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1. A 9-day-old boy is brought to the ED for fever and He was born full term. However, the delivery was complicated by prolonged rup- ture of membranes (PROM) and the mother had a fever for which she was treated with antibiotics before delivery. The baby did well in the nursery, and has been at home and feeding without any difficulties until the day of presentation when he became fussier, less interested in feeding, and the parents noted a temperature of 101.5°F (measured under patient’s arm). On presentation, his temperature is 102.4°F, HR 160 beats per minute, RR 48 breaths per minute, and pulse oxymetry of 97% on room air. His anterior fontanelle is open and flat; conjunctivae are clear; neck is supple without masses; and the heart, lung, and abdominal examinations are normal. The skin shows tiny (1-3 mm) pustules with a surrounding rim of erythema on the patient’s trunk. No vesicular lesions are noted. Which of the following is the most likely organism responsible for this patient’s condition?
- Escherichia coli
- Listeria monocytogenes
- Group B Streptococcus
- Staphylococcus aureus
- Herpes simplex virus (HSV)
2. A 9-year-old boy, who is a recent immigrant from Uzbekistan, pres- ents to the ED complaining of pain and swelling in his right knee, which has been intermittent over the course of several The pain some- times affects his ankles and wrists. His parents, through an interpreter, deny recent fever, vomiting, chest pain, and difficulty breathing. They do indicate that he has had exercise intolerance and dyspnea on exertion. On examination, you note a diastolic murmur at the right upper sternal border. Which of the following findings by itself would establish the diagnosis?
- Elevated ESR
- Positive ASO (antistreptolysin O)
- Choreiform movements
- Positive strep test
- Knee aspiration with 25,000 WBC, primarily neutrophils
3. A 5-month-old previously healthy girl presents to the ED with a 4- to 5-day history of constipation and decreased The patient is a full- term product of an uncomplicated antenatal course and delivery. She also had recent congestion and cough that resolved with administration of tea prepared by a family friend. The mother denies any recent fever or vomiting. On examination, the temperature is 99.9°F, HR 165 beats per minute, and RR 22 breaths per minute. The BP was not obtained. The patient has a weak cry, is notably flaccid, and ill-appearing. You note that patient is drooling. Her pupils are poorly responsive and she is not track- ing to light or faces. Which of the following is the most likely cause of this condition?
- Type I spinal muscular atrophy
- Brain tumor
- Infant botulism
- Organophosphate poisoning
4. A 6-month-old boy is brought to the ED after being found apneic and cyanotic at The patient’s mother called 911 and began cardio- pulmonary resuscitation (CPR). The patient responded within seconds to minutes. On arrival to the ED, he was noted to be awake and respon- sive but slightly mottled with mild respiratory distress. Within minutes of arrival, the patient becomes apneic suddenly, cyanotic, and bradycardic. Which of the following is the most important initial response?
- Administer epinephrine.
- Provide oxygen via non-rebreather face mask.
- Jaw thrust, chin lift, and bag-valve-mask ventilation.
- Endotracheal intubation.
- Chest compressions.
5. A 4-year-old boy is brought to the ED by his parents who state that he is having difficulty The patient has a 1-week history of fever, congestion, and cough. Over the last 2 days, he has appeared tired with intermittent vomiting and persistently increased RR despite administration of acetaminophen. On presentation, his vital signs are temperature 100.5°F, HR 185 beats per minute, RR 50 breaths per minute, BP 75/40 mm Hg, and pulse oxymetry of 88% on room air. He is ill-appearing and listless. He has diffuse rales noted on auscultation, pulses are weak and thready, and his liver is palpable 3 to 4 cm below the right costal margin. After several attempts at a peripheral IV, the patient becomes increasingly somnolent. Which of the following is the most appropriate method of obtaining access in this patient?
- Internal jugular central line
- Femoral vein central line
- Saphenous vein cutdown
- Large-bore IV in antecubital fossa
- Intraosseous needle
6. A 3-year-old girl is brought to the ED with acute onset of respiratory distress. She recently emigrated from Her initial vitals include HR of 115 beats per minute, BP of 110/60 mm Hg, and RR of 28 breaths per minute with oxygen saturation of 88% on room air. She is also febrile to 103.5°F. She is ill- and anxious-appearing, sitting forward in her mother’s lap, and drooling. Her mother tells you that she had a sore throat that began 2 days ago and that she was going to see her pediatrician this week for her initial vaccinations. Given this patient’s history and presentation, which of the following should be of particular concern?
- Retropharyngeal abscess
- Epstein-Barr virus (EBV) pharyngitis
- Ludwig angina
- Peritonsillar abscess
7. A 5-month-old boy, ex-34-week preemie, is brought to the ED by his mother who reports that the infant has been breathing with extra effort for the last 2 He has no other past medical history and is currently on immunizations having received the full course of vaccines at both 2 and 4 months. The mom reports the child has had rhinorrhea and cough. Upon physical examination, the patient has a temperature of 101.1°F, HR 160 beats per minute, RR 70 breaths per minute, pulse oximetry of 87% on room air. He has copious nasal discharge, audible wheezing with dif- fuse rhonchi, and rales upon chest auscultation. He also has intercostal retractions and nasal flaring. A chest radiograph shows increased perihi- lar markings, hyperinflation, and diffuse patchy areas of atelectasis versus infiltrates. Given this patient’s history and physical examination, which of the following is the most likely etiology of his symptoms?
- Foreign body aspiration
- Pneumococcal pneumonia
- Respiratory syncytial virus (RSV)
- Parvovirus B19
8. A 4-year-old girl is brought to the ED after falling from a She hit her head on the ground and has significant temporal swelling on the left side. In transit to the hospital by her parents, the patient had multiple epi- sodes of emesis. On arrival to the ED, the patient is confused and agitated and then becomes acutely unresponsive and apneic. You make the decision to endotracheally intubate the patient. Which of the following is the most appropriate endotracheal tube (ETT) to use in this intubation?
- 4.0 uncuffed ETT
- 4.0 cuffed ETT
- 5.0 cuffed ETT
- 5.5 uncuffed ETT
- 4.5 uncuffed ETT
9. A 2-year-old boy is brought to the ED shortly after a choking His parents noted he had been playing with coins on the floor just before the episode. There has been no previous history of fever or runny nose in the past few days. The parents tried to feed the patient after the episode, but he has been unwilling to take anything orally. On examination, the patient is calm with stable vital signs and a pulse oximetry of 98% on room air. He spits in a cup every couple of minutes but is otherwise in no apparent distress. His oropharynx is unremarkable and lungs are without wheezes or rales. His radiograph is seen below. Which of the following most likely accounts for the patient’s symptoms?
(Courtesy of Adam J Rosh, MD.)
- Foreign body aspiration
- Foreign body ingestion
- Allergic reaction
10. A 2-year-old girl is brought into the ED with 2 days of fever and runny Today she developed a dry, harsh, “barking” cough. Her tem- perature is 103.3°F, HR 123 beats per minute, RR 25 breaths per minute, and pulse oximetry of 98% on room air. On evaluation you note an alert, responsive but somewhat anxious female, in moderate respiratory distress with stridor and suprasternal retractions at rest. She has nasal congestion, equal air entry bilaterally with no rales or wheezes, and a normal ear and throat examination. After receiving a single treatment of racemic epineph- rine, she feels better and her work of breathing improves. Which of the following is the most appropriate next step in management?
- Chest radiograph
- CBC and blood culture
- Soft tissue radiograph of the neck
- Broad-spectrum antibiotics
- A dose of steroids
11. A 3-month-old boy with decreased feeding over the last 24 hours is brought to the ED by his The patient has been doing well without any prior medical problems until today when the mother noted sweating and irritability, particularly with feeding. In the ED, the patient attempts to feed but within minutes stops and begins to cry. Vital signs include a pulse of 240 beats per minute, RR of 50 breaths per minute, temperature of 98.2°F, and pulse oximetry of 98% on room air. On physical examina- tion, the patient is pale and clammy to touch. Breath sounds are clear on auscultation. Pulses are normal and symmetric in all extremities. An ECG is seen below. Which of the following is the most appropriate next step in management?
- Synchronized cardioversion at 0.5 J/kg
- Verapamil 0.1 mg/kg bolus
- Defibrillation at 2 J/kg
- Adenosine at 0.1 mg/kg followed by 0.2 mg/kg if first dose is ineffective
- Carotid massage
12. A 4-year-old uncircumcised boy is brought to the ED by his caretaker for an 8-hour history of swelling and redness of the The caretaker states that she retracted the foreskin over the penis to clean it and could not move it back afterward. The patient’s vital signs are within normal limits. On examination, he is crying and becomes irritable whenever you try to examine the genital area. The glans is edematous and erythematous. The testicular examination shows bilateral descended testicles with a normal cremasteric reflex. Which of the following is the most appropriate next step in management?
- Manual reduction of the foreskin over the glans
- Dorsal slit incision or circumcision
- Topical lidocaine
- Catheterization to prevent obstruction and urinary retention
- Topical steroids to reduce the swelling
13. A 10-week-old girl is brought to the ED after 5 hours of abdominal distension and green stained The patient is a previously well infant with an uncomplicated antenatal course and normal vaginal delivery. However, she spent an extra day in the neonatal intensive care unit (NICU) when born because of “water on the lungs.” On the day of presentation, the patient is unable to hold any fluids down without vomiting. Her vital signs reveal HR of 185 beats per minute, RR of 65 breaths per minute, and temperature of 100.8°F. Abdominal examination reveals a diffusely tender abdomen that is hypertympanic. Which of the following is the definitive study of choice?
- Upper GI series
- Abdominal ultrasound
- Findings on physical examination
- CBC, electrolytes, and urine analysis
- Serum lactate
14. A 5-year-old boy who fell from the monkey bars and landed on his left elbow is brought into the ED for The patient has no sig- nificant medical history. On physical examination, you note the patient is holding his left arm in an adducted position. There is obvious swelling around the elbow with decreased range of motion secondary to pain. He complains of hand numbness, but the motor and vascular examination is normal. The radiograph shown below shows posterior displacement of the capitellum with evidence of a dark shadow posterior to the distal humerus. Which of the following is the most serious complication associated with this injury?
- Transection of the brachial artery
- Malunion of distal humerus
- Motor deficit from injury to the ulnar nerve
- Chronic arthritis of the elbow
- Chronic deformity of the hands and fingers caused by contractures
15. A 7-year-old boy presents to the ED 1 hour after slipping and landing on his right outstretched He was evaluated and splinted by emer- gency medical technicians (EMTs) and brought to the ED. On examination, you note a deformity of his right wrist. There are no neurovascular deficits. A radiograph of the wrist is shown below. Which of the following states is true regarding physeal fractures in children?
- Salter-Harris type IV is defined as a crush injury of the growth plate.
- The most common type of fracture is the Salter-Harris type II.
- This patient’s radiographic findings are consistent with Salter-Harris type V.
- Fractures through the physis, metaphysis, and epiphysis are classified as Salter- Harris type III.
- The worse prognosis is seen with Salter-Harris type I fractures.