Pediatrics End of Rotation Exam

Pediatrics End of Rotation Exam

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Question 1
6 y/o male presents w/ hemarthrosis of the L knee. Coag studies: PT 12.5s (normal12-14 sec), INR 1.0, aPTT 58s (normal 18-28 sec), platelet 430,000/microliter (normal 150,000-450,000/microliter), & bleeding time 4m (normal 2-12m). Which is the best tx option for this pt?
A
Desmopressin acetate
Hint:
Desmopressin acetate is indicated in von Willebrand's disease, which presents with a prolonged bleeding time.
B
Corticosteroids
Hint:
Corticosteroids are indicated in immune-mediated thrombocytopenia.
C
Vitamin K
Hint:
Vitamin K deficiency will prolong the PT greater than the aPTT. Vitamin K supplement is not indicated in this patient.
D
Cryoprecipitate
Question 1 Explanation: 
Hemophilia A presents with a prolonged aPTT and normal platelet count and function. Hemophilia A is treated with factor VIII concentrate or cryoprecipitate.
Question 2
A newborn weighs 8 pounds at birth. On average, what should the infant weigh at 1 year of age?
A
16 pounds
Hint:
An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.
B
20 pounds
Hint:
An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.
C
24 pounds
D
28 pounds
Hint:
An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.
Question 2 Explanation: 
An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.
Question 3
Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)?
A
Drooling
Hint:
Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup.
B
High fever
Hint:
Fever is usually absent or low-grade in patients with viral croup.
C
Hot potato" voice
Hint:
Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup.
D
Barking cough
Question 3 Explanation: 
Viral croup is characterized by a history of upper respiratory tract symptoms followed by onset of a barking cough and stridor.
Question 4
A 3 year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is
A
renal.
Hint:
The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
B
cardiac.
C
pulmonary.
Hint:
The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
D
hepatic
Hint:
Children with Kawasaki syndrome may have associated hydrops of the gallbladder, but liver involvement is not part of this disorder.
Question 4 Explanation: 
The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
Question 5
Annual blood pressure determinations should be obtained beginning at the age of
A
3 years.
B
5 years.
Hint:
Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years.
C
12 years.
Hint:
Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years.
D
18 years..
Hint:
Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years.
Question 5 Explanation: 
Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years.
Question 6
In infants, the eyes should move in parallel without deviation by the age of
A
2 weeks.
Hint:
Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months.
B
3 months.
Hint:
Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months.
C
6 months.
D
1 year.
Hint:
Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months.
Question 6 Explanation: 
Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months.
Question 7
A 24 year-old male presents for routine physical examination. On physical examination, you find that the patient's upper extremity blood pressure is higher than the blood pressure in the lower extremity. Heart exam reveals a late systolic murmur heard best posteriorly. What is the most likely diagnosis in this patient?
A
Hypertrophic obstructive cardiomyopathy
Hint:
Patients with hypertrophic obstructive cardiomyopathy do not present with hypertension or weak femoral pulses.
B
Patent foramen ovale
Hint:
The murmur associated with patent foramen ovale is a systolic ejection murmur heard in the second and third intercostal spaces and patients do not present with hypertension.
C
Coarctation of the aorta
D
Patent ductus arteriosus
Hint:
Patent ductus arteriosus is rare in adults and patients are noted to have a continuous rough, machinery murmur.
Question 7 Explanation: 
Coarctation of the aorta commonly presents with higher systolic pressures in the upper extremities than the lower extremities and absent or weak femoral pulses.
Question 8
Which of the following primitive reflexes should begin to disappear at about 2-3 months of age in a normal infant?
A
Moro
Hint:
Sudden abduction of the arms, extension of the legs, and flexion of the hips when the position of the head is changed abruptly in relationship to the body. The Moro reflex is present in all normal, full term infants. It is an indicator of the symmetry and intactness of the nervous system. It diminishes during the first months of life and usually disappears by 4 to 5 months
B
Rooting
C
Tonic neck
Hint:
With the infant supine, turning the head to one side results in extension of the arm and leg on that side with flexion of the contralateral area (i.e., fencing posture). It is usually not present in the newborn but appears after 2 to 3 weeks. The reflex is most prominent during the second month of life and infants may assume it spontaneously. An obligate or persistent tonic neck reflex is abnormal. The tonic neck reflex starts to disappear at about 6-7 months of age.
D
Parachute
Hint:
The infant is suspended horizontally then plunged downwards; the reflex consists of arm extension to "break the fall." It begins at 6 to 7 months and is well developed by 1 year. The parachute reflex is an excellent test of upper extremity pyramidal function, and if asymmetrical, may be a sign of hemiparesis.
Question 8 Explanation: 
A newborn infant will turn its head toward anything that strokes its cheek or mouth, searching for the object by moving its head in steadily decreasing arcs until the object is found. The rooting reflex starts to disappear at about 2-3 months of age.
Question 9
Which of the following is the treatment of choice for a torus (buckle) fracture involving the distal radius?
A
Open reduction and internal fixation
Hint:
A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as painful as unstable fractures. They heal uneventfully in 3-4 weeks
B
Ace wrap or anterior splinting
C
Closed reduction and casting
Hint:
A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as painful as unstable fractures. They heal uneventfully in 3-4 weeks
D
Corticosteroid injection followed by splinting
Hint:
A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as painful as unstable fractures. They heal uneventfully in 3-4 weeks
Question 9 Explanation: 
A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as painful as unstable fractures. They heal uneventfully in 3-4 weeks
Question 10
A mother brings in her five year-old boy for his school physical. She voices some concerns about his readiness for school, saying he seems to be socially immature. She has noticed he does not interact with other children well, and that when he plays with them, he has a tendency to "place them" and then run around them as if they were statues. He rarely cries when he is hurt, and he shrugs off any attempt to hug him. He has good attention to details, and will sit and draw the same geometric shapes over and over again, but does not seem interested in learning the alphabet. He avoids eye contact with anyone. Which of the following is the most likely diagnosis?
A
Normal 5 year-old
Hint:
This behavior is not normal for a child this age.
B
Social phobia
Hint:
Social phobia is an excessive and persistent fear of social situations in which the person may be scrutinized by others.
C
Autism
D
Avoidant personality
Hint:
Avoidant personality disorder is characterized by timidity, social awkwardness, and a pervasive sense of inadequacy and fear of criticism.
Question 10 Explanation: 
Children with autism do not tend to make eye contact, and even avoid it. They do not accept comfort when hurt and stiffen up when hugged. They do not tend to play with others, and do not tend to imitate grown-ups in play. They approach play in a more mechanical way, using others as props rather than interacting with them.
Question 11
An 8 year-old boy is brought to a health care provider complaining of dyspnea and fatigue. On physical examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is
A
ventricular septal defect.
Hint:
Ventricular septal defect causes a holosystolic murmur rather than a continuous machinery-like murmur.
B
atrial septal defect.
Hint:
Atrial septal defect causes a fixed split S2 rather than a continuous systolic heart murmur.
C
congenital aortic stenosis.
Hint:
Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in the second intercostal space.
D
patent ductus arteriosus.
Question 11 Explanation: 
Patent ductus arteriosus is classically described in children as a continuous machinery-type murmur that is widely transmitted across the precordium
Question 12
A 2 year-old female presents with purulent nasal discharge bilaterally with fever and cough for several days. Her mom had taken her out of daycare for a similar occurrence 2 months ago, that was treated with Amoxicillin. Exam further reveals halitosis and periorbital edema. Treatment should be initiated with which of the following?
A
Antihistamines
Hint:
Antihistamines and intranasal corticosteroids have not been adequately studied in children to prove they make a difference in treating recurrent sinusitis.
B
Ribavirin (Rebetol)
Hint:
Ribavirin is approved for the treatment of RSV infection.
C
Intranasal corticosteroids
Hint:
Antihistamines and intranasal corticosteroids have not been adequately studied in children to prove they make a difference in treating recurrent sinusitis.
D
Amoxicillin-clavulanate (Augmentin)
Question 12 Explanation: 
High dose amoxicillin-clavulanate is the treatment of choice for resistant bacterial sinusitis, especially in children presenting with risk factors (daycare attendance, previous antibiotic treatment 1-3 months prior, age younger than 2 years).
Question 13
A 16 year-old male is brought into your office by his girlfriend. She states that "he hasn't been himself lately" and seems to fluctuate from being almost "euphoric" to being depressed and irritable. The patient states that "he is really okay" and that he "just feels a little irritable occasionally." On physical examination his pulse is 120 beats/minute, blood pressure is 180/110 mmHg, he is sweating and his pupils are widely dilated. Which of the following is the most likely diagnosis?
A
Opiate abuse
Hint:
Opiate abuse would be suspected with the presence of euphoria, drowsiness, and constricted pupils. More severe cases present with bradycardia, hypotension, coma, or respiratory arrest.
B
Acute anxiety attack
Hint:
While acute anxiety disorder may present with tachycardia, agitation, diaphoresis, and hypertension, this diagnosis should be a diagnosis of exclusion. Failure to diagnose cocaine intoxication could lead to severe consequences.
C
Cocaine intoxication
D
Bipolar affective disorder
Hint:
While the history may suggest the diagnosis of bipolar affective disorder, the physical exam findings do not support this diagnosis.
Question 13 Explanation: 
Cocaine is a stimulant and presenting clinical manifestations of intoxication include agitation, tachycardia, hypertension, diaphoresis, and dilated pupils.
Question 14
Which of the following clinical manifestations is most commonly seen in viral croup?
A
drooling
Hint:
Drooling is common in epiglottitis not viral croup.
B
wheezing
Hint:
Wheezing is noted in asthma.
C
sputum production
Hint:
Sputum production is noted in bacterial infections.
D
inspiratory stridor
Question 14 Explanation: 
Viral croup typically presents with a barking cough and stridor.
Question 15
You are called to the nursery to see a male infant, born by uncomplicated vaginal delivery. He weighs 2,600 grams and has one deep crease on the anterior third of each foot. Respirations are 88 breaths/minute with expiratory grunting and intercostals retractions. He is cyanotic on room air and becomes pink when placed on 60% oxygen. Chest x-ray shows atelectasis with air bronchograms. Which of the following is the most likely diagnosis?
A
neonatal pneumonia
Hint:
While tachypnea, grunting, retractions and cyanosis may be signs of neonatal pneumonia, they are primarily late findings of progressive respiratory distress and would not be seen immediately at the time of delivery. A chest x-ray in pneumonia would also most commonly reveal an infiltrate or effusion.
B
congenital heart disease
Hint:
While congenital heart disease may present with cyanosis, the chest x-ray will reveal a cardiac abnormality, such as cardiomegaly.
C
hyaline membrane disease
D
chronic lung disease of prematurity
Hint:
Chronic lung disease of prematurity is a complication in about 20% of infants with hyaline membrane disease. It is defined as respiratory symptoms, oxygen requirement and chest x-ray abnormalities at 1 month of age so it cannot be diagnosed at this time in this newborn.
Question 15 Explanation: 
Hyaline membrane disease is the most common cause of respiratory distress in the premature infant. The infant typically presents with tachypnea, cyanosis and expiratory grunting. A chest x-ray reveals hypoexpansion and air bronchograms.
Question 16
A 20 year-old female presents with episodes of binge eating, overuse of laxatives, and periods of starvation. Which of the following is the best treatment option for this patient?
A
fluoxetine (Prozac)
B
gabapentin (Neurontin)
Hint:
Gabapentin is used in the treatment of seizure disorders.
C
amitriptyline (Elavil)
Hint:
Amitriptyline, a tricyclic antidepressant, is not effective in the treatment of bulimia nervosa.
D
phenelzine (Nardil)
Hint:
Phenelzine, a monoamine oxidase inhibitor, is not indicated in the treatment of bulimia nervosa.
Question 16 Explanation: 
Fluoxetine, a SSRI, is the drug of choice for the treatment of bulimia nervosa.
Question 17
Which of the following laboratory abnormalities is most commonly noted in bulimia nervosa?
A
glycosuria
Hint:
Glycosuria is associated with diabetes mellitus, not bulimia.
B
hypokalemia
C
metabolic acidosis
Hint:
A metabolic alkalosis may be noted if potassium losses from purging are great enough.
D
hyperalbuminemia
Hint:
Serum albumin levels may be normal or decreased.
Question 17 Explanation: 
Episodes of binge eating are followed by purging in the bulimic patient. Vomiting and laxative abuse are the most common methods of purging, leading to hypokalemia.
Question 18
Which of the following leads to retropatellar pain?
A
increased Q angle
B
increased quadriceps tone and strength
Hint:
Quadriceps strengthening aids in restoring patellofemoral tracking.
C
Osgood-Schlatter Disease
Hint:
Osgood-Schlatter disease involves the tibial tubercle, not the patellofemoral joint.
D
hamstring stretching
Hint:
Hamstring stretching aids in restoring patellofemoral tracking.
Question 18 Explanation: 
Patients with an increased Q angle have more force directed laterally during knee flexion and are at greater risk of patellofemoral pain syndrome.
Question 19
Which of the following is a milestone usually achieved by a 15-month old infant?
A
walks alone
B
puts three words together
Hint:
The ability to put three words together, feed oneself well with a spoon and build a tower of seven cubes does not occur until 24 months.
C
feeds self well with spoon
Hint:
The ability to put three words together, feed oneself well with a spoon and build a tower of seven cubes does not occur until 24 months.
D
builds tower of seven cubes
Hint:
The ability to put three words together, feed oneself well with a spoon and build a tower of seven cubes does not occur until 24 months.
Question 19 Explanation: 
A 15-month-old infant should be able to walk alone.
Question 20
At birth an infant weighs 8 pounds. The optimal weight for this infant at 1 year would be
A
16 pounds.
Hint:
An infants birth weight should double by 4-5 months of age and triple by 1 year of age.
B
20 pounds.
Hint:
An infants birth weight should double by 4-5 months of age and triple by 1 year of age.
C
24 pounds.
D
28 pounds.
Hint:
An infants birth weight should double by 4-5 months of age and triple by 1 year of age.
Question 20 Explanation: 
An infants birth weight should double by 4-5 months of age and triple by 1 year of age.
Question 21
A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding?
A
stridor
B
aphonia
Hint:
Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.
C
inability to cough
Hint:
Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.
D
progressive cyanosis
Hint:
Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.
Question 21 Explanation: 
An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea or larynx.
Question 22
A 14 year-old male who is overweight presents with complaints of left knee and anteromedial thigh pain for the past month. He states the pain gets better with rest and denies any known trauma. On examination of the gait, a slight limp is noted. X-ray films of the left knee are normal. The most likely diagnosis is
A
genu valgum
Hint:
Genu valgum is a knock-knee deformity of the knees and would be detected on physical examination.
B
Legg-Calve-Perthes disease.
Hint:
Legg-Calve-Perthes presents in a younger population.
C
Osgood-Schlatter disease.
Hint:
Osgood-Schlatter disease is characterized by local pain, swelling, and tenderness to palpation overlying the tibial tubercle, and x-ray findings of tibial tubercle prominence, with or without free bony fragments.
D
slipped capital femoral epiphysis.
Question 22 Explanation: 
Slipped capital femoral epiphysis is most common in overweight adolescent males who present with complaints of pain that is referred to the thigh or medial side of the knee associated with a limp. X-ray films of the knee are normal since the condition involves the hip.
Question 23
An x-ray reveals a break in the cortex of one side of the ulna shaft without a separation or break of the opposite cortex describes what type of fracture?
A
greenstick
B
transverse
Hint:
A transverse fracture is a complete fracture of both cortices.
C
torus (buckle)
Hint:
A torus fracture is a bowing, bending, or buckling without a break in the cortex.
D
epiphyseal
Hint:
Epiphyseal fracture occurs at the growth plate.
Question 23 Explanation: 
A greenstick fracture is a break in the cortex of one side of bone shaft without a break in the opposite cortex.
Question 24
Which of the following is the most appropriate intervention in suspected child abuse?
A
Arrange for the arrest of the parents.
Hint:
Law enforcement would be contacted after an investigation of the incident(s) by the proper authorities. It is not the responsibility of the medical caregiver to arrange for the arrest, only to report your suspicions.
B
Confront the suspected assailant in front of the child.
Hint:
Confrontation should be done by the investigators of the incident(s).
C
Assure the safety of the child, with hospitalization if necessary.
D
Contact social service department after discharge of the child.
Hint:
Any abuse suspicion should be reported prior to the discharge of the child. Discharging the child to the person or people responsible for the abuse may cause greater harm to the child.
Question 24 Explanation: 
The primary goal should be the safety and well-being of the child. Hospitalization may be the only way the clinician has to remove the child from the care of a possible abusive home if no other recourse is available due to a lack of social services and investigators.
Question 25
A woman brings her 3 month-old son to the clinic. Upon examination, it is noted he has a round face, a large protruding tongue, dry skin, an umbilical hernia, and his weight gain is below average. He appears apathetic and the mother says the infant is usually constipated. Which of the following is the most likely diagnosis?
A
hyperparathyroidism
Hint:
Hyperparathyroidism results in abnormal bone development, nausea, vomiting, and anorexia.
B
nephrotic syndrome
Hint:
Nephrotic syndrome is associated with proteinuria, with resultant edema and ascites. Anorexia, abdominal pain and diarrhea are common findings.
C
phenylketonuria
Hint:
Phenylketonuria is associated with mental retardation, motor deficits, and convulsions.
D
hypothyroidism
Question 25 Explanation: 
Congential hypothyroidism presents gradually, and at 3-6 months findings include poor appetite and feeding, sluggishness, constipation, enlarged abdomen and umbilical hernia, enlarged tongue, and the child does not meet developmental milestones.
Question 26
A newborn is seen for an initial two week visit. Physical examination reveals a thrill and a continuous machinery murmur in the left second intercostal space. Which of the following is the most likely diagnosis?
A
patent ductus arteriosus
B
ventricular septal defect
Hint:
Ventricular septal defect is characterized by a holosystolic murmur at the lower left sternal border.
C
tetralogy of Fallot
Hint:
Tetralogy of Fallot is characterized by a systolic thrill at the left sternal border with a systolic ejection murmur that may or may not have an associated systolic click.
D
coarctation of the aorta
Hint:
Coarctation of the aorta is associated with a systolic ejection click or a short systolic murmur at the left sternal border.
Question 26 Explanation: 
Patent ductus arteriosus is characterized by a classic harsh, machinery-like murmur that is continuous through systole and diastole. This is heard best at the left second interspace and is commonly associated with a thrill.
Question 27
A 37-year-old-woman delivers a male infant with Down syndrome at 38 weeks. His Apgar scores at one and five minutes are both 8, with scores of 1 for acrocyanosis and irregular breathing. He passes meconium several hours later. Between 24 and 48 hours after birth, the infant has multiple episodes of vomiting despite lack of feedings and does not have additional bowel movements. Vomitus is bilious and nonbloody. On physical exam, the infant is crying, he appears jaundiced, and his abdomen is distended. An abdominal radiograph is performed, which is shown here. Which is the first step in the management of this patient?
A
Initiation of phototherapy
Hint:
Phototherapy is used for decreasing, circulating unconjugated bilirubin levels in management of neonatal jaundice.
B
Abdominal ultrasound
Hint:
An abdominal ultrasound would be performed if the infant's jaundice continues and there is reason to suspect an obstructive cause, such as biliary atresia. There is no role for abdominal ultrasound in the management of duodenal atresia, which is the more pressing issue.
C
Endotracheal intubation
Hint:
Endotracheal intubation is not indicated, as the infant is not having respiratory distress.
D
Nasogastric tube placement
E
Immediate surgical intervention
Hint:
The need for surgery is not immediate. Decompression with a nasogastric or orogastric tube and initiation of IV fluids should be preformed pre-operatively.
Question 27 Explanation: 
The clinical presentation and radiograph are consistent with duodenal atresia. Nasogastric or orogastric tube placement is the first step in management prior to surgical intervention. Duodenal atresia is the congenital failure of the duodenal lumen to recanalize during fetal development. The condition is often seen in infants with Down syndrome and is associated with a number of congenital anomalies including biliary atresia, as well as cardiac and renal malformations. Duodenal atresia presents with vomiting 1-2 days after birth. Abdominal radiograph reveals the "double bubble" sign, caused by gastric and proximal duodenal dilation with narrowing at the pylorus.
Question 28
A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is most consistent with which of the following?
A
spondylolysis
Hint:
Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.
B
spondylolisthesis
Hint:
Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.
C
scoliosis
D
herniated disc
Hint:
Herniated disc presents with lumbar muscle spasm and a positive straight leg test.
Question 28 Explanation: 
Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.
Question 29
A 5 year-old boy presents to the office for follow-up of complaints of pruritus in the perianal area. A cellophane tape test is positive. Which of the following is the treatment of choice?
A
mebendazole (Vermox)
B
metronidazole (Flagyl)
Hint:
Metronidazole can be used in the treatment of protozoal infections but it is not indicated in the treatment of pinworms.
C
chloroquine (Aralen)
Hint:
Chloroquine is an amebacide that interferes with parasite protein synthesis. Its main indications are in the treatment of malaria and amebiasis.
D
paromomycin (Humantin)
Hint:
Paromomycin is an aminoglycoside that acts directly on amoebas and against normal and pathogenic organisms in the GI tract.
Question 29 Explanation: 
Treatment of choice for enterobiasis (pinworms) is mebendazole.
Question 30
A 2 year-old child is brought to the office because of a cough and a fever of 102 degrees F for 2 days. The physician assistant notes the presence of hoarseness, a barking cough, and stridor. The ears and nose exam are unremarkable. Auscultation of the chest reveals decreased breath sounds without crackles or expiratory wheezes. Which of the following would be the initial diagnostic impression?
A
pneumonia
Hint:
Pneumonia would not produce the stridor noted on physical exam. Pneumonia would more than likely produce crackles, also not noted in this patient.
B
bronchiolitis
Hint:
Bronchiolitis would produce inspiratory wheezes which are absent in this patient.
C
croup
D
asthma
Hint:
Asthma would not normally present with fever and stridor.
Question 30 Explanation: 
Hoarseness, inspiratory stridor, and a barking cough are classic signs of croup, all of which are noted in this patient.
Question 31
A 7 year-old boy wets the bed nearly every night. Which of the following is the best pharmaceutical agent to use in treating this patient?
A
desmopressin (DDAVP)
B
paroxetine (Paxil)
Hint:
Paroxetine is not indicated for enuresis.
C
lorazepam (Ativan)
Hint:
Lorazepam is used for treatment of sleep terrors.
D
hyoscyamine (Levsin)
Hint:
Hyoscyamine is used in the treatment of pediatric overactive bladder.
Question 31 Explanation: 
Desmopressin, while not curative, will relieve symptoms.
Question 32
Which of the following is the most appropriate study for diagnosing Hirschsprung disease?
A
Rectal biopsy
B
Stool leukocyte test
Hint:
Stool leukocyte testing can indicate an infectious etiology of diarrhea and is not indicated in the diagnosis of Hirschsprung disease.
C
CT of the abdomen and pelvis
Hint:
Radiographic examination may show dilated proximal colon and absence of gas in the pelvic colon, but is not diagnostic for Hirschsprung disease.
D
Fecal occult blood test
Hint:
Fecal occult blood testing is not indicated in the diagnosis of Hirschsprung disease.
Question 32 Explanation: 
A rectal biopsy showing the absence of ganglion cells in both the submucosal and muscular layers of the involved bowel is the most appropriate diagnostic study for Hirschsprung disease.
Question 33
Which of the following groups is most likely to present with Duchenne's muscular dystrophy?
A
Adolescent females
Hint:
Duchenne's muscular dystrophy, a genetic defect on the short arm of the X chromosome, affects toddler-aged males.
B
Middle-aged males
Hint:
Duchenne's muscular dystrophy, a genetic defect on the short arm of the X chromosome, affects toddler-aged males.
C
Infant females
Hint:
Duchenne's muscular dystrophy, a genetic defect on the short arm of the X chromosome, affects toddler-aged males.
D
Toddler-aged males
Question 33 Explanation: 
Duchenne's muscular dystrophy, a genetic defect on the short arm of the X chromosome, affects toddler-aged males.
Question 34
Spina bifida occulta is usually detected by which initial diagnostic evaluation?
A
Electroencephalogram
Hint:
Electroencephalogram (EEG) cannot detect or diagnose spina bifida occulta.
B
Alpha-fetoprotein levels
Hint:
Alpha-fetoprotein, measured at 16-18 weeks of pregnancy, if elevated, would indicate a neural tube defect, such as spina bifida.
C
Folic acid levels
Hint:
Folic acid has been shown to decrease the incidence of neural tube defects, not as an aid in diagnosis of the defect.
D
X-ray of the spine
Question 34 Explanation: 
X-ray or MRI is the definitive test to diagnose spina bifida occulta, showing the vertebral bony defect.
Question 35
At what age should a child's eyes be consistently well aligned?
A
Two months
Hint:
A child's eyes should be consistently well-aligned by five to six months of age.
B
Six months
C
Twelve months
Hint:
A child's eyes should be consistently well-aligned by five to six months of age.
D
Eighteen months
Hint:
A child's eyes should be consistently well-aligned by five to six months of age.
Question 35 Explanation: 
A child's eyes should be consistently well-aligned by five to six months of age.
Question 36
A four-year-old boy and his mother present to general pediatrics clinic for follow-up. She is in distress because she has tried everything to get him toilet trained. Her prior child was toilet trained at the age of 2. Her 4-year-old is developmentally appropriate. He can sit upright and can communicate that he needs to use the bathroom. The mother has tried to place him on the toilet at regular intervals and has given him rewards for using the toilet successfully. However, he is not motivated to stay dry and asks to keep using diapers. The mother is desperate and asks what she can do to get her son toilet trained immediately. Which of the following is the best advice to give the mother of this patient?
A
To stop trying to toilet train for a few months then reassess
B
To stop trying to toilet train for a year then reassess
Hint:
Stopping toilet training for a year would be too long. Such a long break would be unnecessary and would make this child 5 - an age when he should be able to use the toilet.
C
To continue to motivate the child and discipline him if he fails to void appropriately
Hint:
To continue to motivate the child and discipline him if he fails to void appropriately is incorrect only because of the discipline aspect of this answer. Discipline may make the child fear toilet training and be even more hesitant to begin using it potentially worsening the entire process.
D
To obtain an evaluation from a developmental psychologist
Hint:
Evaluation from a developmental psychologist is unnecessary because 1. You are a physician who can evaluate this child's NORMAL development fine on your own (do not refer patients in general) and 2. There is nothing abnormal here that would need a consult.
E
To stop using positive reinforcement rewards
Hint:
Positive reinforcements should be continued to make the child enjoy the success of using the toilet. To discontinue positive reinforcements may slow the process of toilet training.
Question 36 Explanation: 
Toilet training occurs between 2-4 years of age. If the child is not motivated to stay dry, the best advice is to wait for a few months then reassess. This will give the child and mother a break and allow for both to approach the situation fresh. Regardless, it is normal for children to not use the toilet up until age 5. Toilet training occurs between ages 2 and 4 with 5 being the cutoff age when an inability to use the toilet may be considered a problem. To be ready for toilet training, the child must be aware of bladder filling, able to consciously tighten their external sphincter, has normal bladder growth, and be motivated to stay dry. Further, the child must have met motor milestones and be able to walk to the toilet, sit upright, as well as have met language milestones to communicate the need to use the bathroom. The process involves placing the child on a toilet at regular intervals and using positive reinforcement as a reward. If the child is very reluctant, the best strategy is to stop trying to toilet train for a few months and then reassess.
Question 37
A 3 month-old female presents with her mom for physical examination. The patient's mom denies any complaints. On examination you note a well-developed, well-nourished infant in no apparent distress. There is no cyanosis noted. Heart examination reveals a normal S1 with a physiologically split S2. There is a grade III/VI high-pitched, harsh, pansystolic murmur heard best at the 3rd and 4th left intercostal spaces with radiation across the precordium. Which of the following is the initial diagnostic study of choice in this patient?
A
CT angiogram
Hint:
This patient has signs and symptoms consistent with a ventricular septal defect (VSD). CT angiogram and electrocardiogram are not indicated in establishing the diagnosis of a VSD.
B
Electrocardiogram
Hint:
. This patient has signs and symptoms consistent with a ventricular septal defect (VSD). CT angiogram and electrocardiogram are not indicated in establishing the diagnosis of a VSD.
C
Echocardiogram
D
Cardiac catheterization
Hint:
Cardiac catheterization may be necessary to accurately measure pulmonary pressures or if a VSD can not be well localized on echocardiogram, but it is not the initial diagnostic study of choice.
Question 37 Explanation: 
Echocardiogram is the initial diagnostic study of choice in the diagnosis of a VSD.
Question 38
Which of the following would be expected on physical examination of a newborn diagnosed with Tetrology of Fallot?
A
Palpable right ventricular lift
B
Pulse discrepancy between arms and legs
Hint:
Coarctation of the aorta is associated with a pulse discrepancy between the upper and lower extremities.
C
Mid-diastolic murmur with opening snap
Hint:
A mid-diastolic murmur with an opening snap is heard in a patient with mitral stenosis, not Tetralogy of Fallot.
D
Polymorphous exanthema
Hint:
Polymorphous exanthema is seen in patients with Kawasaki disease.
Question 38 Explanation: 
Tetralogy of Fallot is commonly associated with a palpable right ventricular lift.
Question 39
A 12-year-old boy presents with fever and severe sore throat. Which of the following physical exam findings helps differentiate a peritonsillar abscess from epiglottitis?
A
Muffling of the voice
Hint:
Muffling of the voice, dysphagia, cervical lymphadenopathy, and fever can all be seen with both peritonsillar abscess and epiglottitis.
B
Dysphagia
Hint:
Muffling of the voice, dysphagia, cervical lymphadenopathy, and fever can all be seen with both peritonsillar abscess and epiglottitis.
C
Deviation of the uvula
D
Cervical lymphadenopathy
Hint:
Muffling of the voice, dysphagia, cervical lymphadenopathy, and fever can all be seen with both peritonsillar abscess and epiglottitis.
E
Fever
Hint:
Muffling of the voice, dysphagia, cervical lymphadenopathy, and fever can all be seen with both peritonsillar abscess and epiglottitis.
Question 39 Explanation: 
While epiglottitis and peritonsillar abscess share several similar presenting signs and symptoms, the key differentiating finding is a uvular deviation which is only found with a peritonsillar abscess. Peritonsillar abscesses occur primarily in young adults. This condition most often follows Group A streptococcal pharyngitis and exudative tonsillitis. The abscess is polymicrobial and generally presents with fever, malaise, sore throat, dysphagia, and otalgia. On physical exam, the patient may have trismus and a muffled voice (classically called a "hot potato voice").
Question 40
A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient?
A
Mast cell stabilizer
Hint:
A mast cell stabilizer is an alternative treatment but not the preferred treatment.
B
Long acting beta agonist
Hint:
Long acting beta agonist can be used as adjunctive therapy with an anti-inflammatory.
C
Leukotriene receptor antagonist
Hint:
Leukotriene receptor antagonists are an alternative treatment but not the preferred treatment.
D
Low dose inhaled corticosteroid
Question 40 Explanation: 
Low dose inhaled corticosteroids are the preferred treatment for mild persistent asthma.
Question 41
A 5 year-old presents with perianal pruritus that is worse at night. Scotch tape is positive for Enterobius vermicularis. The treatment of choice is
A
mebendazole (Vermox).
B
metronidazole (Flagyl).
Hint:
Metronidazole is used in the treatment of amebic dysentery and trichomoniasis.
C
clindamycin (Cleocin).
Hint:
Clindamycin is used in the treatment of anaerobic bacterial infections.
D
thiabendazole (Mintezol).
Hint:
Thiabendazole is used in the treatment of helminth infections.
Question 41 Explanation: 
Treatment of choice for pinworms is mebendazole.
Question 42
A 17 year-old female is seen who has a history of eating large amounts of food at night 3 to 4 times weekly. These episodes are always followed by extreme guilt and either induced vomiting or hours of strenuous exercise. She excels at work and school and maintains many active relationships. Her physical examination reveals a normal BMI and an otherwise normal exam. What is the best initial intervention for this patient?
A
Begin an anxiolytic
Hint:
Uncomplicated bulimia generally does not require hospitalization as the physical manifestations encountered in bulimia are generally mild if present at all. Some patients with bulimia have concomitant substance abuse issues but her successful relationships and work activities lessen the probability. Antidepressants, not anxiolytics, have been found helpful in lessening the binge/purge cycles and improving overall well-being even outside of comorbid mood disorders.
B
Immediate hospitalization
Hint:
Uncomplicated bulimia generally does not require hospitalization as the physical manifestations encountered in bulimia are generally mild if present at all. Some patients with bulimia have concomitant substance abuse issues but her successful relationships and work activities lessen the probability. Antidepressants, not anxiolytics, have been found helpful in lessening the binge/purge cycles and improving overall well-being even outside of comorbid mood disorders.
C
Start an antidepressant
D
Test for substance abuse
Hint:
Uncomplicated bulimia generally does not require hospitalization as the physical manifestations encountered in bulimia are generally mild if present at all. Some patients with bulimia have concomitant substance abuse issues but her successful relationships and work activities lessen the probability. Antidepressants, not anxiolytics, have been found helpful in lessening the binge/purge cycles and improving overall well-being even outside of comorbid mood disorders.
Question 42 Explanation: 
Uncomplicated bulimia generally does not require hospitalization as the physical manifestations encountered in bulimia are generally mild if present at all. Some patients with bulimia have concomitant substance abuse issues but her successful relationships and work activities lessen the probability. Antidepressants, not anxiolytics, have been found helpful in lessening the binge/purge cycles and improving overall well-being even outside of comorbid mood disorders.
Question 43
What is the most effective prophylaxis against respiratory syncytial virus (RSV) infection in the general pediatric population?
A
Proper hand-washing techniques
B
A monoclonal antibody
Hint:
Prophylaxis with a monoclonal antibody has proven effective in high risk infants but is not indicated in the general pediatric population.
C
H. Influenzae B vaccine
Hint:
Prophylaxis with H. Influenzae B vaccine has reduced incidence of epiglottis, not RSV.
D
Oseltamivir (Tamiflu)
Hint:
Oseltamivir is not indicated in the prophylaxis of RSV.
Question 43 Explanation: 
Proper hand washing and reduction in exposure is most effective in general population to prevent RSV.
Question 44
At what age should the first hepatitis B vaccine be administered
A
Birth
B
1 month
C
4 months
D
6 months
Question 44 Explanation: 
Hepatitis B vaccine is first given at birth, then at 1 to 2 months, and again at 6 to 18 months
Question 45
By what age should the posterior fontanel be closed?
A
2 months
B
6 months
C
12 months
D
18 months
Question 45 Explanation: 
The posterior fontanel is typically closed at birth, but if open should close by 2 months of age
Question 46
An examination of the hips of a newborn, a "clunk" is noted with abduction of the right hip to almost 90 degrees while lifting the greater trochanter. Which of the following is the most likely diagnosis?
A
Ligamentum teres rupture
B
Legg-Calve-Perthes disease
C
Slipped capital femoral epiphysis
D
Developemental dysplasia of the hip
Question 46 Explanation: 
the Ortolani test is positive in the newborn patient with developmental dysplasia of the hip. The test is performed by lifting the greater trochanter while abducting the hip to 90 degrees.
Question 47
While examining a newborn, the PA notes symmetrical abduction of the upper extremities and extension of the fingers when the newborn's head is allowed to drop a few centimeters while supporting the body. This describes which of the following reflexes?
A
Moro's
B
Galant's
C
Placing
D
Parachute
Question 47 Explanation: 
Moro's reflex is noted by symmetrical abduction of the upper extremities and extension of the fingers after dropping the head a few centimeters while supporting the body. The parachute reflex is noted by extension of all extremities with forward flexing of the infant as if to fall. Galant's reflex is noted by lateral curvature of the trunk with stroking one side of the back. Placing response is noted by flexion of the knee and hip and placing the foot on the table when allowing the newborn's feet to lightly touch the surface of the table.
Question 48
A 16-year-old male presents with decreased body hair and gynecomastia. On physical exam, the patient is noted to be tall and thin, with a wide arm span. Genital exam reveals a small phallus and small, soft testicles. Which of the following is the most likely the diagnosis?
A
Trisomy 18
B
Turner's syndrome
C
Noonan's syndrome
D
Klinefelter's syndrome
Question 48 Explanation: 
The Klinefelter syndrome is an autosomal recessive disorder due to an extra X chromosome. Manifestations typically present at puberty with incomplete masculinization, decreased the body hair, gynecomastia, small phallus, and small, soft testicles. Noonan's syndrome presents with short stature, web neck, and pectus excavatum. Turner's syndrome presents with short stature, webbed neck , and phenotypical female. Trisomy 18 presents with mental retardation, prominent occiput and low-set ears
Question 49
An 8-year old male presents with pain in his legs after exercise. Physical examination reveals radial-femoral pulse delay and the blood pressurein the lower extremities is 15 mmHG lower than in the upper extremities. Which of the following lab or radiologica findings would be most commonly noted in this patient?
A
Inferior border rib notching
B
Decreased hemoglobin
C
Left atrial enlargement
D
Elevated troponin
Question 49 Explanation: 
Coarctation of the aorta presents with disparity in both pulses and blood pressure between the upper and lower extremities. Laboratory or radiologic findings include inferior border rib notching, cardiomegaly, and ventricular hypertrophy on EKG
Question 50
A 2-year-old presents with fever and drooling. The patient appears toxic and is sitting up with chin forward. Thumbprint sign is noted on lateral neck x-ray film. Which of the following is the treatment of choice for this patient?
A
Ampicillin
B
Prednisone
C
Artificial airway
D
Racemic epinephrine
Question 50 Explanation: 
acute epiglottitis is a medical emergency and immediate treatment with an artificial airway in a controlled environment is indicated. Steroids and racemic epinephrine are ineffective and not indicated. The antibiotic of choice is ceftriaxone, or cefotaxime. Ampicillin is not considered first line due to increased resistance of H. influ to ampicillin
Question 51
Which of the following is the pathophysiologic mechanism of hyaline membrane disease?
A
Surfactant deficiency
B
Meconium aspiration
C
Congenital diaphrgamtic hernia
D
High pulmonary vascular resistance
Question 51 Explanation: 
Hyaline membrane disease (Resp distress syndrome) results from alveoli collapse due to lack of adequate lung surfactant and immature lungs
Question 52
Which of the following is the treatment of choice for Kawaski's disease?
A
Methotrexate
B
Prednisone
C
Pencillin
D
Aspirin
Question 52 Explanation: 
Patients with Kawasaki's disease present with fever, bilateral conjunctival injection, pharyngeal erythema, edema of the hands and feet, rash, and LAD. Tx of choice is high-dose aspirin and IV immunoglobulin
Question 53
Which of the following increases the risk of sudden infant death syndrome?
A
Pacifier use
B
Immunizations
C
Prone sleeping
D
Upper respiratory tract infection
Question 53 Explanation: 
The risk of sudden infant death syndrome is increased with infants sleeping prone, exposure to cigarette smoking, low birth weight, and preterm birth
Question 54
A 1-day-old develops bilious vomiting without abdominal distension. Abdominal xray reveals a double-bubble sign. Which of the following is the intervention of choice for this patient?
A
Duodenoduodenostomy
B
IV glucocorticoids
C
Pyloromyotomy
D
Barium enema
Question 54 Explanation: 
Duodenal atresia presents within the first day of life with bilious vomiting without abdominal distention . A double-bubble sign is noted on abdominal xray film. Treatment of choice is a duodenoduodenostomy.
Question 55
Which of the following results from the deposition of unconjugated bilirubin in the brain?
A
Kernicterus
B
Rett syndrome
C
Neurocysticercosis
D
Sturge-Weber syndrome
Question 55 Explanation: 
Kernicturus results from the deposition of unconjugated bilirubin in the basal ganglia and brainstem. Rett's syndrome is a neurodegenerative disorder of uknown cause. Neurocysticercosis is caused by infection with a tapeworm. Struge-Weber syndrome is caused by abnormal development of meningeal vasculature
Question 56
Which of the following is the treatment of choice for homocystinuria?
A
Vitamin B6
B
Riboflavin
C
Niacin
D
Folate
Question 56 Explanation: 
Homocystinuria is a disorder of amino acid metabolism and is best treated with high doses of Vitamin B6
Question 57
An 18 month old presents with abdominal pain and bloody diarrhea. On physical examination a sausage shaped mass is noted in the upper mid-abdomen. Which of the following is most likely the diagnosis?
A
pyloric stenosis
B
Intussusception
C
Duodenal atresia
D
Hirschsprung's disease
Question 57 Explanation: 
Intussusception, telescoping of proximal bowel into distal bowel, is most common in children younger than age 2, who present with abdominal pain and bloody "currant" jelly" stool. On physical examination a sausage-shaped mass is noted in the mid abdomen. Patients with pyloric stenosis presents with vomiting and an olive size mass in the mid-abdomen. Those with Hirschsprung's disease present with vomiting and abdominal distention. Duodenal atresia is noted in the first day of life, with vomiting without abdominal distension
Question 58
Which of the following is a common side effect of the psychostimulants?
A
Tardive dyskinesia
B
Visual hallucinations
C
Weight loss
D
Headache
Question 58 Explanation: 
The side effects of the psychostimulants, such as Ritalin, include appetite suppression, weight loss, and sleep disturbances
Question 59
A 6 month old male presents with a scrotal mass. The scrotum is swollen and testicles are non-tender. The scrotum does transilluminate. Which of the following is the treatment of choice?
A
Orchidopexy
B
Varicocelectomy
C
Dextranomer/hyaluronic acid copolymer
D
No treatment is needed at this time
Question 59 Explanation: 
A hydrocele presents with a swollen, non-tender scrotum. Due to the scrotum being filled with fluid, the mass will transilluminate. No treatment is required unless the hydrocele persists after the age of 2 years.
Question 60
A 10 year-old female experiences fever and polyarthralgia. On examination you note a new early diastolic murmur. Laboratory results are positive for antistreptolysin O. The patient has no known drug allergies. Which of the following is the recommended prophylaxis for this condition?
A
Doxycycline
Hint:
Doxycycline and Bactrim are not indicated for the prophylaxis of recurrent rheumatic fever.
B
Erythromycin
Hint:
Erythromycin is considered second line for prophylaxis of recurrent rheumatic fever in a patient with a penicillin allergy.
C
Benzathine penicillin G
D
Trimethoprim/sulfamethoxazole
Question 60 Explanation: 
Recurrences of rheumatic fever are most common in patients who have had carditis during their initial episode and in children. The preferred method of prophylaxis is Benzathine penicillin G every four weeks.
Question 61
A 12 year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?
A
abdominal aortic aneurysm
Hint:
Abdominal aortic aneurysm is usually asymptomatic until the patient has dissection or rupture. It is uncommon in a child.
B
pheochromocytoma
Hint:
Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine release from the adrenal medulla, but does not cause variations in blood pressure in the upper and lower extremities.
C
coarctation of the aorta
D
thoracic outlet syndrome
Hint:
Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old.
Question 61 Explanation: 
Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the "3" is due to the coarctation site with proximal and distal dilations.
Question 62
A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical features?
A
Chest pain
Hint:
Chest pain is not a feature of tetralogy of Fallot
B
Cyanosis
C
Convulsions
Hint:
Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a feature of tetralogy of Fallot.
D
Palpitations
Hint:
Palpitations are uncommon in tetralogy of Fallot.
Question 62 Explanation: 
Cyanosis is very common in tetralogy of Fallot.
Question 63
An 8-year-old boy is brought to a physician because of palpitation, fatigue, and dyspnea. On examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is
A
ventricular septal defect.
Hint:
VSD causes a holosystolic murmur rather than a continuous machinery-like murmur.
B
atrial septal defect.
Hint:
ASD causes a fixed split S2 rather than a continuous systolic heart murmur.
C
congenital aortic stenosis.
Hint:
Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in the second intercostal space.
D
patent ductus arteriosus.
Question 63 Explanation: 
Patent ductus arteriosus is classically described in children as a continuous machinery-type murmur that is widely transmitted across the precordium.
Question 64
A 3-year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is
A
renal
B
cardiac.
C
pulmonary.
D
hepatic.
Hint:
Children with Kawasaki syndrome may have associated hydrops of the gallbladder, but liver involvement is not part of this disorder.
Question 64 Explanation: 
The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
Question 65
A 9 year-old presents with increasing shortness of breath while playing basketball recently. On examination, radial pulses are exaggerated while femoral pulsations are weak. Chest radiograph shows rib notching and a mildly enlarged heart. Which of the following is the most likely diagnosis for this patient?
A
Atrial septal defect
Hint:
In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and a mildly enlargedheart. Rib notching may also be seen in older children (>8 years old) with large collaterals.
B
Coarctation of the aorta
C
Patent ductus arteriosus
Hint:
In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and a mildly enlargedheart. Rib notching may also be seen in older children (>8 years old) with large collaterals.
D
Tetralogy of Fallot
Hint:
In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and a mildly enlargedheart. Rib notching may also be seen in older children (>8 years old) with large collaterals.
Question 65 Explanation: 
In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and a mildly enlargedheart. Rib notching may also be seen in older children (>8 years old) with large collaterals.
Question 66
A 16 year-old athlete with no past medical history collapses after running 50 yards down the field. He is unresponsive, pulseless and cyanotic. Which of the following is the most likely cause of this student's collapse?
A
Hypertrophic cardiomyopathy
B
Myocardial infarction
Hint:
This presentation is consistent with hypertrophic cardiomyopathy which may initially be difficult to diagnose.Infants but not older children frequently present with signs of CHF. Older children may be asymptomatic, with sudden death as the initial presentation
C
Pulmonary embolism
Hint:
This presentation is consistent with hypertrophic cardiomyopathy which may initially be difficult to diagnose.Infants but not older children frequently present with signs of CHF. Older children may be asymptomatic, with sudden death as the initial presentation
D
Reactive airway disease
Hint:
This presentation is consistent with hypertrophic cardiomyopathy which may initially be difficult to diagnose.Infants but not older children frequently present with signs of CHF. Older children may be asymptomatic, with sudden death as the initial presentation
Question 66 Explanation: 
This presentation is consistent with hypertrophic cardiomyopathy which may initially be difficult to diagnose.Infants but not older children frequently present with signs of CHF. Older children may be asymptomatic, with sudden death as the initial presentation
Question 67
A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. Which of the following is the most likely diagnosis?
A
acute bronchitis
Hint:
While the patient's clinical symptoms of dry cough and rhonchi support this diagnosis, the chest x-ray would be normal or only show a mild increase in bronchovascular markings, not infiltrates.
B
viral pneumonia
C
mycoplasma pneumonia
Hint:
While the gradual onset of symptoms suggest mycoplasma, the negative cold agglutinin titer makes this less likely.
D
pneumococcal pneumonia
Hint:
In older children the signs and symptoms of pneumococcal pneumonia are similar to an adult and consist of an abrupt onset of cough, fever and chills. The chest x-ray would reveal a lobar consolidation, not interstitial, picture.
Question 67 Explanation: 
The patient's clinical symptoms as well as chest x-ray findings and negative cold agglutinin titer are most consistent with viral pneumonia.
Question 68
A 3 month-old male presents with a hoarse cough and thick purulent rhinorrhea for the past 2 days. The mother noted that yesterday he appeared to get worse and seemed to have increasing problems breathing and trouble feeding. Examination reveals a temperature of 100.2 degrees F and respiratory rate of 80/minute with nasal flaring and retractions. Lung examination reveals a prolonged expiratory phase with inspiratory rales. He is tachycardic. Pulse oximetry reveals oxygen saturation of 89%. Chest x-ray reveals hyperinflation with diffuse interstitial infiltrates. Which of the following is the most appropriate intervention?
A
antibiotics
Hint:
Antibiotics are utilized to treat bacterial, not viral, illnesses.
B
hospitalization
C
inhaled corticosteroids
Hint:
The use of corticosteroids in children with bronchiolitis has not been studied and does not appear to be helpful.
D
Racemic epinephrine
Hint:
Racemic epinephrine is not indicated in the treatment of bronchiolitis.
Question 68 Explanation: 
This infant most likely has bronchiolitis. While most cases are mild and can be treated at home, hospitalization is recommended for infants with hypoxia on room air, moderate tachypnea with feeding difficulties and marked respiratory distress with retractions. Additionally hospitalization is recommended for infants less than 2-3 months of age, a history of apnea or an underlying chronic cardiopulmonary disease.
Question 69
A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future?
A
Asthma
B
Tinea pedis
Hint:
Patients with atopic dermatitis are more likely to get superimposed viral or bacterial infections such as herpes simplex or staphylococcal, but they are not more at risk for fungal infections.
C
Squamous carcinoma
Hint:
Patients with atopic dermatitis are at no greater risk for any skin cancer.
D
Systemic lupus erythematosus (SLE)
Hint:
Lupus is a connective tissue disorder of the immune system, but unrelated to atopic dermatitis.
Question 69 Explanation: 
Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future.
Question 70
A 15-year-old male was seen last week with complaints of a sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is
A
tuberculosis
Hint:
Most children with pulmonary tuberculosis are asymptomatic with few physical examination findings. The results of the diagnostic studies do not support tuberculosis as the most likely diagnosis.
B
mycoplasma pneumonia.
C
pneumococcal pneumonia.
Hint:
The clinical presentation of bacterial pneumonia in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis.
D
staphylococcal pneumonia.
Hint:
The clinical presentation of bacterial pneumonia in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis.
Question 70 Explanation: 
The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely.
Question 71
Which of the following is an indication for hospitalization in a patient who has acute bronchiolitis?
A
pulse oximetry of 94% on room air
Hint:
A pulse oximetry reading of 94% on room air is equivalent to a PaO2 of approximately 80 mm Hg which indicates the child is not in severe respiratory distress.
B
children between 4-6 months of age
Hint:
Children less than 2 months of age require hospitalization.
C
moderate tachypnea with feeding difficulties
D
hyperinflation and interstitial infiltrates on chest x-ray
Hint:
Hyperinflation and interstitial infiltrates on chest x-ray are frequently seen with acute bronchiolitis and by themselves are not an indication for hospitalization.
Question 71 Explanation: 
Indications for hospitalization include moderate tachypnea with feeding difficulties.
Question 72
A 4 year-old patient presents with episodic wheezing and a non-productive cough for the last 4 weeks. His symptoms are worse at night. Past medical history reveals a history of atopic dermatitis. Physical examination at this time is unremarkable. Which of the following is the most likely diagnosis?
A
Asthma
B
Bronchiolitis
Hint:
Bronchiolitis is common in infants and young children presenting with acute onset of cough, rhinorrhea, tachypnea, and expiratory wheezes.
C
Croup
Hint:
Croup usually presents with a prodrome of upper respiratory tract symptoms followed by onset of a barking cough and stridor.
D
Cystic fibrosis
Hint:
Cystic fibrosis is an autosomal recessive disease and is characterized by a chronic cough, sputum production, dyspnea, and wheezing. Steatorrhea, diarrhea, and abdominal pain are also common.
Question 72 Explanation: 
Asthma is a chronic inflammatory disorder of the airways. It is characterized by episodic or chronic symptoms of airflow obstruction, breathlessness, cough, wheezing, and chest tightness. The strongest identifiable predisposing factor for the development of asthma is atopy.
Question 73
Which of the following is an indication for a pediatric patient to receive the 23-valent polysaccharide vaccine (Pneumovax)?
A
Children at any age with a history of asthma
Hint:
Pediatric patients with cystic fibrosis, not asthma, are included in the indications for vaccination with Pneumovax, however they must be at least 2 years old.
B
All children at 2,4,6 and 12-18 months of age
Hint:
The 7-valent pneumococcal conjugate vaccine (Prevnar) is currently recommended to be given to children under the age of two on the schedule outlined.
C
All children at 12-23 months of age in a two dose series
Hint:
While a two dose series is recommended for appropriate pediatric patients that receive Pneumovax, the recommended timing between doses is 3-5 years.
D
Children age 24-59 months at high risk for invasive pneumococcal disease
Question 73 Explanation: 
Pneumovax is licensed for use in children over the age of 23 months and is indicated for all pediatric patients at increased risk for pneumococcal disease.
Question 74
A 2 month-old infant has been diagnosed with pneumonia due to Chlamydia trachomatis. Which of the following is the treatment of choice?
A
Ceftriaxone (Rocephin)
Hint:
Ceftriaxone is a third-generation cephalosporin that may be safely used in children, however is not indicated for the treatment of Chlamydial pneumonia.
B
Doxycycline
Hint:
Doxycycline is a tetracycline and is contraindicated in children under eight years of age secondary to damaging effects on bone and teeth enamel.
C
Levofloxacin (Levaquin)
Hint:
Levofloxacin is a fluoroquinolone and is contraindicated for use in children under 18 years of age secondary to damaging effects that may occur with growing cartilage.
D
Erythromycin
Question 74 Explanation: 
Erythromycin or sulfisoxazole is the treatment of choice for an infant with Chlamydial pneumonia.
Question 75
A 2 year-old presents to the emergency department in acute respiratory distress. The parents relate a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing. The child is noted to have stridor at rest, but has no evidence of cyanosis. Which of the following is the most appropriate initial intervention?
A
Intravenous antibiotics
Hint:
Laryngotracheobronchitis is caused by viruses, not bacteria, and therefore antibiotic therapy is not indicated.
B
Endotracheal intubation
Hint:
If patients fail to respond to initial treatment and progress to impending respiratory failure, endotracheal intubation is then indicated.
C
Inhaled mucolytic agent
Hint:
Inhaled mucolytic agents are not indicated in the treatment of laryngotracheobronchitis.
D
Nebulized racemic epinephrine
Question 75 Explanation: 
This patient most likely has laryngotracheobronchitis (viral croup). Treatment with nebulized racemic epinephrine and glucocorticosteroids is indicated for patients with stridor at rest.
Question 76
A mother of a newborn infant presents to the office concerned about reducing the risk of sudden infant death syndrome (SIDS). The infant was delivered at 39 weeks gestation weighing 7 pounds 9 ounces. There is no family history of SIDS and this is her first child. Which of the following is appropriate advice to reduce the risk of SIDS?
A
Bottle feeding with soy formula
Hint:
Bottle feeding with soy formula does not reduce the risk of SIDS.
B
Offer a pacifier at nap and bedtimes
C
Have the infant sleep in the prone position
Hint:
Sleeping prone has been consistently shown to increase, not decrease, the risk of SIDS.
D
Infant should sleep with the parents to allow close observation
Hint:
Bed sharing with parents has been shown to increase, not decrease, the risk of SIDS. This risk is increased in infants less than 4 months old and when older children are also present in the bed.
Question 76 Explanation: 
Use of a pacifier during sleeping is a current recommendation to decrease the risk of SIDS.
Question 77
A 7-day-old girl is brought to the general pediatrics clinic by her mother. She was the product of a full-term uncomplicated pregnancy and was delivered via cesarean for breech presentation. The mother received regular prenatal care throughout the pregnancy. This morning, after changing the child's diaper, the mother noticed that the newborn had blood at the vaginal introitus. The mother has no other complaints, and the infant is eating and voiding appropriately. Vital signs are stable. Physical exam reveals moderate mammary enlargement and confirms the vaginal spotting. The remainder of the exam is unremarkable. What is the next step in management?
A
Order a pelvic ultrasound to assess for an estrogen-secreting tumor
Hint:
A pelvic ultrasound is indicated in the workup of a pelvic mass, but this patient has a benign physical exam with no palpable masses. Furthermore, scant blood at this age is a normal finding and needs no further workup.
B
Conduct a karyotype
Hint:
A karyotype would be a step in the workup of Turner's syndrome or Down Syndrome, but would not be indicated in this case.
C
Begin a workup for 21-hydroxylase deficiency
Hint:
This patient does not have findings consistent with congenital bilateral adrenal hyperplasia. In a patient with 21-hydroxylase deficiency, one would expect hypotension and hyperkalemia. A patient with 11 beta-hydroxylase deficiency would present with masculinization (ambiguous genitalia) and hypertension which are also not found in this patient.
D
No tests are needed
E
Begin a workup for 11 beta-hydroxylase deficiency
Hint:
This patient does not have findings consistent with congenital bilateral adrenal hyperplasia. In a patient with 21-hydroxylase deficiency, one would expect hypotension and hyperkalemia. A patient with 11 beta-hydroxylase deficiency would present with masculinization (ambiguous genitalia) and hypertension which are also not found in this patient.
Question 77 Explanation: 
Vaginal spotting or bleeding is normal in female infants less than 3 months of age and will stop as soon as maternal estrogens are cleared from the baby's blood. The parents of this child only require reassurance. Normal findings in the newborn include non-purulent vaginal discharge, vaginal spotting, and mammary enlargement. All of these symptoms are not a cause for concern and generally regress within a few days. They result from the mother's hormones being transferred to the fetus in utero as well as via breast milk. No workup is required.
Question 78
A mother's concern about her child's choppy, gasping snore prompts the practitioner to suspect the possibility of which of the following as the cause of respiratory obstruction?
A
inclusion cysts
Hint:
Inclusion cysts are due to obstruction of mucous glands and membrane structures and do not cause snoring or respiratory obstruction.
B
enlarged adenoids
C
high-arched palate
Hint:
A high-arched palate is usually a genetic trait without clinical consequence.
D
geographic tongue
Hint:
A geographic tongue is a benign disorder of the tongue that does not affect respiration.
Question 78 Explanation: 
Large adenoids are considered part of the differential diagnosis of snoring and upper airway obstruction.
Question 79
A 13 year-old male with known cystic fibrosis presents to the emergency department, accompanied by his parents, with increased coughing, wheezing and low grade fever. Rales are audible on auscultation of the lungs. Treatment should target which of the following organisms?
A
Pneumocystis jiroveci
Hint:
Pneumocystis jiroveci is common in HIV patients, not patients with cystic fibrosis.
B
Haemophilus influenza
Hint:
Staphylococcus aureus and Haemophilus Influenzae often begin in the first few months of life even in asymptomatic infants with cystic fibrosis, but are less common in older children.
C
Mycoplasma pneumoniae
Hint:
Mycoplasma pneumoniae is a less common cause of pneumonia in patients with cystic fibrosis.
D
Pseudomonas aeruginosa
Question 79 Explanation: 
Pseudomonas aeruginosa is the most predominant pathogen in patients with cystic fibrosis.
Question 80
Which of the following is the most common pathogen implicated as the cause of bronchiolitis in children?
A
Haemophilus influenzae
B
Respiratory syncytial virus
C
Streptococcus pneumoniae
D
Adenovirus
Hint:
Adenovirus is a possible cause of bronchiolitis, but RSV is the most common cause.
Question 80 Explanation: 
RSV is the most common cause of bronchiolitis in children.
Question 81
Which of the following is the most important measure in the prevention of epiglottitis?
A
Haemophilus influenzae B vaccine
B
Cephalosporin antibiotic therapy.
Hint:
Cephalosporins are indicated in the treatment of epiglottitis. They are not a preventative measure.
C
Parental smoking cessation
Hint:
Parental smoking cessation is important in the overall reduction of respiratory tract illnesses in children, but it does not directly prevent epiglottitis.
D
Yearly influenza vaccine
Question 81 Explanation: 
Immunization with the HIB vaccine has greatly reduced Haemophilus influenzae as a cause of epiglottitis.
Question 82
A 2-year-old child presents to the emergency department with increasing respiratory distress. The mother states that the child had a "cold" 2 weeks ago. Last week the cough progressed and is described as barky in nature, associated with stridor. The child appeared to be getting better, but last night,developed a fever and increased respiratory distress. Physical examination reveals a temperature of 102°F. The child is in moderate respiratory distress. A portable lateral neck x-ray film reveals severe subglottic and tracheal narrowing. Which of the following is the most likely diagnosis?
A
acute epiglottitis
Hint:
While acute epiglottitis usually presents with respiratory distress and high fever, it is also typically associated with dysphagia and drooling. Findings on a lateral neck x-ray film would be consistent with swelling of the epiglottitis described as a "thumbprint"sign.
B
bacterial tracheitis
C
acute spasmodic croup
Hint:
Acute spasmodic croup is clinically very similar to acute laryngotracheobronchitis, but the patient is usually afebrile and the lateral neck x-ray film would be unremarkable.
D
laryngotracheobronchitis
Hint:
Acute spasmodic croup is clinically very similar to acute laryngotracheobronchitis, but the patient is usually afebrile and the lateral neck x-ray film would be unremarkable.
Question 82 Explanation: 
Bacterial tracheitis usually presents following a viral upper respiratory infection, especially laryngotracheobronchitis (croup). It should be suspected when a patient develops high fever and respiratory distress after a few days of apparent improvement or if the patient fails to respond to the usual treatment for croup. The findings of subglottic and tracheal narrowing on the lateral neck x-ray film highly support this diagnosis.
Question 83
A 14 month-old male who attends day care presents with a two-day history of frequent watery stools. His mother states that he had a fever and vomiting the day before but these have resolved. His mother denies pain in the child. The child is mildly dehydrated but otherwise appears well. Stool samples are free of blood and white blood cells. The lab reports no ova or parasites noted in the stool samples. Which of the following is the most likely diagnosis?
A
Intussusception
Hint:
Intussusception may cause diarrhea, however, after two days the stool would have blood present. The absence of pain or discomfort would also argue against this diagnosis.
B
Viral gastroenteritis
C
Shigella
Hint:
Patients with Shigella have dysentery with the passage of bloody stools in a toxic-appearing child
D
Lactase insufficiency
Hint:
Lactase insufficiency would not have caused fever and vomiting.
Question 83 Explanation: 
Rotavirus is the most common cause of gastroenteritis in children and this is frequently passed in the daycare setting.
Question 84
A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not today. On exam, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. On exam, the child is alert and responsive, with no focal findings. Which of the following is the most appropriate intervention?
A
Antibiotic therapy
Hint:
In the US, infectious gastroenteritis is most frequently due to a virus. Antibiotic therapy may be second-line in cases where the causative organism is bacterial, is identified, and symptoms continue.
B
Begin soft diet
Hint:
The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. IV fluids should be reserved for those who are unable to take fluids orally.
C
IV fluids
Hint:
The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. IV fluids should be reserved for those who are unable to take fluids orally.
D
Oral rehydration
Question 84 Explanation: 
The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. IV fluids should be reserved for those who are unable to take fluids orally.
Question 85
A severely dehydrated child with gastroenteritis who is unable to tolerate oral rehydration should receive which of the following intravenous therapies?
A
10 mg/kg normal saline
Hint:
In a severely dehydrated child, restoring intravascular volume to insure adequate tissue perfusion is the immediate objective. This is best done with either Ringers lactate or normal saline. The addition of potassium would only be done after initial fluid boluses and after insuring adequate kidney function. The addition of glucose to the IV solution may result in an osmotic diuresis worsening the dehydration.
B
20 mg/kg normal saline
C
10 mg/kg D5W
Hint:
In a severely dehydrated child, restoring intravascular volume to insure adequate tissue perfusion is the immediate objective. This is best done with either Ringers lactate or normal saline. The addition of potassium would only be done after initial fluid boluses and after insuring adequate kidney function. The addition of glucose to the IV solution may result in an osmotic diuresis worsening the dehydration.
D
20 mg/kg D5W
Hint:
In a severely dehydrated child, restoring intravascular volume to insure adequate tissue perfusion is the immediate objective. This is best done with either Ringers lactate or normal saline. The addition of potassium would only be done after initial fluid boluses and after insuring adequate kidney function. The addition of glucose to the IV solution may result in an osmotic diuresis worsening the dehydration.
Question 85 Explanation: 
In a severely dehydrated child, restoring intravascular volume to ensure adequate tissue perfusion is the immediate objective. This is best done with either Ringers lactate or normal saline. The addition of potassium would only be done after initial fluid boluses and after ensuring adequate kidney function. The addition of glucose to the IV solution may result in an osmotic diuresis worsening the dehydration.
Question 86
A 3 week-old male infant presents with recurrent regurgitation after feeding that has progressed to projectile vomiting in the last few days. The mother states that the child appears hungry all of the time. She denies any diarrhea in the child. Which of the following clinical findings is most likely?
A
Bile-stained vomitus
Hint:
Gastric obstruction, such as that seen with pyloric stenosis, causes vomiting that is not bilious.
B
Hemoccult positive stools
Hint:
Blood-streaked vomitus, but not hemoccult positive stools, may be seen in pyloric stenosis.
C
Olive-sized mass in the right upper abdomen
D
Sausage-shaped mass in the upper-mid abdomen
Hint:
A sausage-shaped mass may be noted in intussusception, not pyloric stenosis.
Question 86 Explanation: 
An olive-sized mass may be palpated in the right upper abdomen in pyloric stenosis and if found, is pathognomonic for pyloric stenosis.
Question 87
A 3 year-old presents with a 24-hour history of diarrhea. The patient is afebrile and the stool is noted to be loose and watery. No blood is noted in the stool. Fecal WBC is negative. Which of the following is the most likely diagnosis?
A
viral gastroenteritis
B
toxic megacolon
Hint:
Toxic megacolon is a complication of ulcerative colitis and presents with diarrhea, fever, tachycardia, and leukocytosis.
C
ulcerative colitis
Hint:
Ulcerative colitis presents with bloody diarrhea, abdominal pain, and fever.
D
intussusception
Hint:
Intussusception is more common in children age 1-2 years and presents with crampy abdominal pain, vomiting, and currant jelly stool.
Question 87 Explanation: 
Patients with viral gastroenteritis are afebrile and noted to have loose, watery, non-bloody diarrhea. Fecal WBC is negative
Question 88
A 16 day-old male presents in the office with a history of vomiting after feeding for the past 2 days. The vomiting has become progressively worse and the mother describes it as very forceful, sometimes hitting the floor 6 feet away. She says the neonate is always hungry. On physical examination, it is noted that he is 2 ounces below birth weight, and has a small palpable mass (about 1.5 cm) in the epigastrium. The most likely diagnosis is
A
achalasia.
Hint:
Achalasia is uncommon under the age of 5 and the child presents with retrosternal pain and dysphagia.
B
tracheoesophageal fistula.
Hint:
Tracheoesophageal fistula presents with increased secretions, choking, cyanosis, and respiratory distress within the first few hours of life.
C
pyloric stenosis.
D
Meckel's diverticulum.
Hint:
Meckel's diverticulum presents with painless rectal bleeding. Vomiting is rare unless obstruction has occurred.
Question 88 Explanation: 
Pyloric stenosis begins between 2 to 4 weeks of age with vomiting that becomes projectile after each feeding. An olive-size mass can often be felt in the epigastrium.
Question 89
A G1P1 29-year-old mother presents to her 5-week-old son's pediatrician complaining that her son is an "angry" baby and that it is driving her crazy. She is worried that he is never going to become calmer. Over the last couple of weeks, he has been crying for several hours a day on "most days" of the week. She is breastfeeding him every 2-3 hours and changing his diaper after every feed (his urine and stool output is within normal limits). She estimates that he sleeps for 16 hours a day, and when he is awake, she usually carries him in a sling to promote attachment and to provide comfort. On exam, his height, weight, and head circumference are all around the 50th percentile, consistent with his trend since birth. He is alert and active, visually tracks your finger, and has normal muscle tone and reflexes. By what age should this condition improve?
A
6 weeks
Hint:
Although there is some variation among individual infants, most case of infantile colic will resolve by around 4 months of age.
B
4 months
C
9 months
Hint:
Although there is some variation among individual infants, most case of infantile colic will resolve by around 4 months of age.
D
12 months
Hint:
Although there is some variation among individual infants, most case of infantile colic will resolve by around 4 months of age.
E
18 months
Hint:
Although there is some variation among individual infants, most case of infantile colic will resolve by around 4 months of age.
Question 89 Explanation: 
This 5-week-old healthy male infant is crying for at least 3 hours a day, at least 3 days a week, without evidence of a condition that would provoke crying (e.g. - hunger, wet/soiled diaper, fatigue, emotional neglect, organic illness). Thus, he likely has infantile colic, which should resolve by around 4 months of age. Infantile colic usually begins between 2 and 6 weeks of age, with an estimated prevalence of 10-20% of infants. Although the cause is unknown, some theories include: immature gastrointestinal systems or central nervous systems; allergies; sensitive disposition; and maternal misinterpretation of normal crying. Risk factors include smoking, higher socioeconomic status, older parental age, and parental depression.
Question 90
The birth weight of an infant has usually tripled by
A
the second and third month.
Hint:
A child triples his/her birthweight by one year.
B
the fourth and fifth month.
Hint:
A child triples his/her birthweight by one year.
C
the seventh and eighth month.
Hint:
A child triples his/her birthweight by one year.
D
one year
Question 90 Explanation: 
A child triples his/her birthweight by one year.
Question 91
A 3 week-old infant is evaluated for persistent projectile vomiting described as breast milk without bile or blood. The abdomen is distended before vomiting and a small, mid-epigastric mass is palpable after vomiting. Which of the following is the most appropriate diagnostic study for the evaluation of this patient?
A
Barium enema
Hint:
Barium enema is usually both diagnostic and therapeutic for intussusception which usually presents as recurring paroxysms of abdominal pain, vomiting and bloody diarrhea.
B
Esophageal manometry
Hint:
Esophageal manometry is used to measure LES pressure which may be increased in esophageal achalasia. Usually a child over 5 years presents with dysphagia, retrosternal pain and slow eating.
C
H. pylori stool antigen
Hint:
Positive H. pylori stool antigen is used to test for bacterial infection associated with PUD that presents with pain and bleeding.
D
Upper GI contrast radiographs
Question 91 Explanation: 
This infant has pyloric stenosis and an upper GI series will reveal a narrowed distal stomach with double tract of barium.
Question 92
A newborn male is evaluated 30 minutes after birth. He was born at 39 weeks gestation to a 27-year-old primigravid via cesarean section for cervical incompetence. The pregnancy was complicated by gestational diabetes, and the amniotic fluid was clear. Upon delivery, the patient had strong respiratory effort and a strong cry. His Apgar scores at 1 and 5 minutes were 7 and 8, respectively. The patient now is exhibiting increased work of breathing and is becoming progressively more tachypneic. His birth weight is 3,568 g (7 lb 14 oz). His temperature is 99.0°F (37.2°C), blood pressure is 60/44 mmHg, the pulse is 146/min, and respirations are 72/min. On physical exam, the patient is grunting with nasal flaring and subcostal retractions. Breath sounds are decreased at the bases bilaterally. The patient has central cyanosis. His chest radiograph can be seen here. Which of the following is the most likely etiology of this patient’s presentation?
A
Meconium aspiration syndrome
Hint:
Meconium aspiration syndrome can cause respiratory distress in the immediate newborn period, but it would be unlikely in a patient with a history of clear amniotic fluid, and a milder clinical picture.
B
Neonatal respiratory distress syndrome
Hint:
Neonatal respiratory distress syndrome (RDS) is a disease of prematurity and does not occur in infants born at term. The chest radiograph in RDS is also more likely to demonstrate low lung volumes.
C
Persistent pulmonary hypertension
Hint:
Persistent pulmonary hypertension (PPHN) is a cause of respiratory distress in the newborn period, but chest radiograph typically shows clear lungs.
D
Transient tachypnea of the newborn
E
Viral pneumonia
Hint:
Viral pneumonia is extremely uncommon in the immediate newborn period. Bacterial pneumonia is more common but usually presents with signs of infection in the mother, which are not present in this case.
Question 92 Explanation: 
This newborn is presenting with increased work of breathing and progressive tachypnea in the first hour of life, which is consistent with a diagnosis of transient tachypnea of the newborn. Transient tachypnea of the newborn (TTN) presents with respiratory distress and marked tachypnea within two hours of delivery. TTN is caused by delayed resorption and clearance of alveolar fluid, which results in mild pulmonary edema. Chest radiography typically demonstrates bilateral perihilar streaking and hyperinflation of the lungs. TTN is benign and usually self-resolves by day two of life, and management is supportive.
Question 93
The initial sign or symptom of iron poisoning in a 3 year-old child is usually
A
vomiting and bloody diarrhea.
B
convulsions and tetany.
Hint:
Convulsions and tetany are symptoms of hypocalcemia.
C
somnolence and coma.
Hint:
Somnolence and coma are not initial findings in iron ingestion.
D
ataxia and colicky abdominal pain.
Hint:
Ataxia and colicky abdominal pain are consistent with lead poisoning.
Question 93 Explanation: 
Iron causes localized necrosis and hemorrhage at the point of contact in the GI system resulting in abdominal pain, vomiting, bloody diarrhea, and hematemesis.
Question 94
Physical exam findings in a 4-year-old child that include blue sclerae and recurrent fractures indicate which of the following?
A
Ehlers-Danlos syndrome
Hint:
Physical exam findings in Ehlers-Danlos include laxity and hypermobility of joints, mitral valve prolapse, and associated degenerative arthritis.
B
Marfan syndrome
Hint:
Children with Marfan syndrome have hypotonia, arachnodactyly, joint laxity, and dislocations.
C
Achondroplasia
Hint:
Children with achondroplasia are below normal standards on growth charts. They have difficulty balancing their large heads when beginning to walk.
D
Osteogenesis imperfecta
Question 94 Explanation: 
Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.
Question 95
A 4 year-old boy presents to the ED after sustaining a crush injury to his distal third phalanx. Physical exam reveals an associated nail bed injury. Which of the following is the appropriate management?
A
Rest, ice, elevation
Hint:
Rest, ice, and elevation are only palliative measures and not appropriate management
B
Immobilize, antibiotics, orthopedics referral
C
Splint for 48 hours, aspirin, ice
Hint:
The digit must be immobilized until seen by ortho. Aspirin is not an appropriate analgesic for children.
D
Surgical referral for amputation of digit
Hint:
Distal phalanx fracture should be immobilized and if there is an associated nailbed injury the fracture is considered "open" and the patient should be given antibiotics and follow-up with ortho in one week.
Question 95 Explanation: 
Distal phalanx fracture should be immobilized and if there is an associated nailbed injury the fracture is considered "open" and the patient should be given antibiotics and follow-up with ortho in one week.
Question 96
A 12 year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a slight limp that favors the left leg. Radiographs show a 1 cm radiolucent nidus surrounded by osteosclerosis. Which of the following is the most likely diagnosis?
A
Osteosarcoma
Hint:
Osteosarcoma and Ewing sarcoma are malignant bone tumors that present with pain and swelling. No improvement is noted with conservative therapy.
B
Legg-Calve-Perthes disease
Hint:
Legg-Calve-Perthes disease is avascular necrosis of the hip affecting boys ages 4-10.
C
Osgood-Schlatter disease
Hint:
Osgood-Schlatter disease is inflammation of the tibial tuberosity affecting mainly boys in the ages of 10-15. Commonly associated bilaterally and due to jumping.
D
Osteoid osteoma
Question 96 Explanation: 
Osteoid osteoma is a benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin.
Question 97
In the neonate, unequal thigh folds may indicate which of the following?
A
Coxa vara
Hint:
Coxa vara is a hip deformity that would present with a decrease in the hip angle and a shift of the femoral shaft medially.
B
Legg-Calve-Perthes disease
Hint:
Legg-Calve-Perthes disease presents with a painless limp in children ages 4-10 due to avascular necrosis of the femoral head.
C
Developmental hip dysplasia
D
Slipped capital femoral epiphysis
Hint:
A slipped capital femoral epiphysis is primarily an adolescent disorder with decreased range of motion in abduction and internal rotation of the hip on physical examination.
Question 97 Explanation: 
A dislocated hip displaces proximally in developmental hip dysplasia, causing a shortening of the leg that may present as unequal thigh folds.
Question 98
A mother brings her 14 month-old son to your clinic. Earlier today she lifted her son by grabbing him by the wrists and pulling him up off the floor. The child is sitting in his mother's lap with his left forearm is extended and in pronation. He is refusing to move the left arm, forearm or wrist. The arm and joints appear normal with no noted deformities, edema or erythema. Distal pulses and capillary refill are normal and he can move his fingers. Which of the following is the most likely diagnosis?
A
Nursemaid's elbow
B
Fractured left wrist
Hint:
There is no edema, deformity or erythema to suggest a fractured wrist.
C
Osteochondritis dissecans
Hint:
Osteochondritis dissecans is avascular necrosis of subchondral bone, most commonly seen during adolescence.
D
Child abuse
Hint:
Although child abuse could be suspected the clinical history best describes nursemaid's elbow.
Question 98 Explanation: 
This clinical history is classic for radial head dislocation or nursemaid's elbow.
Question 99
Which of the following is the treatment of choice for stage one Lyme disease in a patient less than 8 years of age?
A
doxycycline
B
amoxicillin
C
chloramphenicol
Hint:
Chloramphenicol is only indicated in disseminated disease with known drug resistance. It is not indicated as first line therapy due to its tendency to cause aplastic anemia.
D
azithromycin
Hint:
Azithromycin is not as effective as doxycycline or amoxicillin.
Question 99 Explanation: 
Amoxicillin or cefuroxime are first-line therapy in a patient less than 8 years of age due to the harmful effects of doxycycline on teeth and bones in children.
Question 100
A 13 year-old female presents to the office with right knee and thigh pain and the inability to bear weight since waking yesterday morning. The mother states the child had a fever of 100.9 degrees F this morning and continues to be non- weight bearing. Examination reveals a warm, erythematous, swollen knee. Which of the following tests would be most beneficial in the diagnosis and treatment of this patient?
A
Plain x-ray of the femur
Hint:
Plain x-rays may aid in diagnostic suspicion, usually after a week or two, but do not aid in treatment choice.
B
Antistreptolysin O titer
Hint:
ASO titer is not indicated in a patient with osteomyelitis.
C
Magnetic resonance imaging (MRI) of the femur
Hint:
MRI will detect the early inflammation of osteomyelitis but does not aid in the treatment choice.
D
Culture of joint aspirate
Question 100 Explanation: 
A culture of the joint fluid will confirm the diagnosis and offer information regarding infectious agent.
Question 101
A 14-year old male active in sports, has been complaining of intermittent anterior right knee pain for several months. He denies any specific injuries. On examination, there is no erythema, swelling, deformities, joint laxity, or crepitus. Palpation reveals tenderness over the tibial tubercle and bursa of the right knee. This finding is characteristic of which of the following disorders?
A
Discoid meniscus
Hint:
Discoid meniscus causes clicking over the lateral meniscus during flexion. This disorder is mostly painless and occasionally may cause mild aching or effusion.
B
Osgood-Schlatter disease
C
Chondromalacia patella
Hint:
Chondromalacia patella may demonstrate exaggerated knee valgus and subluxation.
D
Osteochondritis dissecans
Hint:
Osteochondritis dissecans in older children may have effusions, pain, and locking of the joint caused by a portion of the joint surface softening and a shearing leading to a loose fragment.
Question 101 Explanation: 
Osgood-Schlatter disease causes pain at the tibial tubercle and it is caused by fragmentation of the tip of the proximal tibial physis.
Question 102
The most accurate way to determine the exact degree of spinal curvature in a child with scoliosis is by which of the following?
A
Calculation of the Cobb angle
B
Measurement of waist asymmetry
Hint:
While waist asymmetry and rib hump deformity may be observed on physical examination of the patient with scoliosis, none of them can be used to determine the exact degree of the spinal curvature.
C
Measurement of rib hump deformity
Hint:
While waist asymmetry and rib hump deformity may be observed on physical examination of the patient with scoliosis, none of them can be used to determine the exact degree of the spinal curvature.
D
Calculation using a scoliometer
Hint:
A scoliometer or inclinometer measures distortions of the torso and is good for screening angle of rotation, but is not exact to determine exact degree of curvature.
Question 102 Explanation: 
The scoliotic curve is measured by the Cobb method using AP and lateral x-ray films of the entire length of the spine.
Question 103
A 6 year-old female presents to the clinic with her parents because of lower back pain and difficulty walking for one week. The pain is described as a dull ache that is constant in the midlumbar region with radiation into the abdomen. She has a low grade fever of 100 degrees F which the parents note has been persistent for several days. Upon exam it is noted that the child has restricted forward flexion and extension secondary to pain. She has tenderness over the L3 vertebrae. An area of cellulitis from an insect bite is discovered over her left scapula. Which of the following is the most likely diagnosis?
A
Scheurmann's disease
Hint:
Scheuermann's disease is a fixed kyphosis that develops near the time of puberty. Cause is unknown and poor posture, fatigue and pain is a common complaint.
B
Discitis
C
Lyme disease
Hint:
Lyme disease is a tick borne illness that manifests with flu like symptoms and a distinct skin rash (erythema migrans). Joint involvement is a late complication with less than two or three joints involved.
D
Osteitis condensans ilii
Hint:
Osteitis condensans ilii is bilateral sclerosis of the ilium. It is most common in multiparous women.
Question 103 Explanation: 
Discitis is an infectious disease that occurs in the mid lumbar region of children at the age of about 6 years old. Symptoms are low back pain that radiates into the abdomen or lower extremity. A low-grade fever with nausea and vomiting occasionally occur.
Question 104
A 10-year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a slight limp that favors the left leg. Radiographs show a 1 cm radiolucent nidus surrounded by osteosclerosis. The most likely diagnosis is
A
osteosarcoma.
Hint:
Osteosarcoma and Ewing sarcoma are malignant bone tumors that present with pain and swelling.No improvement is noted with conservative therapy.
B
bone cyst.
Hint:
Bone cysts are not symptomatic
C
osteoblastoma.
Hint:
Osteoblastoma is benign and typically involves the spine. Pain is dull and aching with no change at night.
D
osteoid osteoma.
Question 104 Explanation: 
Osteoid osteoma is a benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin
Question 105
A 4 week-old female is seen for a well child visit. Birth history is significant for breech presentation and weighing 9 pounds 8 ounces at delivery. Which of the following is indicated to rule out developmental dysplasia of the hip?
A
Ultrasound
Hint:
Ultrasound is useful for the diagnosis of developmental dysplasia of the hip (DDH). False positive readings prior to 8-10 weeks of age, expense, and comprehensive training needed for interpretation exclude this as a standard evaluation tool.
B
Physical examination
C
Anterior/posterior radiograph
Hint:
Radiographs are not helpful because the femoral head is composed of radiolucent cartilage in the newborn.
D
Computed tomography
Hint:
Computed tomography is not indicated in a newborn.
Question 105 Explanation: 
A careful physical examination at birth and repeated evaluation at each well visit until the child walks is indicated to identify DDH. A high degree of suspicion is necessary in children with risk factors for DDH, such as positive family history, ligamentous laxity, breech presentation, female gender, large fetal size, and first-born status.
Question 106
An obese 12 year-old male presents with a 1 month history of right thigh pain worsened with weight bearing.Examination is normal, however, radiographs reveal a posterior and medial displacement of the femoral head. Which of the following is the most likely diagnosis?
A
Legg Calvé Perthes disease
Hint:
Legg Calvé Perthes disease is thought to be secondary to avascular necrosis of the hip in children small for their age with retarded bone growth
B
Developmental dysplasia of the hip
Hint:
Developmental dysplasia of the hip is partial or complete dislocation of the hip in the newborn.
C
Slipped capital femoral epiphysis
D
Osgood-Schlatter disease
Hint:
Osgood-Schlatter disease is a painful swelling over the tibial tubercle, most commonly in a male adolescent athlete.
Question 106 Explanation: 
Slipped capital femoral epiphysis is the posterior and usually medially displacement of the femoral head in overweight adolescents during puberty. The growth plate is susceptible to slippage due to the rapidly thickened cartilage physis secondary to growth hormone, the lack of sex hormone secretion for physis stability, mechanic stress secondary to obesity, and the anatomy and hip mechanics.
Question 107
A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears well with a respiratory rate of 42 per minute. What is the next best step in the evaluation and treatment of this patient?
A
lateral soft tissue x-ray of the neck
Hint:
While lateral x-ray of the soft tissues of the neck may be done only 7% of all aspirated foreign bodies are radiopaque. Lateral x-ray is typically done for epiglottitis and retropharyngeal abscess.
B
indirect laryngoscopy
C
thoracocentesis
Hint:
Thoracocentesis is not indicated in patients with airway foreign body aspiration.
D
barium swallow
Hint:
Barium swallow is used to evaluate for possible esophageal foreign body aspiration. Wheezing and stridor are not common.
Question 107 Explanation: 
Laryngoscopy is indicated not only for diagnosis, but also removal of the foreign body.
Question 108
A 4-year-old patient presents with increasing redness and swelling involving her right eye for the past 2 days. The mother states that the child has become increasingly irritable, less active, and appears to have an increased temperature. The child had a recent "cold" and nasal congestion prior to onset of these symptoms. Examination reveals an ill-appearing 4-year-old child lying quietly on the exam table. Temperature is 102° F. Visual activity is 20/40 in the right eye and 20/30 in the left eye. The right eye reveals mild proptosis and severe erythema, increased warmth, and swelling involving the eye and surrounding tissues. Which of the following is the most appropriate diagnostic evaluation?
A
applanation tonometry
Hint:
Applanation tonometry is utilized in the measurement of intraocular pressure with suspected glaucoma and is, therefore, not indicated in this patient.
B
electronystagmography
Hint:
Electronystagmography is an objective recording of induced nystagmus utilized for the evaluation of vertigo and is not indicated in this patient.
C
orbital and sinus CT scan
D
ultrasonography of sinuses
Hint:
Ultrasonography of the sinuses is not clinically utilized to evaluate for the presence of sinusitis or orbital cellulitis.
Question 108 Explanation: 
This is the typical presentation of orbital cellulitis. A CT scan of the orbit and sinuses is indicated to check for the presence of a subperiosteal abscess and underlying sinusitis, which is often the cause of orbital cellulitis.
Question 109
A 4-year-old presents with a history of having failed two courses of antibiotic therapy for acute otitis media. Initially she was on high-dose amoxicillin for 10 days followed by amoxicillin-clavulanate (Augmentin). Mother has been compliant with administering the medication. Which of the following is the next most appropriate intervention?
A
tympanocentesis
B
ENT referral for tubes
Hint:
Myringotomy with tube insertion is considered once a child has a 3 month history of bilateral hearing loss or evidence of speech delay with unilateral hearing loss.
C
repeat course of Augmentin
Hint:
It is not appropriate to repeat a course of Augmentin since the infection did not respond to it. If a tympanocentesis is unable to be performed, clindamycin or ceftriaxone are third-line antibiotic options.
D
antibiotic and corticosteroid therapy
Hint:
An antibiotic and corticosteroid is an appropriate option of treatment for unresolved otitis media with residual effusion still present after 6 weeks of observation.
Question 109 Explanation: 
This child has unresponsive acute otitis media having failed two courses of appropriate antibiotic therapy. Tympanocentesis is indicated to identify the causative organism and appropriate antibioticselection.
Question 110
A 4-year-old presents with severe pain in the left ear. The tympanic membrane is red, dull, bulging, and immobile. The child has no known drug allergies. The most appropriate first-line drug would be
A
cefaclor (Ceclor).
Hint:
Cefaclor is used in resistant cases, not in initial treatment.
B
amoxicillin (Amoxil).
C
trimethoprim-sulfamethoxazole (Septra).
Hint:
Trimethoprim-sulfamethoxazole is used for long-term prophylaxis against recurrent acute otitis media.
D
amoxicillin/clavulanate (Augmentin).
Hint:
Amoxicillin/clavulanate is used in resistant cases, not in initial treatment.
Question 110 Explanation: 
Amoxicillin will cover the most common pathogens and is considered first-line therapy.
Question 111
A 4-year-old patient presents with a sore throat and fever. Throat culture shows Group A beta-hemolytic streptococcus. Which of the following is the treatment of choice?
A
sulfasoxazole
Hint:
Sulfasoxazole is not effective against streptococcal pharyngitis.
B
tetracycline
Hint:
Tetracycline is not effective against streptococcal pharyngitis and is contraindicated in children under the age of 12.
C
floxacin
Hint:
Floxacin is contraindicated in children under the age of 18.
D
penicillin
Question 111 Explanation: 
Penicillin VK 250 mg po qid for 10 days is the recommended treatment for streptococcal pharyngitis. Erythromycin is an alternative in patients allergic to penicillin.
Question 112
A 23 month-old male presents to the office with his father who reports the patient has had an acute onset of severe pharyngitis, fever of 103.5 degrees F and what sounds like harsh, high-pitched breath sounds. His dad states the child has started drooling and seems to be worsening. The child is not presently crying but has muffled voice sounds. The child has not been immunized due to religious reasons. What is the most appropriate next step?
A
Administer ceftriaxone (Rocephin)
B
Emergent transfer
C
Administer racemic epinephrine
D
Obtain intravenous access
Question 112 Explanation: 
Epiglottitis requires endotracheal intubation to maintain the airway but should be performed only in the operating room or emergency room with a competent physician prepared to place an endotracheal tube or less often to perform a tracheostomy.
Question 113
A 3 year-old presents with sore throat and fever. The child appears toxic and is having trouble handling oral secretions. Which of the following is the next most appropriate step in the evaluation of this patient?
A
Order a chest airway fluoroscopy.
Hint:
With suspected epiglottitis, a chest airway fluoroscopy will not be helpful.
B
Examine the patient's throat directly.
Hint:
Direct visualization of the throat in a patient with suspected epiglottitis may lead to laryngeal spasm and suffocation of the patient.
C
Prepare for immediate laryngoscopy.
Hint:
Direct visualization of the throat in a patient with suspected epiglottitis may lead to laryngeal spasm and Laryngoscopy should be attempted only under controlled condition, usually the operating room.
D
Order a lateral neck x-ray study.
Question 113 Explanation: 
n a patient with suspected epiglottis a lateral neck x-ray films may be helpful in demonstrating a classic "thumbprint" sign that will guide intervention
Question 114
A 2 year-old child is brought to the office because of a cough and a fever of 102 degrees F for 2 days. The physician assistant notes the presence of hoarseness, a barking cough, and stridor. The ears and nose exam are unremarkable. Auscultation of the chest reveals decreased breath sounds without crackles or expiratory wheezes. Which of the following would be the initial diagnostic impression?
A
pneumonia
Hint:
Pneumonia would not produce the stridor noted on physical exam. Pneumonia would more than likely produce crackles, also not noted in this patient.
B
bronchiolitis
Hint:
Bronchiolitis would produce inspiratory wheezes which are absent in this patient.
C
croup
D
asthma
Hint:
Asthma would not normally present with fever and stridor.
Question 114 Explanation: 
Hoarseness, inspiratory stridor, and a barking cough are classic signs of croup, all of which are noted in this patient.
Question 115
A 2 month-old infant presents for a routine health maintenance visit. The mother has been concerned about the infant's hearing since birth. Physical examination reveals no apparent response to a sudden loud sound. Which of the following is the most appropriate diagnostic evaluation?
A
audiometry
Hint:
Pure tone audiometry can be used to screen for hearing deficits in children over the age of 3 years.
B
tympanometry
Hint:
Tympanometry is used to identify an effusion as the cause of hearing loss, but in infants over the age of months.
C
acoustic reflectometry
Hint:
Acoustic reflectometry measures the spectral gradient of the tympanic membrane, but is not used clinically due to concerns about its reliability.
D
auditory-evoked potentials
Question 115 Explanation: 
Brainstem auditory-evoked potentials evaluate the sensory pathway and identify the site of any anatomical disruption. The test does not require any active response from the patient and is useful in the evaluation of suspected hearing loss in an infant.
Question 116
Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism?
A
Epstein-Barr virus
Hint:
Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate.
B
Group C Streptococcus
Hint:
Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates
C
Coxsackievirus
D
Gonorrhea
Hint:
Neisseria gonorrhea of the pharynx may be asymptomatic
Question 116 Explanation: 
Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx.
Question 117
A 13 year-old boy with leukemia presents with epistaxis for 2 hours. The bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is
A
electrocautery of the bleeding site.
Hint:
Cautery is not used because the edges of the cauterized area may begin to bleed.
B
silver nitrate application.
Hint:
Silver nitrate is not used in children because it increases the risk for nasal septal perforation.
C
posterior nasal packing.
Hint:
Posterior nasal packing is indicated for posterior bleeds in the inferior meatus.
D
intranasal petrolatum gauze.
Question 117 Explanation: 
Petrolatum gauze will provide pressure to the bleeding point while the cause of bleeding is corrected.
Question 118
A 3-year-old male presents to the emergency department with difficulty breathing. On physical examination, the patient is febrile and tachypneic. The patient's lateral neck radiograph is shown here. Which of the following signs on physical examination is most specific for this patient's disease?
A
Cough
Hint:
The presence of cough is specific for croup.
B
Stridor
Hint:
Patients with epiglottitis are classically "toxic-appearing", but the literature points to drooling as a more specific sign of the disease.
C
Drooling
D
Rhinorrhea
Hint:
Rhinorrhea and conjunctivitis are not typically present in epiglottitis.
E
Conjunctivitis
Hint:
Rhinorrhea and conjunctivitis are not typically present in epiglottitis.
Question 118 Explanation: 
This patient's presentation is consistent with epiglottitis. Among the choices, drooling is the physical finding most specific for epiglottitis. Epiglottitis is a serious and rapidly progressive infection of the epiglottis and contiguous structures that affects children from age 3-7. It presents with fever, tachypnea, stridor, drooling, the "tripod position," and the "thumbprint sign" on lateral neck radiograph. It is classically caused by H. influenzae type B (Hib) but S. aureus and Streptococcus are now common causative agents due to the Hib vaccine. Epiglottitis is is a true airway emergency and requires immediate intubation in the OR. Patients remain intubated while receiving IV antibiotics for up to 72 hours. It must be differentiated from croup, which presents similarly and is not immediately life-threatening; croup shows the "steeple sign" on CXR and presents with cough and a lack of drooling.
Question 119
A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?
A
Croupy cough and drooling
B
Thick gray, adherent exudate
Hint:
Thick gray adherent exudate is suggestive of diphtheria.
C
Beefy red uvula, palatal petechiae, white exudate
Hint:
Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of streptococcal pharyngitis.
D
Inflammation and medial protrusion of one tonsil
Hint:
Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.
Question 119 Explanation: 
A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.
Question 120
There is considerable debate about the use of tympanostomy tubes in the management of recurrent otitis media in children. Tympanostomy tube placement has been proven to
A
improve hearing
B
prevent mastoiditis.
Hint:
Mastoiditis is prevented by early treatment of otitis media with antibiotics.
C
prevent recurrence of effusion.
Hint:
Effusion can occur even with tympanostomy tubes in place.
D
prevent delayed language development.
Hint:
Tympanostomy tubes have not been proven to prevent delayed language development.
Question 120 Explanation: 
Hearing is improved with tympanostomy tubes by eliminating middle ear effusion when the tubes are functioning properly.
Question 121
An afebrile 2 year-old female presents with a three-day history of foul smelling, blood-tinged, mucoid drainage from the left nostril. Which of the following is the most likely diagnosis in this patient?
A
Acute bacterial sinusitis
Hint:
Bacterial sinusitis typically follows a viral upper respiratory infection with symptoms of cough, nasal drainage and fever. The symptom duration is typically 10-14 days without improvement.
B
Nasal foreign body
C
Acute viral rhinitis
Hint:
The patient with acute viral rhinitis typically presents with sudden onset of mucoid rhinorrhea, sore throat, fever and cough.
D
Allergic rhinitis
Hint:
Allergic rhinitis is associated with recurrent nasal congestion, frequent sneezing and clear rhinorrhea.
Question 121 Explanation: 
Nasal foreign body typically presents in children under 3 years of age. The symptoms include mucopurulent drainage, epistaxis, foul odor and nasal obstruction.
Question 122
A 4-month-old female presents with her parents to your office. The patient’s parents are concerned because she used to push up to her elbows during tummy time, but she now struggles to lift her head. She has been urinating and stooling well, but her parents report decreased interest in food. All prenatal screening for the patient was unremarkable. There is no family history of genetic abnormalities in the patient’s mother. The patient’s father was adopted and knows little about his biological family. The patient has two older siblings who are both developmentally normal. On physical exam, the patient appears well-developed and well-nourished. She is in the 40th and 48th percentiles for height and weight, respectively. She has no dysmorphic features. Her abdomen is soft and non-tender. Hepatosplenomegaly is present. Ophthalmologic exam reveals the finding seen here. Of the following, which is most likely to be found in this patient?
A
Corneal clouding
Hint:
Corneal clouding is a feature of Hurler syndrome, an autosomal recessive mucopolysaccharidosis caused by deficiency of lysosomal hydrolase that presents at age 6 months to 2 years with coarse facial features (“gargoylism”), developmental delay, inguinal or umbilical hernias, corneal clouding, and hepatosplenomegaly.
B
Hypohydrosis
Hint:
Hypohydrosis is a finding in Fabry disease, an X-linked recessive sphingolipidosis caused by deficiency of a-galactosidase A. Early findings include the triad of episodic peripheral neuropathy, angiokeratomas, and hypohidrosis, while late findings include progressive renal failure and cardiovascular disease.
C
Hyporeflexia
D
Hyperreflexia
Hint:
Hyperreflexia is a feature of Tay-Sachs disease, which is an autosomal recessive deficiency of beta-hexosaminidase A that presents with many of the same findings as Niemann-Pick disease but without hepatosplenomegaly. Hyporeflexia or areflexia are seen in Niemann-Pick disease.
E
Pancytopenia
Hint:
Pancytopenia is a feature of Gaucher disease, an autosomal recessive sphingolipidosis caused by deficiency in glucocerebrosidase that presents with pancytopenia and hepatosplenomegaly.
Question 122 Explanation: 
This 4-month-old patient presents with loss of motor milestones, a “cherry-red” spot on the macula, and hepatosplenomegaly, which suggests a diagnosis of Niemann-Pick disease. Niemann-Pick disease also presents with hyporeflexia. Niemann-Pick disease (NPD) is a sphingolipidosis caused by a deficiency in sphingomyelinase. NPD shares many features with Tay-Sachs disease, as both present in infants aged 2-6 months with progressive neurodegeneration, hypotonia, feeding difficulties, and a “cherry-red” macula. The two can be distinguished by the fact that only NPD presents with hepatosplenomegaly, and NPD presents with hyporeflexia or areflexia, whereas Tay-Sachs disease presents with hyperreflexia. In addition, NPD is characterized by an accumulation of sphingomyelin and other lipids in macrophages, which gives affected cells a “foamy” appearance.
Question 123
A 7-year-old child with a history of type 1 diabetes mellitus for 3 years presents for routine follow-up. The mother states that the child has been having nightmares and night sweats. Additionally, his average morning glucose readings have risen from an average of 100 mg/dL to 145 mg/dL over the past week. This child is most likely experiencing
A
a growth spurt
Hint:
Nightmares and night sweats are not associated with growth spurts.
B
emotional problems.
Hint:
With this limited history, it is impossible to label the child as emotionally unstable.
C
the Somogyi effect.
D
the dawn phenomenon.
Hint:
This refers to an early morning rise in plasma glucose due to reduced tissue sensitivity to insulin between 5 AM and 8 AM. It is not associated with nightmares and night sweats.
Question 123 Explanation: 
This refers to nocturnal hypoglycemia, which stimulates counter-regulatory hormone release resulting in rebound hyperglycemia.
Question 124
The most definitive treatment for primary enuresis is
A
oxybutynin chloride (Ditropan)
Hint:
Oxybutynin chloride is used for bladder spasms. It cannot be used for children under 5 years of age and is not indicated in primary enuresis.
B
imipramine (Tofranil)
Hint:
Imipramine is an older form of treatment that is moderately effective, but many patients relapse when therapy is stopped. This is no longer considered the treatment of choice.
C
trimethoprim-sulfamethoxazole (Bactrim)
Hint:
TMP-SMX is indicated for urinary tract infections that may cause secondary enuresis, but it is not used in primary enuresis.
D
desmopressin (DDAVP)
Question 124 Explanation: 
Intranasal desmopressin is effective in 50% of patients treated and is the treatment of choice.
Question 125
A 9 year-old boy who has had cold-like symptoms for the past few days is brought to the clinic by his mother who states that her son had gross hematuria this morning. Prior to the cold-like symptoms the boy has been in excellent health. He is up-to-date on all of his immunizations. The patient does not have any edema, hypertension or purpura. Urinalysis reveals the urine to be cola-colored with a 2+ positive protein and 2+ hemoglobin. Microscopic analysis reveals 50-100 RBCs/HPF, no WBCs, bacteria, casts or crystals. What is the most likely diagnosis?
A
Post streptococcal glomerulonephritis (PSGN)
Hint:
PSGN usually presents 2-3 weeks after a streptococcal infection (pharyngeal or skin) and usually presents with nephritic symptoms (edema, hypertension, cola-colored urine). This is due to trapping of the streptococcal antigen within the glomerulus
B
IgA nephropathy
C
Minimal change disease (MCD)
Hint:
MCD is the most common nephrotic presentation (edema, hypoproteinemia, hyperlipidemia, >3.5 gms. of proteinuria in 24 hours) in children following an upper respiratory illness. This patient is not exhibiting any of these signs at this time.
D
Membranous nephropathy
Hint:
Membranous nephropathy is the most common cause of adult nephrotic syndrome.
Question 125 Explanation: 
IgA nephropathy presents after an upper respiratory illness with deposition of IgA within the mesangium of the glomerulus.
Question 126
Upon stroking of the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan. This is a positive
A
Kernig's sign.
Hint:
Kernig's sign is positive when pain is noted on straightening the knee after flexing both the hip and knee.
B
Brudzinski's sign.
Hint:
Brudzinski's sign occurs with neck flexion resulting in resultant flexion of the hips. It is a sign of meningeal irritation.
C
Babinski's sign.
D
Gower's sign
Hint:
A positive Gower's sign is noted in certain types of muscular dystrophy and is described as children rising to stand by rolling over prone and pushing off the floor with arms while the legs remain extended.
Question 126 Explanation: 
A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan in a positive test.
Question 127
During an influenza epidemic, a 6 year-old child is seen with fever and a severe sore throat. A throat swab is taken for culture and the child is sent home. The next day, he is reported to have persistent vomiting and increased lethargy. On examination, he is delirious and disoriented. No rash is noted. His reflexes are hyperactive. The liver edge is 3 cm below the right costal margin in the midclavicular line. Which of the following is the most likely diagnosis?
A
acute bacterial meningitis
Hint:
Acute bacterial meningitis presents with fever, malaise, and neck stiffness. The liver is typically normal.
B
Guillain Barré syndrome
Hint:
Guillain Barré syndrome typically presents post-Campylobacter enteritis. Signs and symptoms include an ascending weakness. No hepatomegaly is noted and reflexes are diminished.
C
Reye syndrome
D
measles encephalitis
Hint:
Measles encephalitis typically presents one week after the measles rash with ataxia, vomiting, and seizures.
Question 127 Explanation: 
Reye syndrome is typically post-influenza or URI. The patient develops lethargy, drowsiness, and vomiting. Babinski reflex is positive and hyperreflexia is noted. The liver is normal or enlarged.
Question 128
A 7-year-old patient presents with an abrupt onset of fever, chills, malaise, muscular aching, headache, and nasal stuffiness. The patient is taking two baby aspirin every 6 hours for fever, muscle aches, and headache. Which of the following complications is the patient most at risk for?
A
iron deficiency anemia
Hint:
Iron deficiency anemia present with easy fatigability, tachycardia, palpitations, and tachypnea on exertion.
B
diarrhea
Hint:
Diarrhea is not associated with the use of aspirin.
C
Reye's syndrome
D
urinary tract infection
Hint:
Urinary tract infection presents with irritative voiding symptoms and is not associated with the use of aspirin.
Question 128 Explanation: 
Reye's syndrome is a rare and severe complication of influenza, particularly in young children. The pathogenesis is unknown, but the syndrome is associated with aspirin use in viral infections.
Question 129
A 5 year-old child has just been hospitalized with meningococcemia. Family members and close contacts should be given which of the following as prophylaxis?
A
Rifampin orally
B
Doxycycline orally
C
Erythromycin orally
D
No chemoprophylaxis
Question 129 Explanation: 
Exposed household, school, or day-care contacts of children with meningococcemia should receive chemoprophylaxis to eliminate the organism from the nasopharynx. The drug of choice is rifampin (10 mg/kg, up to 600 mg) every 12 hours for 48 hours. Sulfisoxazole, ceftriaxone, and ciprofloxacin are alternative choices for prophylaxis.
Question 130
Rates of alcohol use in the adolescent are reportedly higher in:
A
families with rigorous parental monitoring
Hint:
Families with the lowest measures of parental supervision, children initiated alcohol, tobacco, and drug use earlier than children from families with more supervision.
B
Japanese families
Hint:
Alcoholism has been reported to be lower among Japanese families.
C
adoptive children whose biological parent is an alcoholic
D
mood disorders in a grandparent
Hint:
There is no correlation suggesting that mood disorders in a grandparent increases the risk of alcohol dependency in the adolescent.
Question 130 Explanation: 
There is a three-to fourfold increase in risk for alcohol dependence in adopted children whose biological parents are alcohol dependents.
Question 131
A child has been under treatment for attention-deficit hyperactivity disorder (ADHD). No response has occurred with behavioral adaptations. Which of the following categories of medication should this patient be given?
A
stimulants
B
anxiolytics
Hint:
Anxiolytic agents, such as Xanax, are used in treating anxiety disorders.
C
antipsychotics
Hint:
Antipsychotics, such as Thorazine, are used in treating psychosis.
D
antidepressants
Hint:
Antidepressants, such as Elavil, are used to treat depression.
Question 131 Explanation: 
Stimulants, such as Ritalin, Dexedrine, and Cylert, are effective in 50 to 80% of children with ADHD.
Question 132
A mother brings her 6 year-old boy for evaluation of school behavior problems. She says the teacher told her that the boy does not pay attention in class, that he gets up and runs around the room when the rest of the children are listening to a story, and that he seems to be easily distracted by events outside or in the hall. He refuses to remain in his seat during class, and occasionally sits under his desk or crawls around under a table. The teacher told the mother this behavior is interfering with the child's ability to function in the classroom and to learn. The mother states that she has noticed some of these behaviors at home, including his inability to watch his favorite cartoon program all the way through. Which of the following is the most likely diagnosis?
A
Antisocial disorder
Hint:
Antisocial behavior disorder is characterized by disregard for rights of others; a defect in the experience of compunction or remorse for harming others.
B
Dysthymic mood disorder
Hint:
Dysthymic mood disorder is characterized by chronic, sad mood occurring for at least 2 years in an adult (one year in a child). Behavioral problems are not part of this disorder.
C
Obsessive-compulsive disorder
Hint:
Obsessive-compulsive disorder is characterized by recurrent obsessions and compulsions that result in anxiety and disruptive behaviors related to those compulsions.
D
Attention deficit hyperactivity disorder
Question 132 Explanation: 
Attention deficit hyperactivity disorder is characterized by inattention, including increased distractibility and difficulty sustaining attention; poor impulse control and decreased self-inhibitory capacity; and motor overactivity and motor restlessness, which are pervasive and interfere with the individual's ability to function under normal circumstances.
Question 133
A 3-day-old male infant born at 39 3/7 weeks to a 29-year-old G2P1001 mother exhibits yellow discoloration of the skin notable from the forehead to the level of the umbilicus. Which of the following would be concerning and prompt further evaluation of this infant?
A
Total serum bilirubin level of 10 mg/dL at 72 hours of life
Hint:
Pathologic jaundice is defined as total bilirubin level greater than 12 mg/dL in a term infant at any age of life
B
Conjugated serum bilirubin level of 1.6 mg/dL at 60 hours of life
Hint:
Pathologic jaundice is defined as conjugated or direct serum bilirubin level greater than 2 mg/dL or greater than 20% of total serum bilirubin.
C
Appearance of the infant's jaundice first occurring at 48 hours of life
Hint:
Pathologic jaundice is defined as the clinical presence of jaundice in the first 24-36 hours of life.
D
Clinical persistence of the infant's jaundice through 1 week of age
Hint:
Pathologic jaundice is defined as persistence of jaundice beyond 10-14 days of life.
E
Total serum bilirubin of 4 mg/dL at 48 hours followed by 11 mg/dL at 72 hours
Question 133 Explanation: 
This infant's clinical picture is consistent with a diagnosis of neonatal jaundice. A rising serum total bilirubin at a rate of greater than 5 mg/dL/24hr is indicative of pathologic jaundice and warrants further investigation. It is important to differentiate pathologic from physiologic neonatal jaundice, as there are numerous potential underlying causes to pathologic hyperbilirubinemia that, if present, must be identified so that further work-up and treatment can be initiated. Indications to pursue further evaluation of neonatal jaundice include: 1) conjugated bilirubin > 2 mg/dL or > 20% of total bilirubin, 2) jaundice in the first 24 to 36 hours, 3) bilirubin rate of rise > 5 mg/dL/24hrs, 4) total bilirubin > 12 mg/dL in a term infant, 5) jaundice persisting beyond 10-14 days of life, and 6) presence of any additional signs or symptoms indicative of underlying disease.
Question 134
A 19 year-old woman has been consuming up to six beers daily since she was 16. She is now pregnant with her first child, has had little prenatal care, and is due to deliver in four weeks. Of the following, which neonatal problems should you anticipate?
A
kernicterus
Hint:
Kernicterus is typically due to ABO/Rh incompatibility, not fetal alcohol syndrome.
B
hydrocephalus
Hint:
While a wide variety of disorders, such as infection, tumors, and congenital malformations, may play a role in the development of hydrocephalus, it is not a feature of fetal alcohol syndrome.
C
low birth weight
D
teeth discoloration
Hint:
Teeth discoloration is common in infants exposed to tetracycline.
Question 134 Explanation: 
Fetal alcohol syndrome is a common cause of low birth weight.
Question 135
Which of the following is the leading cause of injury-related death in children between the ages of 1 and 15?
A
Drowning
Hint:
Drowning is a frequent, but not the leading, cause of death in early childhood.
B
Firearms
Hint:
Childhood death due to firearm related injuries is becoming more common, but it is not the leading cause.
C
House fires
Hint:
House fires are a common, but not the leading, cause of death in early childhood.
D
Motor vehicle injuries
Question 135 Explanation: 
Motor vehicle injuries are the leading cause of death in children.
Question 136
Who is the most likely adult to sexually abuse a child?
A
School teacher
Hint:
Adults within the immediate or extended family perpetrate the most child sexual abuse, usually this is a trusted member of the family.
B
Friend of the family
Hint:
Adults within the immediate or extended family perpetrate the most child sexual abuse, usually this is a trusted member of the family.
C
Scout leader
Hint:
Adults within the immediate or extended family perpetrate the most child sexual abuse, usually this is a trusted member of the family.
D
Family member
Question 136 Explanation: 
Adults within the immediate or extended family perpetrate the most child sexual abuse, usually this is a trusted member of the family.
Question 137
A 9 year-old male is brought in by his mother who reports the patient has exhibited an extremely negative attitude for the past year. He seems angry much of the time and frequently loses his temper. Arguing over even trivial details is common place and he seems to take delight in annoying his family. His grades and conduct at school remain excellent. He has few friends, though he has never been seen bullying or destroying others' property. What is the most likely diagnosis?
A
Attention deficit disorder
Hint:
Oppositional defiant disorder (ODD) best fits this scenario and is differentiated from conduct disorder by the lack of bullying and the lack of destruction of property. Many children with ODD do drift into conduct disorders over time. His good grades and conduct at school lessen the probability of untreated ADD. Personality disorders (i.e. antisocial personality disorder) can not be diagnosed at this early an age.
B
Conduct disorder
Hint:
Oppositional defiant disorder (ODD) best fits this scenario and is differentiated from conduct disorder by the lack of bullying and the lack of destruction of property. Many children with ODD do drift into conduct disorders over time. His good grades and conduct at school lessen the probability of untreated ADD. Personality disorders (i.e. antisocial personality disorder) can not be diagnosed at this early an age.
C
Antisocial personality disorder
Hint:
Oppositional defiant disorder (ODD) best fits this scenario and is differentiated from conduct disorder by the lack of bullying and the lack of destruction of property. Many children with ODD do drift into conduct disorders over time. His good grades and conduct at school lessen the probability of untreated ADD. Personality disorders (i.e. antisocial personality disorder) can not be diagnosed at this early an age.
D
Oppositional defiant disorder
Question 137 Explanation: 
Oppositional defiant disorder (ODD) best fits this scenario and is differentiated from conduct disorder by the lack of bullying and the lack of destruction of property. Many children with ODD do drift into conduct disorders over time. His good grades and conduct at school lessen the probability of untreated ADD. Personality disorders (i.e. antisocial personality disorder) can not be diagnosed at this early an age.
Question 138
A 5 year-old is being evaluated for autism. Of the following, the finding most consistent with this diagnosis is
A
extremely high IQ
Hint:
About 75% of children with autism also have mental retardation.
B
avoids eye contact.
C
easily consoled by hugging when hurt.
Hint:
Children with autism do not accept comfort when hurt. They stiffen up when hugged.
D
frequently plays "house" or "cops and robbers" with other children
Hint:
Children with autism do not tend to imitate grown-ups in their play, and do not usually play interactively with others; they tend to use others as "props" in their play.
Question 138 Explanation: 
Children with autism do not tend to make eye contact, and even avoid it.
Question 139
A six-year-old child presents with circular patches of baldness and hair that fluoresces yellow-green under a Woods lamp. Which of the following would be the best treatment?
A
shaving the hair
Hint:
Shaving the hair is not necessary in the treatment of tinea capitis.
B
oral griseofulvin
C
topical miconazole
Hint:
Topical antifungals are ineffective for treating tinea capitis because the fungus grows deep in the hair follicle.
D
lindane shampoo
Hint:
Lindane shampoo is used for the treatment of pediculosis capitis, not tinea capitis.
Question 139 Explanation: 
Tinea capitis is best treated with oral griseofulvin until the lesions clear, usually 4-8 weeks.
Question 140
An infant presents with bullous impetigo involving the face, extremities, and trunk. Which of the following is the best treatment for this child?
A
topical cleomycin.
B
topical mupirocin.
C
oral penicillin
D
oral dicloxacillin.
Question 140 Explanation: 
Bullous impetigo that is localized may be treated with topical mupirocin, but extensive involvement is best treated with oral antibiotics that are penicillinase-resistant, such as dicloxacillin.
Question 141
A mother brings in her 2 year-old child stating that the child has had a 3-day history of a nonproductive cough, thick copious rhinorrhea, conjunctivitis, and a fever to 103 degrees. Physical examination reveals a well-hydrated child, with numerous 1-2 mm white papules on both buccal mucosa, normal heart and breath sounds. This presentation is most consistent with early
A
rubeola.
B
rubella.
Hint:
Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a fever as a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapular rash and are pathognomonic for rubeola.
C
varicella.
Hint:
Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a fever as a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapular rash and are pathognomonic for rubeola.
D
streptococcal pharyngitis
Hint:
Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a fever as a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapular rash and are pathognomonic for rubeola.
Question 141 Explanation: 
Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a fever as a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapular rash and are pathognomonic for rubeola.
Question 142
A mother brings a 3 month-old infant to the office because she is concerned about a red, vascular, nodular growth on the child's back. It appears to be enlarging slightly and the vessels are slightly dilated. It seems to cause the child no discomfort. The most likely diagnosis is
A
a hemangioma.
B
a pigmented nevus.
Hint:
A pigmented nevus is not a vascular lesion.
C
a salmon patch (stork bite).
Hint:
A salmon patch is a light red macule over the nape of the neck or the glabella.
D
a malignant melanoma.
Hint:
A malignant melanoma presents as a hyperpigmented, asymmetric lesion with irregular borders and is typically seen in the adult population.
Question 142 Explanation: 
A hemangioma is a bright red to deep purple vascular nodule or plaque that often develops at birth, may enlarge, and may regress and disappear with aging.
Question 143
According to the Advisory Committee on Immunization Practices, which of the following is the recommended age range for the first or initial MMR (measles, mumps and rubella) vaccination?
A
2-4 months
Hint:
MMR vaccination is not approved for use in infants below the age of 12 months.
B
12-15 months
C
4-6 years
Hint:
The second dose of the MMR vaccine is routinely recommended to be administered between 4-6 years of age.
D
11-12 year
Hint:
Any child not previously vaccinated by 11-12 years of age may receive the vaccine. This is considered to be a "catch-up" immunization and is not the recommended age range for the initial vaccination.
Question 143 Explanation: 
The recommended age range for the initial vaccination against MMR is 12-15 months.
Question 144
What scabicide has been associated with neurotoxicity in infants and young children?
A
lindane (Kwell)
B
crotamiton (Eurax)
Hint:
Crotamiton (Eurax) is not associated with CNS toxicity and is an effective scabicide. Its primary side effects include dermatitis and conjunctivitis.
C
10% sulfur ointment
Hint:
Sulfur ointment is no longer used because newer agents have been developed and is not neurotoxic.
D
permethrin (Elimite)
Hint:
Permethrin (Elimite) is the drug of choice for the treatment of scabies and is not associated with neurotoxicity.
Question 144 Explanation: 
Lindane (Kwell) is concentrated in the CNS and toxicity from systemic absorption in infants has been reported.
Question 145
A mother brings in her 3 month-old infant and states that she has noticed a rash on her infant's scalp. Physical examination reveals the presence of erythematous and scaling crusty lesions involving the vertex of the scalp. Which of the following is the most appropriate initial intervention?
A
selenium sulfide shampoo
Hint:
While selenium sulfide shampoos can be used in treatment of scalp seborrheic dermatitis in adults, it is not recommended for use in infants and young children.
B
permethrin 1% cream rinse
Hint:
Permethrin 1% cream rinse is utilized in the treatment of pediculosis, not seborrheic dermatitis.
C
warm olive oil compresses
D
scrubbing of scalp with hexachlorophene
Hint:
Hexachlorophene is a bacteriostatic skin cleanser which is not indicated in the treatment of seborrheic dermatitis. It is also not recommended for use in infants and young children.
Question 145 Explanation: 
This infant most likely has scalp seborrheic dermatitis ("cradle cap"). Initial treatment consists of warm olive oil compresses to remove any crusts followed by use of baby shampoo or mild hydrocortisone cream.
Question 146
A 13 year-old child presents with a lesion on his right forearm that is occasionally pruritic. On examination, a 2 cm ring of erythema with a scaly border and central clearing is noted. A suspected diagnosis is confirmed by the presence of
A
a positive patch test.
Hint:
Patch testing is positive with allergic dermatitis, not fungal disorders.
B
hyphae on a KOH prep.
C
gram-positive cocci on Gram stain.
Hint:
A positive Gram stain is found with bacterial skin infections, not fungal.
D
multinucleated cells on Tzanck smear.
Hint:
Multinucleated cells found on Tzanck smear indicate herpes, not fungal infections.
Question 146 Explanation: 
Ring-shaped lesions with scaly borders and central clearing are most likely caused by fungal infection. Microscopic examination of scrapings reveals hyphae on KOH prep.
Question 147
A young child is brought to the clinic because the mother noticed a rash while bathing the child. There is a very red slightly raised eruption on the child's face across both cheeks. The child has been in good health and does not appear ill today. The most likely diagnosis is
A
scarlet fever.
Hint:
Scarlet fever is associated with fever, pharyngitis, and "sandpaper rash" over face, neck, trunk, and extremities.
B
rubella.
Hint:
Rubella presents with round or oval maculopapular lesions that begin on the neck or face and spread to the extremities.
C
roseola.
Hint:
Roseola presents with a high fever with few symptoms, followed by the appearance of a macular rash over the trunk and neck.
D
erythema infectiosum.
Question 147 Explanation: 
Erythema infectiosum is generally asymptomatic, presenting with red papules on the face that coalesce to give a "slapped cheek" appearance.
Question 148
A 3 year-old child playing in an abandoned shed is bitten by a black widow spider. The mother rushes the child to the emergency department within 20 minutes of the incident. Which of the following if the best initial intervention?
A
Intramuscular steroids
Hint:
The bite of this spider does not cause an inflammatory reaction; therefore, steroids are not indicated.
B
Administration of antivenin
Hint:
Administration of antivenin should be administered to patients with severe envenomation manifested as seizures, respiratory failure, or hypertension.
C
Immediate immersion in a cold bath
Hint:
Application of an icepack initially would be helpful for pain relief, however, immersion in a cold bath may cause hypothermia.
D
Hospital admission for symptomatic care
Question 148 Explanation: 
Hospital admission for symptomatic care should be considered in children, pregnant women, and patients with preexisting cardiovascular disease.
Question 149
An 8 year-old child is brought in by his mother with a two day history of spreading, non-pruritic red rash. The rash was preceded by moderate fever, sore throat and rhinorrhea. Examination reveals a moderately ill appearing child with a fine, macular-papular rash on an erythematous base spread diffusely over the trunk with some accentuation in the skin folds. The face is flush with perioral pallor. There is palpable anterior cervical lymphadenopathy. Which of the following is the most appropriate diagnostic study to establish the diagnosis?
A
Shave biops
Hint:
Disorders such as erythema multiforme (EM) minor favors the extremities while the EM major may favor the trunk and have associated oral mucosa involvement but generally has blistering lesions. Direct immunofluorescence studies are negative in these disorders.
B
Epstein-Barr virus Ig G
Hint:
Epstein-Barr virus Ig G would not be helpful in that it screens for prior exposure to this virus or illness such as mononucleosis.
C
Complete blood count
Hint:
Though a complete blood count is commonly ordered and may be helpful in stratifying illness in this case it would not be diagnostic as to the etiology.
D
Throat culture
Question 149 Explanation: 
Scarlatina rash is due to infection with group A strep. A throat culture would be the most appropriate diagnostic study to establish the diagnosis in this patient.
Question 150
A 3 year-old male presents with a history of high fever, red watery eyes, rhinitis and cough for the past several days. The parents brought him in today due to development of a rash. They deny a history of childhood immunizations. On examination, the child has a barky cough, fever and clear rhinorrhea and sits listlessly on the exam table. The rash is red and maculopapular located on the face and trunk. Koplik spots are noted on the buccal mucosa. Which of the following is the most likely diagnosis?
A
Roseola
Hint:
Roseola is characterized by an abrupt onset of fever that ceases upon the onset of the maculopapular rash.
B
Rubeola
C
Rubella
Hint:
Rubella or German measles is characterized by a maculopapular rash and a prodrome of nonspecific respiratory symptoms as well as postauricular and occipital adenopathy. The prodromal phase is usually absent in young children.
D
Scarlet fever
Hint:
Scarlet fever is characterized by a prodrome that includes fever, abdominal pain, headache and sore throat. A diffuse erythema with a texture of "sandpaper" commonly involves the neck, axillae, and inguinal areas before it spreads to the rest of the body.
Question 150 Explanation: 
Rubeola or measles is characterized by a prodrome of high fever, conjunctivitis, coryza (rhinitis) and a harsh cough. A maculopapular rash quickly spreads from the face to the trunk while the respiratory symptoms are at the worst.
Question 151
A 5 year-old male is brought to the office by his father who reports a 2 day history of low grade fever and coryza. The child awoke this morning with bright red cheeks. Physical examination reveals edematous, confluent plaques over the malar region of the face and reticular rash over the child's extensor surfaces. Which of the following is the most likely diagnosis?
A
Rubeola
Hint:
Rubeola (measles) is a highly contagious viral infection characterized by cough, conjunctivitis and coryza.There is an associated rash which is an erythematous maculopapular that spreads centrally and inferiorly.
B
Parvovirus B19
C
Respiratory syncytial virus
Hint:
RSV is a viral infection of the airway that causes annual outbreaks causing pneumonia, bronchiolitis and tracheobronchitis.
D
Epstein-Barr virus
Hint:
EBV is a common human virus that is present in >90% of the adult population and persists in the host for his/her lifetime. The most common presentation is a 10-35 year-old with mononucleosis.
Question 151 Explanation: 
This is a classic presentation of Fifth Disease, a childhood exantham associated with human parvovirus B19.
Question 152
Which of the following therapies is recommended for a 13 month-old child with sickle cell disease?
A
Folic acid and penicillin V
B
Ferrous sulfate and penicillin V
Hint:
Patients with sickle cell disease should receive prophylactic penicillin V starting at 2 months of age and folic acid starting at 1 year of age. Ferrous sulfate is not globally recommended for patients with sickle cell disease.
C
Folic acid and ferrous sulfate
Hint:
Patients with sickle cell disease should receive prophylactic penicillin V starting at 2 months of age and folic acid starting at 1 year of age. Ferrous sulfate is not globally recommended for patients with sickle cell disease.
D
Folic acid, ferrous sulfate and penicillin V
Hint:
Patients with sickle cell disease should receive prophylactic penicillin V starting at 2 months of age and folic acid starting at 1 year of age. Ferrous sulfate is not globally recommended for patients with sickle cell disease.
Question 152 Explanation: 
Patients with sickle cell disease should receive prophylactic penicillin V starting at 2 months of age and folic acid starting at 1 year of age. Ferrous sulfate is not globally recommended for patients with sickle cell disease.
Question 153
A 17-year-old male presents to your office for evaluation. In addition to struggling academically, you notice he is tall for his age, has small testes, and gynecomastia. Upon further workup, what genetic finding will this patient most likely have?
A
46, XXY
Hint:
Unless another chromosome other than a sex chromosome is missing, this is not an actual karyotype.
B
47, XXY
C
21-hydroxylase deficiency
Hint:
This is the cause of over 95% of cases of congenital adrenal hyperplasia, of which manifestations may range from severe salt wasting and virilization of female genitalia prenatally to excess androgen effects and infertility depending on the severity of enzyme deficiency.
D
46, XY, androgen insensitivity syndrome
Hint:
In cases of androgen insensitivity, affected individuals are genetically male, but have female genitalia and habitus.
E
45, X
Hint:
This is the karyotype of Turner's Syndrome.
Question 153 Explanation: 
This patient's clinical findings are most consistent with Klinefelter syndrome. This is a genetic disorder in which patients have an extra X-chromosome and a karyotype of 47, XXY. Klinefelter syndrome is caused by the presence of an additional X-chromosome. Affected individuals are typically asymptomatic throughout childhood and present in adolescence or early adulthood. The typical clinical presentation includes tall stature, small testes, and gynecomastia. Further workup reveals a 47, XXY karyotype and typically, azoospermia. Almost all men with Klinefelter syndrome are infertile. Late onset of puberty should prompt further evaluation, however often at diagnosis, the window for any therapeutic interventions has passed.
Question 154
A 6-year-old child with sickle cell anemia presents with fever and pain over the right tibia. There is tenderness along the anterior tibia, but no pain with motion of the knee or ankle. Which of the following is the most appropriate initial treatment?
A
aspirin
Hint:
Aspirin is not indicated for the treatment of osteomyelitis
B
codeine
Hint:
Codeine might relieve pain, but will not treat the cause of osteomyelitis
C
cefotaxime
D
norfloxacin
Hint:
Norfloxacin is contraindicated in children.
Question 154 Explanation: 
Cefotaxime provides coverage for osteomyelitis caused by staphylococcus or salmonella.
Question 155
An 8-year-old male presents to a geneticist for further workup of a series of developmental delays, learning disabilities, and dysmorphic features. His past medical history is significant for delays in motor development, including sitting without support at 10 months and walking at 20 months. Academically, he is currently struggling with math in school. On exam, he displays a long, thin, face, a large jaw, and protruding ears seen here. Given this patient's likely diagnosis, what physical finding is he likely to demonstrate following puberty?
A
Tall stature
Hint:
These are characteristic physical findings in Klinefelter syndrome.
B
Microorchidism
Hint:
These are characteristic physical findings in Klinefelter syndrome.
C
Microcephaly
Hint:
Those with Fragile X syndrome tend to exhibit macrocephaly, not microcephaly.
D
Macroorchidism
E
Neurofibromas
Hint:
These tumors appear in those with Neurofibromatosis Type I and II, not Fragile X syndrome.
Question 155 Explanation: 
Given the patient's characteristic physical features of a long face, protruding ears, male sex, and learning disability, he likely has Fragile X syndrome. Following puberty, these individuals characteristically have macroorchidism. Fragile X is caused by CGG trinucleotide expansion within the FMR1 gene located on the X chromosome. Affected individuals have characteristic physical features such as macrocephaly, a large jaw, frontal bossing, and macroorchidism following puberty. Additionally, affected individuals may also exhibit strabismus, connective tissue dysplasia including mitral valve prolapse and hyperextensible joints. They may also exhibit specific behaviors such as attention deficit, hand flapping, hand biting, and averting one's gaze. Most affected males have mild to severe mental retardation.
Question 156
A 14-year-old male is brought to an endocrinologist because his parents are concerned he is "too short." His pediatrician is contacted for his medical records, and his growth chart is obtained. If this patient's short stature is secondary to constitutional growth delay, which of the following curves would likely correspond to this presentation?
A
A
Hint:
Line A corresponds to postnatal onset pathologic short stature.
B
B
C
C
Hint:
Line C corresponds to familial short stature.
D
D
Hint:
Line D corresponds to prenatal onset pathologic short stature.
Question 156 Explanation: 
Curve B corresponds to constitutional growth delay, attaining a normal height by 18 years. The most common cause of short stature and pubertal delay is constitutional growth delay. This condition has a classic presentation on growth charts: normal birth weight and height, drop in percentiles on growth curve between 6 months and 3 years, re-establishment of normal growth velocity, and following the growth curve at the 5th to 10th percentiles. Adolescents will have a normal growth spurt and normal adult height. Constitutional growth delay is characterized by a bone age that is less than chronological age; the child's short height is often appropriate when assessed in the context of their skeletal age. The only management is reassurance and regular follow-up.
Question 157
A four-year-old boy is brought to your office by his concerned mother who states that he intermittently turns blue. She reports that he has been growing and developing normally, but recently he has been having crying fits where he turns blue and then squats down into a ball. Vital signs are stable. Physical examination reveals a pansystolic murmur at the left lower sternal border. Which of the following is true regarding the disease affecting this patient?
A
The condition is associated with Turner's syndrome
Hint:
Turner's syndrome is associated with coarctation of the aorta.
B
The condition is the most common congenital cardiac anomaly
Hint:
The most common congenital cardiac anomaly is a ventricular septal defect.
C
A boot-shaped heart will be found on chest radiograph
D
The condition may be treated with indomethacin
Hint:
A patent ductus arteriosus may be treated with indomethacin.
E
A chest radiography would reveal notching of the ribs
Hint:
Notching of the ribs would be found in a patient with coarctation of the aorta.
Question 157 Explanation: 
This patient has cyanotic spells, relieved by squatting, consistent with Tetrology of Fallot (TOF). One can expect a boot-shaped deformity on chest radiograph due to right ventricular hypertrophy. In TOF, patients have the classic clinical features of pulmonary stenosis (the most important determinant for prognosis), right ventricular (RV) hypertrophy, and an (overriding) aorta that lies directly over a ventricular septal defect (VSD). Because of pulmonary stenosis (elevated RV pressures) and the overriding aorta, patients experience early cyanosis from right to left intracardiac shunting. Patients may squat to improve symptoms because compressing the femoral arteries increases total peripheral resistance and decreases the right to left shunt, directing more blood from the right ventricle to the lungs and less across the VSD and into the aorta.
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