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1.A 6-month-old girl is brought to the ED because of persistent crying for the past 6 Her teenage father informs you that she has been inconsol- able since awaking from her nap. No recent illness, trauma, fever, or other complaints are reported. On physical examination the patient is alert, awake, and crying. You note swelling, deformity, and tenderness of the left femur. When inquired about this finding, the caretaker responds, “Her leg got stuck between the rails of her crib.” You obtain the following radiograph as seen below. Which of the following is the next best step in management?
- Genetic workup for osteogenesis imperfecta and other bone abnormalities
- Orthopedic consultation for closed reduction
- Serum electrolytes including calcium and phosphate
- Perform skeletal survey and contact Child Protective Services
- Placement of posterior splint and discharge home with orthopedic follow-up
2. A 4-year-old boy is brought to the ED by a concerned mother after she noticed lesions under his nose and around his mouth as seen in the image The patient is otherwise well with no change in behavior, fever, or vomiting reported. On physical examination, you note a well- nourished, well-developed male in no acute distress with multiple small round, honey-colored lesions with slightly erythematous centers. What is the predominant organism involved?
- Group B Streptococcus
- Staphylococcus aureus
- Streptococcus pyogenes
- Streptococcus pneumoniae
- Salmonella spp.
3. A 3-year-old African American boy with a history of sickle-cell dis- ease presents to the ED after he developed a low-grade fever, runny nose, and an erythematous discoloration of both His vital signs are heart rate (HR) 110 beats per minute, respiratory rate (RR) of 24 breaths per minute, and pulse oximetry of 98% on room air. The patient looks well and is in no acute distress. You note a macular lesion in both cheeks. The rash is not pruritic and there is no associated cellulitis or suppuration. What is the most serious complication to consider in this patient?
- Viral encephalitis
- Aplastic anemia
4. A 9-month-old boy is brought to the ED with a 2-day history of fever, vomiting, and The patient has had multiple episodes of emesis that follow intense periods of fussiness after which the patient seems to relax and go to sleep. He has had no fever or diarrhea. In between these episodes, he has slightly decreased energy but otherwise seems well. Oral intake is decreased and urine output has been decreased since the day of presentation. Which of the following statements is true regarding this condition?
- The majority present with vomiting, colicky abdominal pain, and currant jelly stools.
- Air enema is the therapeutic intervention of choice.
- Plain films of the abdomen can usually confirm the diagnosis.
- Surgical intervention is often indicated.
- Most of these have a “lead point” as the underlying pathologic cause.
5. A 7-year-old girl with sickle-cell disease and a previous history of admissions for acute painful crises presents with a 1-day history of fever and She is tachypneic on presentation with a temperature of 102°F. Auscultation of the chest reveals rales on the right. A chest radiograph con- firms the diagnosis of pneumonia. After initial treatment with antibiotics and intravenous (IV) fluids, patients with this condition are most at risk of developing which complication?
- Acute chest syndrome
- Sepsis as a result of the relative immunodeficiency of patients with sickle-cell disease
- Congestive heart failure because of the anemia coupled with infection
6. A 2-year-old boy is brought to the ED by his parents stating that he is The mother states that he was fine yesterday but woke up today and would not bear weight. He had a normal active day yesterday with no notable falls. On examination, the patient is in mild distress. His vital signs are a temperature of 101°F, HR 120 beats per minute, RR 24 breaths per minute, and blood pressure (BP) 90/55 mm Hg. He has mild nasal conges- tion. He is able to move his left lower extremity only a small amount and has discomfort with range of motion of his left hip. He is unable to bear weight. There is no swelling, rash, warmth, or erythema. White blood cell (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) are all normal. Radiograph of the hips bilaterally and left femur and knee are all negative. After high-dose ibuprofen in the ED, the patient is able to bear weight. What is the most appropriate management of this patient?
- Admit for IV antibiotics for septic arthritis or osteomyelitis.
- Consult orthopedics after ultrasound for aspiration of hip in the operating room (OR).
- Bone scan to evaluate for osteomyelitis.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and reassurance to parents with follow-up in 24 hours.
- Splint leg for treatment of occult fracture through growth plate that cannot be visualized on initial radiographs.
7. A 21-month-old girl, previously well, presents with 7 days of fever and She has been seen previously during this episode by her primary physician and diagnosed with a “viral illness.” On further questioning, the mother indicates that the patient has had red eyes, but no discharge. She has had no vomiting, diarrhea, cough, congestion, or complaints of pain. She has, however, seemed very irritable and fussy throughout the last few days and cannot seem to get comfortable. On examination, the patient is highly irritable and intermittently consolable. Vital signs reveal tempera- ture 101°F rectally, HR 170 beats per minute, RR 22 breaths per minute, and BP 100/60 mm Hg. Her conjunctivae are mildly injected with no puru- lent discharge. The oropharynx is clear though she has dry, cracked lips. There are two anterior cervical nodes measuring 2.5 cm each. The heart is tachycardic without a murmur. The lungs are clear, and abdomen is soft and nontender with no hepatosplenomegaly. The skin reveals a diffuse, blanching, erythematous, macular rash. The extremities have no swelling or tenderness. Laboratory evaluation reveals WBC 13,500/μL, Hgb 9.5 mg/dL, platelets 870/μL, CRP 89, ESR 85, and normal electrolytes; liver function tests reveal aspartate aminotransferase (AST) 110 U/L and alanine amin- otransferase (ALT) 88 U/L. Which of the following is the most appropriate next step in the management of this patient?
- Consult cardiology for statim (STAT) echocardiogram.
- Perform additional laboratory tests, including Epstein-Barr viral titers, strep test, antinuclear antibody, and bone marrow biopsy.
- Reassure the parents that the initial diagnosis was probably accurate.
- Administer IV antibiotics and perform lumbar puncture.
- Admit for administration of intravenous immunoglobulin (IVIG) and aspirin.
8. A 6-day-old infant is brought to the ED by his mom who describes the newborn as breathing fast, poor feeding, and appearing He has no history of fever or vomiting. The patient was born full term at home to a G4P3 mother with an uncomplicated antenatal course. The mom had prenatal laboratory tests but is unaware of the results. On examination, the patient is lethargic with central and peripheral cyanosis. The rectal temperature is 95.4°F, HR 180 beats per minute, RR 70 breaths per min- ute, and BP unobtainable in the extremities by automatic pressure meter. The oxygen saturation on room air is 65%, which does not improve with administration of 100% oxygen by face mask. Auscultation reveals a harsh 3/6 systolic murmur with an active precordium. Lungs reveal diffuse, bilat- eral rales, and wheezes. Liver edge is palpated 3 to 4 cm below right costal margin. Which of the following is the most important next step in the management of this patient?
- Intubation for administration of 100% oxygen
- STAT portable chest radiograph and electrocardiogram (ECG)
- Administration of IV antibiotics and full sepsis workup
- Administration of prostaglandin bolus followed by continuous drip
- Immediate surgical intervention and activation of extracorporeal membrane oxygenation (ECMO) team
9. A 27-day-old presents to the ED with a complaint of a 2-day history of nonbilious The child has had no fever and no diarrhea. He has always been a “spitter,” according to mom, but this seems more exces- sive and “forceful.” The patient has had no wet diapers over the course of the previous 12 hours and is fussy in the examination room. There are no other complaints. The mother has just finished feeding the child formula as you walk into the room and you see the child has an episode of projectile vomiting. The examination reveals temperature 99.8°F, HR 180 beats per minute, RR 50 breaths per minute, and pulse oxymetry of 95% on room air. The remainder of the examination is nonfocal and benign except for slightly prolonged capillary refill. You order the appropriate radiographic studies and consult the appropriate services. If you were to check a set of electrolytes in this patient, what would be the most likely result?
- Na 137, K 3.7, Cl− 112, HCO3 22, glucose 110
- Na 137, K 3.1, Cl− 89, HCO3 39, glucose 55
- Na 145, K 6.2, Cl− 122, HCO3 35, glucose 55
- Na 145, K 3.1, Cl− 89, HCO3 16, glucose 80
- Na 122, K 6.2, Cl− 122, HCO3 35, glucose 55
10. A 35-year-old G4P3 woman presents to the ED in The mother says that her due date is not for 2 more weeks. She indicates that she rup- tured her membranes several hours ago and that her contractions have been within a few minutes for a few hours. She is placed immediately in position to check her progress and the infant’s head is seen to be crowning. The baby is then born precipitously in the ED. Which of the following interven- tions should be immediately instituted for this newborn?
- Begin resuscitative efforts with positive-pressure ventilation immediately because this is a high-risk infant.
- Administer two breaths of positive-pressure ventilation to assist movement of fluid out of lungs so that the newborn may begin effective respirations.
- Call the neonatal ICU to let them know that a premature infant will be coming and will probably need to have a “workup.”
- Assign an Apgar score so that all of the medical personnel may know the status and understand their roles for the next few minutes.
- Dry the infant, suction the mouth and nose, stimulate semivigorously, and observe for several seconds for respiratory effort before initiation of any other intervention.
11. A 15-month-old girl is brought to the ED by EMS secondary to sei- zure activity noted at The patient is a previously well child. Her immunizations are up to date. The patient is reported to have been recently well but was noted to be a little cranky this morning. She has had no cough, congestion, vomiting, diarrhea, or rash. This afternoon, the patient was being observed in the playroom when her eyes rolled back and she began having generalized tonic-clonic activity that lasted for approximately 2 minutes. When emergency medical services (EMS) arrived, the patient was in her mother’s arms, tired but arousable, and in no apparent dis- tress. On examination, the temperature is 103.1°F, HR 155 beats per minute, RR 32 breaths per minute, and BP 95/50 mm Hg. She has nor- mal tympanic membranes, oropharynx reveals several tiny erythematous and vesicular appearing lesions posteriorly, lungs and heart examinations are normal, and abdomen is soft and nontender. Skin examination is clear with brisk capillary refill. Over the course of your evaluation, the patient becomes increasingly interactive, well-appearing, and playful. Which of the following is the most appropriate course of action for this patient?
- Obtain complete blood count (CBC), blood culture, urinalysis, urine culture, chest radiograph, and determine treatment on the basis of the results of these tests.
- Obtain blood and urine for culture, administer ceftriaxone, and discharge home.
- Reassure parents that this is a benign condition and that no further testing is indicated at this time.
- Obtain routine blood work and head computed tomographic (CT) scan and call for neurology consultation for first-time seizure.
- Obtain head CT scan and perform lumbar puncture secondary to fever and sei- zure to rule out meningitis.
12. A 13-year-old African American boy is brought to the ED by his mother for a complaint of right knee pain over the course of 1 to 2 The only notable trauma that the patient can recall was jumping on a tram- poline 1 to 2 weeks ago with friends that resulted in right lower-extremity pain. On the morning of presentation, the patient complained of increased pain when ambulating and was noted to be limping. He denies fever. No other trauma and no recent illness were noted by the family. On examina- tion, the patient is afebrile with normal vital signs. He has no previous medical problems and is noted to be overweight but is in otherwise good health. The lower-extremity examination reveals no swelling or erythema over any of the joints. His knee has no focal tenderness or pain with range of motion, but the hip is noted to be painful with internal and external rotation. He has a normal neurosensory examination of the distal extremity. A radiograph is performed. Which of the following is the most likely diagnosis?
- Legg-Calvé-Perthes disease
- Slipped capital-femoral epiphysis (SCFE)
- Septic arthritis
- Osgood-Schlatter disease
- Transient synovitis of the hip
13. A 4-year-old girl is brought to the ED by her mother with a chief complaint of abdominal pain and bloody The patient has a 2-day his- tory of abdominal and leg pain. The leg pain worsened today to where the patient did not want to walk and the abdominal pain is so severe that she is buckled over in pain. There is no significant past medical history, no recent travel, and no family history of inflammatory bowel disease. On examination, the patient has temperature of 37.5°C, HR 122, RR 24, and BP 95/60 mm Hg. She is alert but in moderate painful distress. HEENT (head, eyes, ears, nose, and throat) is normal. Lungs are clear to ausculta- tion. Heart is regular with no murmur. Abdomen is soft but diffusely tender. Extremities reveal bilateral swelling and tenderness of her knees. Skin examination reveals nonblanching purple and red lesions (macules and patches) on the flexural surface of her lower extremities and on buttocks. These lesions are nontender. Which of the following is the most appropri- ate test to evaluate her current condition?
- Gastrointestinal (GI)
14. A 4-year-old boy is brought to the ED by his mother with a complaint of ear pain since last The patient also complains of mild conges- tion and cough. He has normal oral intake, activity, and urine output. On examination, the patient is alert, interactive, and playful. His temperature is 100.6°F, HR 128 beats per minute, RR 26 breaths per minute, and pulse oxymetry is 98% on room air. His right tympanic membrane has slight ery- thema with several bubbles of clear fluid noted inferiorly. His left tympanic membrane is erythematous and bulging with opaque, purulent fluid noted. There is no neck stiffness, mastoid tenderness, or difficulty breathing. The patient has a primary care physician who checks the patient regularly. Which of the following is the best treatment for this patient?
- Analgesics only.
- A third-generation cephalosporin.
- Amoxicillin 40 to 50 mg/kg/d.
- Treatment with analgesics initially and consideration of oral high-dose amoxicil- lin in 48 to 72 hours if no resolution of symptoms.
- No treatment is needed for this viral illness.
15. A 3-week-old girl is brought to the ED by her parents after they noticed blood in her The patient is the full-term product of an uncomplicated pregnancy and delivery without any medical issues up to this point. She has been feeding well (breast-feeding primarily) and active without fever, respiratory problems, or fussiness. She has had several epi- sodes of nonforceful, nonbilious emesis after feeds with multiple wet dia- pers each day. She normally has several soft, seedy stools. In the last day, the parents noticed streaks of blood in her stool and today she had grossly bloody stool. The patient does not seem to be in any distress or discomfort. On examination, the temperature is 98.9°F, HR 155 beats per minute, and RR 44 breaths per minute. The patient is awake, active, and in no apparent distress. Her abdomen is soft and nontender with normal bowel sounds and no masses. Examination of her anus does not reveal a fissure. Which of the following is the most likely diagnosis?
- Acute gastroenteritis
- Milk protein colitis
- Clostridium difficile colitis
- Intestinal malrotation
- Necrotizing enterocolitis