infant is being evaluated for hematochezia. His mother states that the infant passed stools j that contain both blood and mucus. There were no complications during her pregnancy, and the infant has been otherwise healthy. On physical examination, his temperature is 37.1 C (98.9 F), pulse is 110/min, and respirations are 18/min. He appears well, and his fontanelle is flat and level. Abdominal examination reveals normal active bowel sounds; his abdomen is nontender to palpation and there is no mass. His diaper contains stool that has bright red blood on it with mucus. Which of the following is the most likely explanation of his hematochezia?
Food allergy-induced colitis
Meckel diverticulum
Necrotizing enterocolitis
Rectal fissure
Ulcerative colitis
353) A 7-year-old boy is brought to the physician because of a persistent mucopurulent nasal discharge for 2 weeks following a common cold. The mother also reports that the child has had frequent cough during the day and occasional temperatures up to 38.0 C (100.5 F). The child does not appear critically ill, but he complains of mild pain in the maxillary region and nasal obstruction. Rhinoscopic examination reveals a rivulet of purulent fluid coming from the inferior meatus. The rest of the physical examination is normal. Which of the following is the most likely diagnosis?
Acute bacterial sinusitis
Acute otitis media
Acute viral rhinitis
Allergic rhinosinusitis
Asthma
354) A 9-year-old boy presents with a several-day history of progressive arm and leg weakness. He has been well except for an upper respiratory infection 2 weeks ago. The patient is alert and oriented. On repeated examination, the heart rate varies between 60 and 140 beats/min, and the blood pressure (BP) varies between 90/60 and 140/90 mmHg. Respirations are shallow, with a rate of 50/min. There is symmetric weakness of the face and all four extremities. Deep tendon reflexes are absent. Sensation is intact. Which of the following is the most likely diagnosis?
Polymyositis
Myasthenia gravis
Transverse myelitis
Guillain-Barré syndrome
Viral encephalitis
355) A previously healthy 4-year-old child pictured below presents to the emergency room (ER) with a 2-day history of a brightly erythematous rash and temperature of 40°C (104°F). The exquisitely tender, generalized rash is worse in the flexural and perioral areas. The child is admitted and over the next day develops crusting and fissuring around the eyes, mouth, and nose. The desquamation of skin shown in the photograph occurs with gentle traction. Which of the following is the most likely diagnosis?
Epidermolysis bullosa
Staphylococcal scalded skin syndrome
Erythema multiforme
Drug eruption
Scarlet fever
356) A 6-year-old boy is brought to the emergency department (ED) by the paramedics due to nausea, vomiting, diarrhea and abdominal pain over the past hour. His mother found an open multivitamin supplement bottle and some pills scattered on the kitchen floor. After his admission to the ED, he starts hyperventilating and experiences hematemesis. His blood pressure is 90/60 mmHg, pulse is 130/min, respirations are 50/min and temperature is 37.2 C (99F). Abdominal plain x-ray reveals several small opacities in the stomach and duodenum. Lab results are: Hb 13.5 g/dL, Ht 42%, WBC 10,000/mm3, Platelets 300,000/mm3, Blood Glucose 118 mg/dL, Serum Na 135 mEq/L, Serum K 34 mEq/L, Chloride 102 mEq/L, Bicarbonate 16 mEq/L, BUN 16 mg/dL, Serum Creatinine 1.0 mg/dL, pH 7.30, P02: 90 mm Hg, PC02: 29 mm Hg. What is the most likely diagnosis?
. Riboflavin poisoning
. Vitamin A poisoning.
. Vitamin D poisoning
. Vitamin K poisoning
. Iron poisoning
357) A 3-year-old boy is brought to the office by his mother because he has been having painless passage of black stools for the past few days. Otherwise, his bowel habits are normal. He has no other medical problems. He takes no medication. His vital signs are within normal limits. The physical examination is unremarkable. What is the most likely diagnosis of this patient?
Peptic ulcer disease
Anal fissure
Intussusception
Inflammatory bowel disease
Meckel's diverticulum
358) A 2-week-old Caucasian male presents with constipation since birth. He was born full term via a normal vaginal delivery. He did not pass meconium till his 3rd day of life, after he was given a glycerin suppository. He has since stooled every 3–4 days, only with the help of a suppository. The stools are pellet like. He has had increasing abdominal distention. On rectal examination, tone appears normal and the ampulla contains no stool. Which of the following is the most likely cause?
Cystic fibrosis
Hirschprung disease
Anal stenosis
Functional constipation
Hypothyroidism
359) A 44 year old woman delivers a 3120 g (6 lb 14 oz) newborn male. Her pregnancy was normal except that she noted decreased fetal movement compared to her previous pregnancies. She declined an amniocentesis offered by her obstetrician. Physical examination of the newborn reveals an infant with facial features suggestive of Down syndrome. The infant then has bilious vomiting. An x-ray film showing the kidneys, ureters, and bladder (KUB) is performed, which shows a "double bubble" sign. Which of the following is the most likely cause of the abdominal signs and symptoms?
. Duodenal atresia
. Hirschsprung Disease
. Malrotation
. Meconium ileus
. Pyloric stenosis
360) A 9-year-old Caucasian male complains of fever, sore throat and difficulty swallowing. Small tender lymph nodes are palpated in the cervical region. The symptoms subside quickly on penicillin therapy. Ten days later, the patient presents again with fever, skin rash and fleeting joint pain in the lower extremities. Physical examination reveals scattered urticaria and palpable lymph nodes in the cervical, axillary and inguinal regions. Which of the following is the most likely cause of this patient's current complaints?
. Rheumatic fever
. Drug-induced reaction
. Lymphoproliferative disorder
. Henoch-Schonlein purpura
. Infective endocarditis
361) A 28-month-old female has been living with her mother in a shelter for homeless women and children. She is brought to the Emergency Department in status epilepticus, which is stopped with intravenous lorazepam. She is placed on a cardiac monitor and a wide complex tachycardia is noted. The ventricular tachycardia reverts to sinus tachycardia after defibrillation is performed. Her temperature is 38.5 C (101.3 F), blood pressure is 120/80 mm Hg, pulse is 195, and respirations are 26. Physical examination reveals a lethargic, pale toddler with dilated and reactive pupils, dry mucous membranes, shallow respirations, diaphoresis and brisk deep tendon reflexes. A urine toxicology screen is most likely to detect which of the following substances?
. Barbiturates
. Cocaine
. Heroin
. Marijuana
. PCP
362) A 4-year-old girl is brought to the office due to seizures that occurred 2 hours ago. This is her first episode. Her parents are also concerned because she is not able to carry on activities that children of her age are expected to do. On examination, there is a red flat lesion covering the left eye area and adjacent facial skin, which does not blanch on pressure, and which the parents say has been present since birth. Other pertinent findings are hemianopia, hemiparesis, and hemisensory disturbances. An x-ray of the skull shows tramline intra-cranial calcifications. What is the most likely diagnosis?
. Sturge-Weber syndrome
. Tuberous sclerosis
. Capillary hemangioma
. Epilepsy
. Neurofibromatosis
363) A term neonate is small for date and has a small head. Further physical examination of the infant demonstrates small eyes with short palpebral fissures, a flattened nose, and abnormal palmar creases. With which of the following maternal conditions is this presentation most likely associated?
Alcohol abuse
Cirrhosis
Cocaine abuse
Diabetes mellitus
Hypothyroidism
364) A 10-day-old infant is brought to the office by her mother for the evaluation of purulent discharge from both eyes. The discharge appeared three days ago, after which the child developed a cough. On examination, the infant's eyes appear normal, except for the presence of purulent discharge. Auscultation reveals diffuse rales without wheezing. Chest radiograph shows a hyperinflated thorax. What is the most likely diagnosis?
. Gonococcal conjunctivitis
. Chemical conjunctivitis
. Congenital chlamydial infection
. Congenital rubella infection
. Adenovirus infection
365) A 2-month-old girl presents to her pediatrician's office for well-child care. Her mother complains of excessive tearing of the baby's left eye for the past 4 weeks. Each morning, a yellow crusty discharge is noted along the lashes of the left eye. The conjunctiva appears uninflamed. The right eye is not affected. On physical examination, the infant is otherwise well and achieving adequate weight gain on an exclusive breast milk diet. She is developmentally appropriate, including visually tracking 180 degrees. Which of the following is the most likely diagnosis?
Dacryostenosis
Gonococcal conjunctivitis
Normal infant eye
Viral conjunctivitis
Vitamin A deficiency
366) A 3-week-old female infant born at 38 weeks' gestation through an uncomplicated vaginal delivery, presents to the emergency department with 2-day history of fever. The infant had been healthy since birth. Her temperature in the emergency department is 40.0 C (104.0 F). She appears to be quite lethargic. A culture taken from the infant grows group B Streptococcus (GBS) in 24 hours. Which of the following infections is most consistent with this presentation?
. Endocarditis
. Gastroenteritis
. Meningitis
. Pneumonia
. Pyelonephritis
367) A 10-year-old boy is brought to clinic because of increasing weakness and dyspnea over the past 6 months. He has been previously healthy and is on no medications. There is no significant family history of illness. On examination, he appears pale. His hematocrit is 20%, mean corpuscular volume (MCV) is 60/mm3, and iron level is normal. Smear reveals basophilic stippling. Hemoglobin electrophoresis is consistent with the absence of one beta-globin gene. Which of the following is the most likely diagnosis?
EUiptocytosis
Hemoglobin S-C disease
Porphyria
Sickle cell disease
Thalassemia
368) The child shown below presents with a 3-day history of malaise, fever to 41.1C (106F), cough, coryza, and conjunctivitis. He then develops the erythematous, maculopapular rash pictured. He is noted to have white pinpoint lesions on a bright red buccal mucosa in the area opposite his lower molars. Which of the following is the most likely diagnosis?
. Parvovirus
. Rubella
. Herpes
. Rubeola
. Varicella
369) A 3-week-old infant with hypoplastic left heart syndrome comes to the physician for a follow-up visit. The infant was born at term via normal spontaneous vaginal delivery. The patient had the first of 3 palliative heart surgeries shortly after birth. He did well after surgery and was discharged home one week ago. Over the last 24 hours, the infant has difficulty feeding and one episodes of vomiting. On examination, the infant is afebrile, pulse is 160/min, respiratory rate is 55/min, blood pressure is 90/50mmHg, and pulse oximetry is 80% on room air. He is mildly cyanotic, small, but well developed. His cardiovascular exam reveals tachycardia and distant heart sounds with a systolic ejection murmur heard throughout the precordium. His chest radiographs from discharge and today are shown below. What is the most likely diagnosis?
. Congestive heart failure
. Endocarditis
. Pleural effusion
. Pericardial effusion
. Myocarditis
370) A mother wishes to breast-feed her newborn infant, but is worried about medical conditions that would prohibit her from doing so. You counsel her that of her listed conditions, which of the following is a contraindication to breast-feeding?
. Upper respiratory tract infection
. Cracked and bleeding nipples
. Mastitis
. Inverted nipples
. HIV infection
371) A mother brings her 6-year-old daughter for evaluation because she has never been able to toilet train her. The child states that she perceives the sensation of having to void, and empties her bladder normally at normal intervals, but is nonetheless wet with urine all the time. Which of the following is the most likely diagnosis?
Low implantation of one ureter
Meatal stenosis
Ureteropelvic junction obstruction
Ureterovesical reflux
Urethral valves
372) A 6-day-old girl who was born at home is being evaluated for bruising and gastrointestinal bleeding. Laboratory findings include partial thromboplastin time and prothrombin time, greater than 2 minutes; serum bilirubin, 4.7 mg/dL; alanine aminotransferase, 18 mg/dL; platelet count, 330,000/mm3; and hemoglobin, 16.3 g/dL. Which of the following is the most likely cause of her bleeding?
. Factor VIII deficiency
. Factor IX deficiency
. Idiopathic thrombocytopenic purpura
. Liver disease
. Vitamin K deficiency
373) A 1-year-old African American infant is in for well-child care. He is primarily breast-fed. His parents do not give him much solid food because he has no teeth. He receives no medications or supplements. His parents are concerned about his bowed legs. On examination, you note some other bony abnormalities including frontal bossing, enlargement of the costochondral junctions, a protuberant sternum (pigeon chest), and severe bowing of the legs. You obtain x-rays to confirm your clinical diagnosis and also note a healing fracture of the left femur. Which of the following is the most likely diagnosis?
Osteogenesis imperfecta
Scurvy
Congenital syphilis
Rickets
Chondrodystrophy
374) A 2-year-old boy is brought to the emergency department by his mother for the evaluation of a productive cough and low-grade fever. He has had ten such infections over the past year, all of which required antibiotics. He was delivered vaginally without any complications. He is an only child. His mother's siblings have a history of similar infections. He is alert and has normal vital signs, except for a mild fever. Auscultation reveals rales and rhonchi in both lungs. The chest x-ray is shown below. What is the most likely diagnosis?
. Cystic fibrosis
. Foreign body
. Kartagener's syndrome
. Immunoglobulin deficiency
. Congenital bronchiectasis
375) A 14-year-old boy presents with sudden onset of pain and swelling of his right testicle. There was no history of trauma, he is not sexually active, and denies any history of penile discharge. On examination, the scrotum is swollen and tender. The cremasteric reflex is absent. A testicular flow scan shows a “cold spot” or absent flow to the affected side. Which of the following is the most likely cause?
Inguinal hernia
Hydrocele
Epididymitis
Testicular torsion
Torsion of the appendix testis
376) The developmentally delayed 6-month-old child in the picture below had intrauterine growth retardation (including microcephaly), hepatosplenomegaly, prolonged neonatal jaundice, and purpura at birth. The calcific densities in the skull x-ray shown are likely the result of which of the following?
. Congenital cytomegalovirus (CMV) infection
. Congenital toxoplasmosis infection
. Congenital syphilis infection
. Tuberculous meningitis
. Craniopharyngioma
377) The infant pictured below develops infantile spasms. Which of the following disorders is most likely to be affecting this infant?
. Neurofibromatosis
. Tuberous sclerosis
. Incontinentia pigmenti
. Pityriasis rosea
. Psoriasis
378) A 28-year-old Caucasian female comes to the office due to fever for the past 3 days. She also complains of pain and swelling in her right breast for the past 4 days. She exclusively breastfeeds her 3-month-old baby. On examination, she is febrile. Her right breast is engorged, red and tender, without any area of fluctuation. She wants to know if she can continue to breastfeed. Which of the following is a contraindication to breastfeeding?
. Mastitis
. Acquired immune deficiency syndrome
. Maternal rubella infection
. Breast milk jaundice
. Hemolytic disease of the newborn
379) Among the conditions that cause edema of the eyelids is orbital cellulitis. This is a serious infection that must be recognized early and treated aggressively if complications are to be avoided. Which of the following features is useful in differentiating orbital cellulitis from periorbital (preseptal) cellulitis?
Proptosis
Elevated WBC count
Fever
Lid swelling
Conjunctival inflammation
380) A 30-minute-old male newborn is noted to have central cyanosis. He was born to a 16-year-old white female at 28 weeks gestation. His respirations are rapid and shallow at 70/min. His other vital signs are stable. On examination, there is audible grunting, intercostal and subcostal retractions, nasal flaring, and duskiness. On auscultation, fine rales are heard over the lung bases. Nasal oxygenation does not improve his cyanosis. A chest roentgenogram shows fine reticular granularity, predominantly in the lower lobes. Arterial blood gas analysis shows evidence of hypoxemia and metabolic acidosis. What is the most likely diagnosis of this patient?
. Transient tachypnea of the newborn
. Hyaline membrane disease (HMD)
. Persistent pulmonary hypertension of the newborn (PPHN)
. Meconium aspiration syndrome
. Intracranial hemorrhage
381) A 10-year-old patient (pictured below) calls his parents from summer camp to state that he has had fever, muscular pain (especially in the neck), headache, and malaise. He describes the area from the back of his mandible toward the mastoid space as being full and tender and that his earlobe on the affected side appears to be sticking upward and outward. Drinking sour liquids causes much pain in the affected area. When his father calls your office, you remind him that he had refused immunizations for his child on religious grounds. Which of the following preventable diseases has this child acquired?
. Mumps
. Varicella
. Rubella
. Measles
. Diphtheria
382) A healthy 1-year-old child comes to your office for a routine checkup and for immunizations. His parents have no complaints or concerns. The next day, the CBC you performed as customary screening for anemia returns with the percentage of eosinophils on the differential to be 30%. Which of the following is the most likely explanation?
. Bacterial infections
. Chronic allergic rhinitis
. Fungal infections
. Helminth infestation
. Tuberculosis
383) Two weeks after a viral syndrome, a 2-year-old child develops bruising and generalized petechiae, more prominent over the legs. No hepatosplenomegaly or lymph node enlargement is noted. The examination is otherwise unremarkable. Laboratory testing shows the patient to have a normal hemoglobin, hematocrit, and white blood cell (WBC) count and differential. The plateletcount is 15,000/μL. Which of the following is the most likely diagnosis?
. Von Willebrand disease (vWD)
. Acute leukemia
. Idiopathic (immune) thrombocytopenic purpura (ITP)
. Aplastic anemia
. Thrombotic thrombocytopenic purpura
384) A 30-minute-old male newborn is noted to have central cyanosis. He was born to a 16-year-old white female at 28 weeks gestation. His respirations are rapid and shallow at 70/min. His other vital signs are stable. On examination, there is audible grunting, intercostal and subcostal retractions, nasal flaring, and duskiness. On auscultation, fine rales are heard over the lung bases. Nasal oxygenation does not improve his cyanosis. A chest roentgenogram shows fine reticular granularity, predominantly in the lower lobes. Arterial blood gas analysis shows evidence of hypoxemia and metabolic acidosis. What is the most likely diagnosis of this patient?
. Transient tachypnea of the newborn
. Hyaline membrane disease (HMO)
. Persistent pulmonary hypertension of the newborn (PPHN)
. Meconium aspiration syndrome
. Lntracranial hemorrhage
385) Friends are considering adopting a “special needs” child from another country. The family has few details, but the information they have received so far suggests the 4-year-old child has had surgery for an endocardial cushion defect, is short for his age, and had a history of what sounds like surgically repaired duodenal atresia at birth. You are suspicious this child may have which of the following syndromes?
. Kleinfelter
. Waardenberg
. Marfan
. Down
. Turner
386) An 8-year-old boy is brought to his physician by his mother, who is worried by the child's frequent episodes of daydreaming, which have apparently resulted in a decline in school performance. The child's psychomotor development appears normal. EEG recording reveals bilateral and symmetric 3 Hz spike-and-wave discharges, which begin and end abruptly on a normal background. Which of the following is the most likely diagnosis?
Absence seizures (petit mal)
Complex partial seizures
Pseudoseizures
Simple partial seizures
Tonic-clonk seizures (grand mal)
387) A 1400-g infant, born at 35 weeks' gestation, is 42 cm in length and a head circumference of 28 cm. One day after birth, she becomes very irritable, tremulous, and inconsolable. Her cry is high-pitched. Her pulse is 174/min. There are no dysmorphic facial features. To which of the following substances was this newborn most likely exposed in utero?
. Alcohol
. Barbiturates
. Cocaine
. Marijuana
. Opiates
388) A 16-year-old female presents to the emergency room with severe right- sided abdominal pain. Her last menstrual period was 2 weeks ago and felt to be normal. She displays painful difficulty in positioning herself on the examination table. Her temperature is 38.5 C (101.3 F), blood pressure is 128/75 mm Hg, pulse is 80/min, and respirations are 22/min. Examination of the throat reveals mild pharyngitis. Her abdomen is diffusely tender, especially the lower abdomen. Rectal examination reveals tenderness anteriorly on the right side. Stool guaiac is negative. A pelvic examination is performed, and there is evidence of cervical tenderness and questionable fullness in the right adnexal area. Which of the following is the most likely diagnosis?
. Ovarian cyst
. Pyelonephritis
. Pelvic inflammatory disease
. Constipation
. Endometriosis
389) The mother of one of your regular patients calls your office. She reports that her daughter has a 3-day history of subjective fever, hoarseness, and a bad barking cough. You arrange for her to be seen in your office that morning. Upon seeing this child, you would expect to find which of the following?
. A temperature greater than 38.9C (102F)
. Expiratory stridor
. Infection with parainfluenza virus
. Hyperinflation on chest x-ray
. A child between 6 and 8 years of age
390) A 2 and a half-year-old child is brought to the office for the evaluation of easy bruising, nosebleeds, and decreased activity over the past week. He had an upper respiratory infection that was treated with an antibiotic 2 weeks ago. On examination, he is well-developed, seems well-nourished, anicteric, and pale. Pertinent findings include some small palpable posterior cervical lymph nodes, sinus tachycardia, a grade I/VI systolic ejection murmur, ecchymoses on his left shoulder and both lower extremities, and petechiae over his extremities and groin. There is no hepatosplenomegaly. The laboratory findings are as follows: Hemoglobin 7.9 g/dl, Hematocrit 24%, Platelet count 12, 000/mm3, WBC 3,000/mm3, Reticulocyte count 0.5%. A bone marrow biopsy reveal a markedly hypocellular marrow with decreased megakaryocytes and precursors of the erythroid and myeloid cell lines. What is the most likely diagnosis?
. Acquired aplastic anemia
. Fanconi's anemia
. Diamond-Biackfan anemia
. Transient erythroblastopenia
. Acute myeloid leukemia
{"name":"USMLE Pediatry For Student Diagnostic Pédiatrie P2 190 QCM", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"201) A 2-year-old patient arrives late to your office with his father and a sign-language translator. They are very apologetic, but the father communicates that he had car trouble at his dialysis center and thus was late picking up the child from day care. The father is concerned about his child’s having intermittent red, bloody-looking urine. A gross inspection of the child’s urine in your office looks normal, but the dipstick demonstrates 3+ blood. Which of the following is the most likely cause of this child’s hematuria?, 202) A 2-year-old boy is brought to the clinic by his mother because he is lethargic and not as active as the other kids on their block. He has difficulty walking and getting up, and he always appears tired. His mother thinks that she has a relative with a disorder that causes weakness. On examination, the child is alert but quiet. His calves appear hypertrophied. His reflexes are depressed. When he gets up from the floor, he uses his hands to climb on his legs to assume an upright position. What is the most likely diagnosis of this child?, 203) A 2-month-old male infant is rushed to the emergency department by his baby sitter. She says that the baby became unresponsive and blue while feeding. The whole episode lasted 45-60 seconds, but the baby still appears pale. She denies any history of coughing or choking. On examination, the infant appears cyanotic and tachypneic. His blood pressure is 90\/60 mm of Hg; his pulse rate is 155\/min and regular. On auscultation, a harsh pansystolic murmur is noted at the left sternal border, along with a single S2. Hepatomegaly is noted. Pulse oximetry shows an oxygen saturation of 80%. Based on this history and physical examination, what is the most likely diagnosis?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
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