You diagnose attention-deficit/hyperactivity disorder in an 8-year-old girl and initiate therapy with a daily morning dose of long-acting methylphenidate. Her mother asks about using stimulant medication after school, on weekends, and during the summer. Of the following, your BEST response is that

A 14-year-old boy has a body mass index that is greater than the 95th percentile for age and an accelerating weight curve. His blood pressure is 135/85 mm Hg. His mother has type 2 diabetes that developed during her first pregnancy, and several paternal relatives also have type 2 diabetes. The family emigrated from the Caribbean when he was a toddler. He has dark velvety thickening of the skin on his neck and under his arms. Of the following, the findings that are MOST supportive of a diagnosis of metabolic syndrome in this young man are

You are present at the birth of an infant in whom bilateral hydronephrosis was diagnosed in utero. A fetal shunt was placed in each flank between the renal pelvis and the amniotic cavity. Nonetheless, the infant has bilaterally palpable flank masses, and the shunts are not apparent at birth. The infant shows no dysmorphisms and has no respiratory distress. Renal ultrasonography reveals bilateral hydronephrosis. Of the following, the MOST correct statement regarding the fetus/neonate who has obstructive uropathy is that

Numerous therapeutic agents are known to have teratogenic effects on the developing fetus. Of the following, the findings in the newborn that are MOST suggestive of prenatal exposure to an angiotensin-converting enzyme inhibitor are

The director of a community after-school program for adolescent boys is organizing an orientation session for new mentors. He wants some information about current substance abuse trends. Of the following, you are MOST likely to report that among adolescents

You are evaluating a 6-year-old boy who has Duchenne muscular dystrophy. He is doing well in a regular classroom and will be attending second grade in a different school next year. On physical examination, you note a healthy-appearing boy who has pseudohypertrophy of the calf muscles and uses a Gower maneuver to rise from the floor. In gathering information to help this child's transition to a new school, you are MOST likely to ask about

And a 1-day history of poor feeding. Findings on physical examination are normal. You initiate a sepsis evaluation that includes a lumbar puncture. The cerebrospinal fluid results demonstrate a white blood cell count of 6x103/mcL (6x109/L), with 68% neutrophils, 2% bands, and 30% lymphocytes. The protein concentration is 200 mgldL (2 giL), and the glucose value is 36 mgldL (2.0 mmol/L). The abnormal findings prompt you to order magnetic resonance imaging, which demonstrates abnormal frontal lobes bilaterally that includes some degree of infarction but also abscesses and cerebritis. Of the following, the MOST likely pathogen is

An 11-year-old highly competitive gymnast presents to your office with complaints of increasing right wrist pain over the past 2 to 3 months. She recalls no specific trauma to the wrist or arm. On physical examination, you note no swelling of the distal forearm or wrist. She has normal range of motion at the wrist. There is moderate-to-marked tenderness of the distal radius, but no tenderness more distally over the wrist joint. A radiograph of the forearm shows slight widening of the distal radial physis. Of the following, you are MOST likely to explain to the child and family that

You have just diagnosed Ebstein anomaly in a newborn. Of the following, the MOST likely prenatal exposure to result in this abnormality is

A 14-year-old-boy has been followed yearly by another physician. When you see him for the first time, he brings records that you use to construct a growth curve (Item Q186A). His parents state that they are not worried about his growth because his 20-year-old brother was a slow grower and still seems to be growing a little. Physical examination reveals 6-mL testes and Sexual Maturity Rating 2 pubic hair. There are no other signs of puberty. His bone age on radiography is 12 years. Of the following, the MOST appropriate suggestion for the family is that

You see a 9-month-old girl for a health supervision visit. She is in her infant carrier with a propped bottle. The mother explains that the infant does not sleep through the night, which is disrupting the mother's ability to function well at work. The infant appears well, with length and head circumferences at the 25th percentile and weight at the 95th percentile. During the examination, the infant cries. The mother hands you a bottle and asks if she may leave to check on a referral for her older child. Of the following, you are MOST likely to suggest to the mother

A 4-month-old boy presents to the clinic with a 2-day history of a temperature of 100.6°F (38.1 °C) and vomiting. The infant was born at 26 weeks' gestation, and his birth weight was 960g. He remained in the hospital for 3 months after birth because of multiple complications, including bilateral grade 4 intraventricular hemorrhages necessitating the placement of a ventriculoperitoneal shunt 6 weeks ago. Physical examination reveals an afebrile infant who has a shunt bubble on the right temporo-occipital region and a gastrostomy button. You explain that his shunt bubble requires aspiration to evaluate the cerebrospinal fluid for infection. Of the following, the organism that is MOST likely to be isolated in the aspirate is

A 16-year-old previously healthy boy presents with a 2-week history of intermittent elevated temperatures to 102°F (39°C), headache, malaise, fatigue, myalgias, and a progressively worsening nonproductive cough. During history-taking, he reports that recently he explored several caves while hiking in a forest preserve in Ohio. Physical examination reveals a tiredappearing adolescent who has a temperature of 102.4°F (39.1 °C), a dry cough, and diffuse intermittent rhonchi on chest auscultation. Laboratory findings include a white blood cell count of 12x103/mcL (12x1091L), with 60% neutrophils, 2% band forms, and 38% lymphocytes. Chest radiograph (Item Q190A) shows patchy left upper and left lower lobe opacities and hilar adenopathy. Of the following, the MOST likely pathogen causing this patient's condition is

An African-American mother brings her previously healthy 2-year-old son to the emergency department because he looked pale when he woke up this morning. She also reports fever and decreased activity over the last few days. He was diagnosed with a urinary tract infection and given trimethoprim-sulfamethoxazole 3 days ago. On physical examination, he is markedly pale and appears jaundiced. His heart rate is 170 beats/min, and his respiratory rate is 30 breaths/min. The rest of his physical examination findings are unremarkable. Laboratory evaluation reveals a hemoglobin concentration of 5 gldL (50 giL). Of the following, the MOST likely cause of this boy's anemia is

A 3-year-old girl is brought to your office for re-evaluation of a fever that began 6 days ago. Her mother tells you that her daughter's temperature has been as high as 102.2°F (39°C). Her physical examination was unremarkable when you examined her 3 days ago, but today you note injected sclera; cracked, red lips; a strawberry appearance of her tongue; and a swollen, non tender, cervical node. You tell her mother that you believe this is Kawasaki disease. Of the following, the MOST appropriate statement to make to the mother is that

The mother of a 14-year-old boy arranges to meet with you privately before the boy's annual health supervision visit. She is concerned because he is quiet, has no athletic interests, and has only a few friends. He is content to spend the weekend shopping, cooking, reading, and listening to music. Although he doesn't like school, he is an honor student. The mother also tells you her husband's youngest brother recently disclosed his homosexuality and wants to introduce his male partner to the extended family. Of the following, while counseling the mother, you are MOST likely to include a statement that

You are evaluating a short 14-year-old boy who is underweight for height. His growth curve is shown in Item Q202A. He says he is feeling well. His mother worries that he does not have as much stamina as he did at age 12 years. Of the following, the laboratory study that is MOST likely to be useful in assessing the reason for poor growth is measurement of

You are asked to review a case for morbidity and mortality conference. The infant was born at term to a 19-year-old gravida 1, para 1 woman by normal spontaneous vaginal delivery. The mother was known to be group B Streptococcus-negative, but she did have genital warts. The Apgar scores were 9 at 1 minute and 10 at 5 minutes. On the seventh postnatal day, the infant developed a temperature of 103°F (39.4°C) and was brought to the emergency department. At this time, the infant was in shock and required mechanical ventilation. Physical examination revealed scleral icterus and hepatosplenomegaly but no skin lesions. A lumbar puncture could not be performed. Laboratory results include: White blood cell count of 2.34x103/mcL (2.34x109/L), with 32% lymphocytes, 41% neutrophils, 8% bands, 15% monocytes, 3% eosinophils, and 1% basophils, Hemoglobin of7.1 g/dL (71 giL), Hematocrit of 21% (0.21), Platelet count of 40x103/mcL (40x109/L), Prothrombin time of 41.2 seconds, Activated partial thromboplastin time of >106 seconds, Aspartate aminotransferase concentration of 3,086 UIL, Alanine aminotransferase concentration of 456 UIL, Total bilirubin of 4.4 mg!dL (75.2 mcmol/L). The chest radiograph demonstrated diffuse interstitial infiltrates bilaterally (Item Q204A). The patient did poorly over the next 3 days and died despite aggressive management in a pediatric intensive care unit. Of the following, the MOST likely cause of this patient's death is

A 5-month-old female infant presents with a 1-day history of fever to 102°F (38.9°C), emesis, and multiple episodes of greenish diarrhea with streaks of blood. Her mother states that the infant is less active, sleepier, and has no interest in feeding. Physical examination reveals a listless infant who has a sunken anterior fontanelle, dry mucous membranes with decreased skin turgor, and skin irritation in the diaper area. Of the following, the MOST likely cause of this patient's gastroenteritis is

A mother brings in her 2-year-old boy for food avoidance education after he was seen in the emergency department last week for anaphylaxis following peanut ingestion. This is the third anaphylactic episode after peanut ingestion since he was diagnosed with a peanut food allergy at age 1 year. At that time, he was evaluated by a pediatric allergist and determined to have positive skin tests and an elevated serum immunoglobulin (lg) E to peanut antigen, consistent with an lgE-mediated allergy. The mother is frustrated and would like advice regarding peanut food allergy. Of the following, the BEST advice at this time is to

The family of a diabetic patient in your practice requests evaluation for celiac disease. They have heard from other families of children who have diabetes that patients who have type 1 diabetes are at increased risk for this condition. Of the following, a TRUE statement regarding celiac disease screening is that

A newborn in your neonatal intensive care unit has had intermittent seizures for 72 hours. You have been unable to control the seizures with phenobarbital, hydantoin, and lorazepam. Electrolyte, calcium, magnesium, and glucose concentrations are normal. The infant subsequently becomes apneic, comatose, and unresponsive. Of the following, the BEST laboratory test to determine the cause of coma in this infant is

During clinic rounds with medical students, you are seeing a 2-year-old girl who has otitis media. One of the students asks about the potential complications of otitis media. Of the following, the statement you are MOST likely to make is that

An 18-year-old girl presents for a health supervision visit prior to leaving for college. She has a letter from the college she plans to attend instructing entering freshman who choose to live in the dormitories to obtain a meningococcal vaccination. You review vaccine information and obtain consent for the immunization. Of the following, an ACCURATE statement about recommendations for the use of the meningococcal MCV4 vaccine is that it

You are seeing a 6-year-old girl whose mother is concerned about the girl masturbating. For the past several months, the girl has touched her genitals while watching television with her mother. The parents have been divorced for 2 years, and the girl spends weekends with her father. You question her mother further. Of the following, the response that MOST increases your suspicion for behavior that is out of the norm is

The mother of a 4-month-old infant is planning a winter trip to the tropics with her infant and asks about the use of sunscreens and the safe amount of sun exposure for the infant. Of the following, the MOST appropriate advice for the infant is to

A 5-month-old infant presents with a history of vomiting between 10 and 20 times a day. She is growing and developing normally. There is no blood in the vomitus, no respiratory symptoms, and no history of apnea. The parents are frustrated from cleaning up after the baby vomits and want something done. Physical examination and upper gastrointestinal radiograph evaluation results are normal. Of the following, the MOST accurate statement about this patient is that she

A 4-year-old girl remains intubated, mechanically ventilated, and completely unresponsive in the intensive care unit following a massive subarachnoid hemorrhage of unknown cause. She is hemodynamically stable and not receiving any sedating medications. She has a temperature of 98.1°F (36.7°C) and has no evidence of infection. The girl has not exhibited any brainstem or cerebral function for more than 24 hours. Of the following, the statement you are MOST likely to make while on rounds with the resident team is that

A 4-month-old child is admitted to the hospital for evaluation of failure to thrive and generalized seizures. On physical examination, the child appears wasted and has a protuberant abdomen and marked hepatomegaly. Laboratory evaluation reveals fasting hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia. The boy's parents are first cousins. Of the following, the BEST long-term management of this disorder is

A 17-year-old boy presents for a sports physical. He has a learning disability and is shy. His height is at the 75th percentile, and his body mass index is at the 85th percentile. Physical examination findings include minimal facial hair, bilateral gynecomastia (breast >4 em in diameter), and small testes (testicular volume of 6 mL). Of the following, the MOST likely cause of this patient's gynecomastia is

You are discussing diarrheal diseases with a group of medical students interested in international health. You advise them that there are more than 2,000 serovars of Salmonella. Of the following, the serovar that has the MOST public health implications is

The father of three children in your practice recently was diagnosed with Crohn disease. His wife does not have Crohn disease. He asks you if his children, ages 10, 12, and 16 years, are at increased risk for developing the same illness. Of the following, you are MOST likely to advise the father that

During a health supervision visit of a 6-year-old child, you ask the mother if there are any guns in the home. She states that her husband is a hunter, but he keeps his shotgun in his pickup truck. Of the following, the BEST anticipatory guidance with regard to firearm safety is to tell the mother to

You are seeing a new patient who is 11 years old and has Duchenne muscular dystrophy. His uncle died of the disorder 2 years ago. His mother asks to see you privately and tells you that her son does not know his diagnosis; she asks that you refer to his "walking problem." On physical examination, you note that the boy is in a wheelchair and is unable stand without support. You ask to speak with the mother after evaluating the boy. Of the following, you are MOST likely to tell her that

A 5-year-old girl presents after having a brief generalized seizure. Her mother reports that the child has had a 3-day history of fever, tenesmus, and bloody diarrhea. On physical examination, you find a mildly toxic-appearing child who has a temperature of 104°F (40°C) and diffuse abdominal tenderness. The rectal examination produces significant pain. Stool from her rectum is guaiac-positive. You tell her mother that you believe the diarrhea has an infectious cause. Of the following, the MOST likely pathogen is

A 3-month-old boy is admitted to the hospital for evaluation of failure to thrive. His birthweight was at the 50th percentile and length at the 75th percentile. Currently, his weight is below the 5th percentile and length is at the 25th percentile. His vital signs and physical examination results are otherwise normal. He appears well hydrated. Measurement of serum electrolytes reveals: sodium, 139 mEq/L (139 mmol/L); potassium, 4.7 mEq/L (4.7 mmol/L); chloride, 114 mEq/L (114 mmol/L); bicarbonate 12 mEq/L (12 mmol/L); blood urea nitrogen, 8 mgldL (2.9 mmoi/L); and creatinine, 0.3 mgldL (26.5 mcmol/L). A consulting nephrologist recommends measurement of urine pH (which is 7.5) and urine ammonium (which is 12,000 mcMIL) (normal, >60,000 mcMIL). Of the following, the MOST likely cause of this child's acidosis is

You are asked to evaluate two children, ages 3 and 9 years, on the pediatric hematologyoncology inpatient unit who have developed fever, cough, increased work of breathing, and nodular lesions on their chest radiographs. The children are isolated in private rooms and have different nurses and doctors caring for them. The children's rooms are located adjacent to an area where a new playroom is being constructed. Of the following, the MOST likely pathogen causing these patients' pneumonia is

A 15-year-old boy presents with melena and anemia. Endoscopy demonstrates a nodular gastritis of the antrum and an ulcer. Biopsies of the antrum demonstrate spiralshaped organisms consistent with Helicobacter pylori. You prescribe amoxicillin, clarithromycin, and lansoprazole for 2 weeks. At a follow-up visit, the family asks whether the treatment has been successful in eradicating the organism. Of the following, the PREFERRED noninvasive test to evaluate whether the pathogen has been eradicated is

A term newborn is delivered by emergent cesarean section because of intrauterine growth restriction, oligohydramnios, and nonreassuring fetal heart rate monitoring in labor. Delivery room resuscitation includes endotracheal intubation and assisted ventilation with 100% oxygen, chest compressions, intravenous epinephrine, and volume expansion. Apgar scores are 1, 2, and 3 at 1, 5, and 10 minutes, respectively. An umbilical cord arterial blood gas measurement documents a pH of 6.9 and a base deficit of 20 mmoVL. At 12 hours of age, the infant demonstrates tonic-clonic convulsive activity of the arms and legs with a concomitant decrease in heart rate and bedside pulse oximetry saturation. Of the following, the MOST likely cause for this infant's seizure is:

You are precepting a resident who has just evaluated a 4-year-old incompletely immunized immigrant boy who has classic varicella lesions and a history that is consistent with this diagnosis. Of the following, the MOST accurate statement is that

The parents of a child who has Down syndrome and a 47,XX+21 karyotype come to you for counseling about future pregnancies. Of the following, their risk for giving birth to another child who has trisomy is CLOSEST to:

A 15-month-old infant has been breastfed since birth. He eats finger foods (eg, peas, carrots) and occasionally some cereal. His mother adheres to a vegan diet and plans the same for her child. A complete blood count documents anemia. Of the following, the MOST likely cause of this infant's anemia is a deficiency of:

A 15-year-old boy comes to your office for a health supervision visit. He expresses concern that he is only 5 ft, 2 in tall and is not competitive in track. On physical examination, he appears healthy, has a height of 62 in, and weighs 96lb. His testes are 8 mL in volume bilaterally, there is slight pubertal phallic enlargement, and he has Sexual Maturity Rating 3 pubic hair. He has a small amount of subareolar breast tissue. His last health supervision visit was 2 years ago. He did not have pubic hair at the last visit, and his testes were described as "prepubertal" in size. Of the following, the MOST likely cause of his short stature is

You are examining a 2-year-old girl who has a 6-month history of developmental regression. During her first postnatal year, she met all motor, language, and social milestones. Her head circumference, which currently is at the 3rd percentile, was at the 75th percentile at birth. On physical examination, she makes poor eye contact and repetitively wrings her hands. Of the following, the MOST appropriate diagnostic test is:

You are conducting rounds in the newborn nursery with a group of residents. You describe the choices for infant nutrition that might optimize growth and development. Of the following, you are MOST likely to state that

A 3-year-old child who has a history of recurrent otitis media with effusion (OME) in infancy is brought to the clinic. His mother is afraid that he has a hearing loss because he does not talk as much as his brother did at the same age. He speaks in three-word sentences, and you can understand fewer than 50% of his words. Results of his physical examination, including the ears, are normal. Of the following, the MOST appropriate statement regarding this child's condition is that:

You are asked to see a term infant in the newborn nursery at 8 hours of age and consider her transfer to the neonatal intensive care unit. The problems and findings reported to you include: poor feeding, emesis, temperature instability (core temperature of 96°F [35.5°C]), hypoglycemia (whole blood glucose concentration of 25 mg/dL [1.4 mmoi/L]), and polycythemia (hematocrit of 70% [0.70]). Of the following, the physical finding that is MOST likely to accompany these problems is

A normal-appearing 9-month-old boy is discovered on routine herniorrhaphy to have bilateral Fallopian tubes and a rudimentary uterus. Biopsy of the gonads performed during this procedure revealed normal testicular tissue. On examination today, his phallus is normal in size and appearance, and his descended testes are both 2 mL in volume. Of the following, the MOST likely sex chromosome complement for this child is

An 8-year-old boy has difficulty with reading; he reads slowly and makes many mistakes. He has a history of a febrile seizure at 1 year of age and a fall at age 2 years that resulted in a brief loss of consciousness. His mother read an article about interventions for improving vision function in children who have reading difficulties and would like your opinion. Findings on his physical examination are normal, except for vision of 20/40 bilaterally. Of the following, your BEST response is that you would like to

The mother of a child who is infected with human immunodeficiency virus (HIV) would like to enroll her child in a local child care center. Of the following, the circumstance that is MOST likely to exclude the child who has HIV infection from attending a child care center is