Skin turgor
Respiratory rate
Explanation: Respiratory rate is highest in the neonate and
gradually becomes slower approaching adult rates in the
preadolescent-adolescent age period. Respiratory rate may be
influenced by serious pulmonary or airway infection or
inflammation in addition to non-respiratory causes, such as
fever, anxiety, acidosis, pain, heart failure, central nervous
system disease, drugs (stimulants, depressants, aspirin), and
toxins (ammonia). (See Chapter 49 in Nelson Textbook of
Pediatrics, 17th edition.)
Lung aeration
Fontanel tension
Question . 2. The vulnerable child syndrome most influences which of the following
components of the well child assessment?
Physical examination
Observation
Developmental assessment
History
Explanation: Parents perceive vulnerability due to many real
or exaggerated risks: premature birth, difficult pregnancy,
previous death of a child, disease in other siblings, or minor
low-risk conditions in this child. The history is usually
exaggerated, embellished, and quite detailed. (See Chapter 49
in Nelson Textbook of Pediatrics, 17th edition.)
Growth
Question . 3. During examination of an 8-mo-old child, the difficulty of optimal chest
auscultation is due primarily to:
Stranger anxiety
Explanation: Crying makes the chest physical examination
almost impossible, except for detection of the grossest
abnormalities,. If at all possible, the chest auscultation should
be preceded by observation and then performed in the
sleeping, calm, nursing, or feeding infant. (See Chapter 49 in
Nelson Textbook of Pediatrics, 17th edition.)
Transmitted nasal sounds
Nutritional status
Motor ability
Visual behavior
State variation
Question . 5. Based on an orientation to child development, when would you tell
parents the highest risk of poisoning in children is present?
6 mo
1 yr
2 yr
Explanation: Self-poisoning in toddlers occurs once they
become ambulatory and are able to walk and climb. Consider
no place safe, especially if there are older siblings. Also
consider that child-proof medicine containers will rarely be a
deterrent to a motivated toddler. Remember that plants,
berries, and liquids also present risks for ingestion in this age
group. (See Chapter 49 in Nelson Textbook of Pediatrics, 17th
edition.)
4 yr
6 yr
Not predictable
Not preventable
Random
Not common
Question . 7. Motor vehicle injuries lead the list of injury deaths for all ages and are
most often associated with:
Alcohol use
Occupant injury
Night driving
Toddler age
Female gender
Explanation: After 1-2 yr of age, males have a much higher
injury rate than females. This risk lasts until the 7th decade.
Adolescent risk-taking behavior accounts for some of the
difference during the teen years. (See Chapter 50 in Nelson
Textbook of Pediatrics, 17th edition.)
Poverty
Front-seating in an automobile
4-5 yr
6-7 yr
8-10 yr
10-12 yr
Question . 10. The majority of children with medical emergencies present to all of
the following for care except:
Pediatrician's office
Clinic
Question . 11. A general pediatric office should be prepared for emergencies. This
preparedness includes all of the following except:
Transport protocols
Question . 12. A 15-mo-old child is in your office with stridor at rest and cyanosis
with the presumptive diagnosis of viral croup. You should do all of the following
except:
Administer oxygen
Administer dexamethasone
Is one-touch dialing
Question . 14. Emergency Medical Treatment and Active Labor Act (EMTALA) is a
set of federal regulations that addresses the transfer of patients. Which of the
following statements regarding EMTALA is not true?
The law does not apply to pediatricians who are on call for
consultation to the emergency department
Explanation: This law is meant to benefit patients and includes
patients of all ages and their doctors. All patients must be
stabilized to the best of the ability of the emergency room staff.
All pertinent data must also be transferred with the patient to
the most appropriate hospital capable of caring for the patient's
condition. (See Chapter 51 in Nelson Textbook of Pediatrics,
th
17 edition.)
Question . 15. There are several requirements in preparing a child for transfer to a
higher level of care (e.g., from the office to the emergency department). In preparing
for transfer of a child, which of the following is not recommended?
Question . 16. Emergencies involving children are stressful for the child, parent, and
EMS-C providers. All of the following are useful in decreasing stress to children and
their families in emergency settings except:
Question . 17. The safest and quickest manner to transport a critically ill child from a
community hospital to the regional pediatric center is:
Have the parents drive the child from their local hospital
Question . 18. The transport team from the tertiary hospital is composed of all of the
following except:
Question . 19. Appropriately trained and equipped pediatric transport teams should
be able to:
Question . 20. The mother of a 5-yr-old near-drowning victim arrives at the pediatric
intensive care unit (PICU). She is highly upset and emotional, and forcefully
demands to see her child. The best response of the PICU staff to the mother would
be:
To direct her to the parents' waiting area, and inform her that
she will be summoned when the time is right
Ask the family to discuss the matter further with the cardiology
service
Question . 23. The mother of one of your PICU patients regularly looks through the
bedside medical chart of her child. Bedside nurses report this to you and express
their discomfort with the practice. Your most appropriate response would be to:
Advise the nurses that it is the mother's right to view the chart
and nothing should be done
Instruct the mother that she may not view the chart since it
contains the writings of several different health care providers
who have not consented to her viewing it
Question . 24. You inform the family of a gravely ill child in the PICU that she is very
likely to die soon. The family, consistent with their faith, wishes to apply oils to her
body and place various amulets on the bed. Your reaction should be to:
Question . 25. Proper use of the PRISM scoring system would include:
Question . 26. Which of the following scoring systems is useful for triage decisions?
Question . 27. Regarding resuscitative efforts, the most important goal is:
Question . 28. A 9-mo-old boy is brought to the emergency room in a limp and
unresponsive state. Initial examination shows a pulse rate of 35/min and occasional
irregular breaths. After initiation of CPR (including tracheal intubation), delivery of
oxygen via positive-pressure breaths, and chest compressions, multiple attempts to
insert an IV line fail. The most appropriate next step in management should be to:
Question . 29. A 9-yr-old boy suddenly experiences respiratory distress while dining
in a restaurant, and despite obvious great effort to breathe, he seemingly cannot
move air. He points to his neck and appears progressively cyanotic. The most
appropriate next step should be to:
Give the child a glass of water and urge him to drink it quickly
Any technique that helps clear the upper airway and safely
produces air movement in both lung fields is acceptable
Question . 31. A 2-yr-old patient, previously admitted to the hospital for respiratory
distress, is found apneic and pulseless in the early morning hours. She is intubated
and ventilated adequately, and an intra-osseous needle is placed, but she remains
pulseless. The first medications you should employ are:
Question . 32. Causes of pulseless electrical activity include all of the following
except:
Toxins
Pulmonary embolism
Intracranial hemorrhage
Explanation: Agents that work directly on the heart (toxins,
hypoxia) or interfere with cardiac output (tamponade,
pneumothorax) may all produce pulseless electrical activity,
previously known as electrical-mechanical dissociation. If this is
present, the cause must be searched for and treated to achieve
successful resuscitation. (See Chapter 57.1 in Nelson Textbook
of Pediatrics, 17th edition.)
Pericardial tamponade
Pneumothorax
Question . 33. The drug of choice for shock refractory ventricular fibrillation is:
Magnesium
Bretylium
Aminophylline
Amiodarone
Explanation: Amiodarone is now the treatment of choice for
shock-resistant ventricular tachycardia or ventricular fibrillation.
Lidocaine is a second but effective choice. (See Chapter 57.1
in Nelson Textbook of Pediatrics, 17th edition.)
Digoxin
Question . 34. Supraventricular tachycardia is characterized by all of the following
except:
Response to adenosine
Question . 35. A 9-yr-old with vomiting and diarrhea has a systolic blood pressure of
75 mm Hg. You should:
Question . 36. To check the proper placement of an endotracheal tube, one should
do all of the following except:
A hematocrit
Question . 39. The factor most clearly predicting mortality in shock is:
Cardiac failure
Renal failure
Hepatic failure
Metabolic acidosis
Question . 40. The drug pair that meets the dual goals of stimulating the heart and
relaxing peripheral vasculature is:
>300 mm Hg
<10 mm Hg
Explanation: The alveolar-arterial oxygen gradient in normal
children from about 1 month of age onward is usually <10 mm
Hg. Any deviation suggests a ventilation/perfusion defect,
intrapulmonary shunt, cardiac right-to-left shunt, or rarely an
alveolar diffusion defect. (See Chapter 57.3 in Nelson Textbook
of Pediatrics, 17th edition.)
50 mm Hg
>100 mm Hg
Question . 43. A patient in respiratory distress presents to your office. The most
appropriate immediate response is to:
Call 911
Question . 44. Respiratory failure accounts for PICU admissions in what percentage
of patients?
100%
80%
50%
Explanation: The percentage of children admitted with
respiratory failure varies. Nonetheless, acute airway
compromise and respiratory distress are the most common and
potentially predictable causes of "cardiac" arrest in children,
who actually have respiratory arrest. (See Chapter 57.3 in
Nelson Textbook of Pediatrics, 17th edition.)
<25%
Air leak
Question . 47. Patients with severe forms of reactive airways disease (e.g., asthma)
who require mechanical ventilation may benefit from which of the following initial
ventilator parameters?
Question . 48. The most important maneuver in preserving renal function in septic
shock is:
Question . 50. Appropriate nutritional support for the child receiving mechanical
ventilation for bacterial pneumonia should include:
Question . 51. In the severely ill child, a catabolic state ensues. Which of the
following statements is true?
Intracranial tumor
Explanation: Nausea and vomiting are common complaints in
a pediatric practice. Although most are due to non-specific
(presumed viral) infections or other identifiable infections
(gastroenteritis, otitis media, pharyngitis), the practitioner must
always be cautious of an intracranial cause. The nature of the
nausea, associated headache or vision problems, head tilt, or
cranial nerve abnormalities should suggest an intracranial
cause of vomiting. Always be cautious and, when possible,
check the fundi for papilledema. (See Chapter 57.7 in Nelson
Textbook of Pediatrics, 17th edition.)
Viral gastroenteritis
Salmonella infection
Type A influenza
Question . 53. In the child who has suffered a severe hypoxic ischemic injury, which
of the following is true?
Hemodialysis
Question . 55. A 15-yr-old boy is struck by a car while walking. On arrival in the ED,
he is alert and has no signs of upper airway obstruction. Pulse is 140/min,
respiratory rate 40 breaths/min, and blood pressure 70/50 mm Hg. Heart sounds are
distinct, but breath sounds are decreased in the left hemithorax. What is the most
appropriate next step in patient management?
Needle thoracentesis of the left hemithorax
Explanation: Although an x-ray may be helpful for diagnosis
and fluids may improve venous return, prompt evacuation of a
symptomatic hemothorax or pneumothorax is the most
appropriate step. (See Chapter 57.8 in Nelson Textbook of
Pediatrics, 17th edition.)
Pericardiocentesis
Question . 56. A 4-yr-old girl sustains a head injury after pulling a television set onto
her. The paramedics intubate her at the scene because of inadequate respiratory
effort. On arrival in the ED, she is being ventilated at a rate of 20 breaths/min, and
her chest wall rises adequately. Pulse is 100/min, blood pressure is 100/70 mm Hg,
and peripheral perfusion is good. What is the most appropriate next step in patient
management?
Immediate head CT
Question . 57. A 3-yr-old boy is brought to the ED after falling two stories from an
open window. He arrives appropriately immobilized and is alert. Pulse is 190/min;
respiratory rate, 28 breaths/min; and blood pressure, 70/30 mm Hg. It is clear that he
has a femur fracture. His abdomen is diffusely tender. After a 20 mL/kg bolus of
Ringer's lactate, his pulse is 180/min and blood pressure is 72/35 mm Hg. The most
appropriate next step in patient management would be:
Question . 58. A 10-yr-old boy is brought to the ED after being kicked in the
abdomen by a horse. Pulse is 80/min; respiratory rate, 18 breaths/min; and blood
pressure, 110/70 mm Hg. His abdomen is diffusely tender. The most appropriate
diagnostic study for this patient would be:
Question . 59. In the support of the child with severe ARDS, appropriate goals for
pH, oxygenation, and PCO2 include:
Question . 61. In the management of a child with ARDS and respiratory failure, all of
the following measures are important except:
Question . 62. Transplantation of part of an organ from a donor who will survive the
donation process is possible with transplantation of:
Heart or lung
Heart or liver
Cornea or heart
Kidney or liver
Explanation: Kidney transplantation is quite successful from a
related living donor. Split or partial liver transplantation from a
living related donor is also successful. Both procedures, but
particularly liver transplantation, carry risks for the donor,
including death. (See Chapter 60 in Nelson Textbook of
Pediatrics, 17th edition.)
Heart or kidney
Question . 64. One of the more common pathogens responsible for pulmonary
infections in immunocompromised patients following transplantation is:
Staphylococcus epidermidis
Haemophilus influenzae
Clostridium botulinum
Streptococcus pneumoniae
Pneumocystis carinii
Explanation: Pneumocystis carinii pneumonia (PCP) is seen in
any immunosuppressed patient, particularly when T
lymphocyte function or number is reduced. Prophylaxis against
PCP has greatly reduced this potentially lethal complication.
(See Chapter 60 in Nelson Textbook of Pediatrics, 17th edition.)
Question . 66. A 2-yr-old boy is pulseless and apneic after extrication from a
swimming pool. Paramedics start CPR, intubate him, and administer 100% oxygen
while providing bag-endotracheal tube breaths. An intraosseous line is placed, and
two doses of epinephrine are administered. A pulse is found after 10 min of
resuscitative measures. The child is transferred to your ED. On arrival, he is deeply
comatose with a temperature of 34°C. He is not breathing spontaneously, his heart
rate is 120 beats/min, blood pressure is 60/25 mm Hg, and he has cold extremities.
Oxygen saturation is 85%. Finger stick glucose is 200 mg/dL. Which of the following
interventions is most likely to improve the patient's neurologic outcome?
Hyperventilation to a PaCO2 of 25 mm Hg
Question . 67. Mr. and Mrs. Smith install a new swimming pool in their backyard.
Three months later, their 2-yr-old son is found pulseless and asystolic in the pool.
Which of the following safety measures would have been most likely to prevent this
tragedy?
Swimming lessons
Question . 68. A 4-yr-old boy is admitted to the PICU after resuscitation from a
swimming pool submersion. He was pulseless and apneic at the scene. On
presentation to the PICU, he is intubated and mechanically ventilated. His vital signs
are normal and he is comatose, with a Glasgow Coma Score of 4. His initial arterial
blood gas is pH 7.12, PaCO2 35 mm Hg, and PaO 2 145 mm Hg. In counseling the
family regarding the child's prognosis, which of the following results is most likely to
represent a favorable outcome?
A normal head CT scan
ECMO
Hyperbaric oxygen
Question . 70. A 5-yr-old girl who accidentally spilled hot water on her face and
trunk and is brought to the emergency room. Which of the following is the best
method for estimating body surface area burn?
Rule of 9s
Rule of palm
A growth chart
Question . 71. A 10-yr-old boy spilled gasoline on his legs. His pants became
ignited and he suffered 20% body surface area burns. Of the following, the most
important treatment is:
Question . 72. A 4-yr-old girl sustained a 40% second- and third-degree total body
surface area burn from scalding hot water. Of the following, the most therapeutic
approach is:
Question . 73. A 10-yr-old boy sustained 30% body surface area burns and had
been requiring dressing changes for physical therapy. Which of the following
regimens will provide the best pain management? A. B. C.
Morphine bolus
Electroencephalogram
Radionuclide angiogram
Apnea test
Cerebral angiogram
Question . 76. Correct performance of an apnea test requires:
Provide analgesia
Cause hyperglycemia
Explanation: Fentanyl is an effective and safe analgesic
anesthetic in newborns and has improved the outcome of
complex surgeries in the neonatal period. Use before, during,
and after the procedure has reduced morbidity and probably
mortality. (See Chapter 65 in Nelson Textbook of Pediatrics,
17th edition.)
Avoid hypoglycemia
Prevent acidosis
Question . 78. Deep sedation is associated with all of the following except:
Apnea
Seizures
Explanation: Most agents producing deep sedation will
actually suppress physical and electrical seizure activity. Deep
sedation is a risk factor for a cardiopulmonary arrest and
should only be performed in a setting equipped for response to
apnea and bradycardia. (See Chapter 65 in
Question . 79. Akinesia is:
Analgesia
Sedation
Absence of movement
Explanation: Indeed, akinesia induced by neuromuscular
blocking agents (muscle relaxants) has no effect on reducing
pain or producing amnesia. It simply means no movement.
Sedation and analgesia must also be used when a patient
receives neuromuscular blocking agents. (See Chapter 65 in
Nelson Textbook of Pediatrics, 17th edition.)
Amnesia
Nystagmus
Question . 80. Risks associated with the use of succinylcholine include all of the
following except:
Seizures
Explanation: With much better and safer neuromuscular
blocking muscle relaxants, succinylcholine is rarely used in the
operating room. (See Chapter 65 in Nelson Textbook of
Pediatrics, 17th edition.)
Hyperkalemia
Malignant hyperpyrexia
Myoglobinuria
Question . 81. Malignant hyperthermia is associated with all of the following except:
Hypercarbia
Masseter spasm
Metabolic acidosis
Muscular dystrophy
Morphine
Explanation: Narcotic agents are not associated with the
development of this potentially serious and lethal familial
condition. The spectrum may range from masseter spasms or a
mild increase in intraoperative temperature and CO2 elimination
to severe muscle rigidity, hyperpyrexia, metabolic acidosis, and
cardiovascular collapse. (See Chapter 65 in Nelson Textbook
of Pediatrics, 17th edition.)
Tell her that the oral morphine will be maintained for now, but
make no promises about the future
Ask her to trust your judgment that this is the best route to take
Question . 83. Other approaches to pain management that might be considered for
the patient described in Question 82 include:
Adjuvant analgesics
Spiritual care
Question . 84. When the patient described in Question 82 learns that the pain
medication might be changed, she tells the hospice nurse that she is no longer
hurting. What is the likely reason she might have misled the nurse?
Neuropathic
Explanation: Neuropathic pain may be difficult to diagnose.
This patient has classic symptoms of what used to be called
reflex sympathetic dystrophy but is now called complex
regional pain syndrome, type I. (See Chapter 66 in Nelson
Textbook of Pediatrics, 17th edition.)
Somatic
Visceral
Peripheral
Question . 86. Which type of medication should first be considered to treat the pain
in the child described in Question 85?
Opioids
NSAIDs
Corticosteroids
Question . 87. Other types of treatment that may be considered for the child
described in Question 85 include:
Physical therapy
Explanation: Physical therapy is very useful in rehabilitation. It
also teaches the patient to use the extremity without an
increase in disability, a fear many patients have with chronic
neuropathic extremity pain. (See Chapter 66 in Nelson
Textbook of Pediatrics, 17th edition.)
Question . 88. A 3-yr-old girl is scheduled to have a bone marrow aspiration for the
first time. Which of the following combination of interventions is most likely to be
helpful to her?
Question . 89. Indications for admission to the hospital after a burn injury may
include all of the following except:
Perineal burns
Poor follow-up
No tetanus immunization
Explanation: Lack of immunization against tetanus may be
managed with tetanus toxoid and (if a wound is large or dirty)
with tetanus immune globulin. The other choices indicate that
the patient is at high risk and requires hospitalization. (See
Chapter 62 in Nelson Textbook of Pediatrics, 17th edition.)
Inhalation injury
Question . 90. A 3-mo-old, formerly a 29-wk premature infant, has been scheduled
for repair of bilateral inguinal hernias. The infant had received mechanical ventilation
for the first 6 days of life and had apnea of prematurity that resolved 5 wk previously.
The infant is feeding well and gaining weight and has no requirement for
supplemental oxygen. The hematocrit is 28%. The HMO clerk approves the surgery
on an outpatient basis. All of the following statements are true except:
Question . 91. A 12-yr-old, 45-kg, previously healthy child is now on the pediatric
ward 2 hr after repair of a forearm fracture under general anesthesia. You are called
because the child has a fever of 40.6°C, a respiratory rate of 60 breaths/ min, a
heart rate of 140 beats/min, and skin color described as "a bit off." Over the phone,
the nurse reviews the anesthetic record and reports that general anesthesia was
administered after a "rapid-sequence induction" because the child had eaten a large
meal just before the injury. The nurse notes from the record that anesthetic induction
was performed with thiopental sodium and succinylcholine. Anesthesia was
maintained with halothane in a mixture of nitrous oxide and oxygen, and the child
received morphine, 3 mg IV, before awakening. The anesthesia record notes stable
vital signs during surgery, which lasted 30 minutes. All of the following are true
except:
If the child is older than 6 mo, obtain a blood culture and have
the parents return to the office if the patient remains febrile
Administer acetaminophen and reassess after the infant is no
longer febrile
Question . 93. Paradoxical irritability may be present with all of the following except:
Osteomyelitis
Appendicitis
Extremity cellulitis
Meningitis
Pneumonia
Explanation: Paradoxic irritability is present when a child
becomes anxious and cries during attempts to cuddle and hold
the patient. Movement of a painful extremity, abdomen, or neck
may elicit this response
Question . 94. A previously healthy 7-mo-old white baby boy presents one summer
day with a temperature of 41.1°C, a pulse of 190/min, a respiratory rate of 70
breaths/min, and a blood pressure of 65/20 mm Hg. He has a 1-day history of
diarrhea (five stools in 24 hr) and is now unresponsive to verbal commands or
painful stimuli. The most appropriate initial therapy is:
Question . 95. After receiving normal saline pushes, the patient in Question 97
remains unconscious. A lumbar puncture reveals 3 WBCs/cu mm, 10 RBCs/cu mm,
a protein level of 30 mg/dL, and a glucose level of 75 mg/dL. After the lumbar
puncture, he is noted to be bleeding at venipuncture sites. The most likely diagnosis
is:
Meningococcemia
Salicylate poisoning
Malignant hyperthermia
First degree
Moderate to severe
Second degree
Midlevel
Full thickness
Explanation: This defines a full-thickness burn (also known as
a third-degree burn). (See Chapter
Question . 97. A 12-yr-old boy with spina bifida experiences respiratory distress
during induction of anesthesia for an orthopedic procedure. He has been otherwise
well prior to this hospital admission. Past medical history reveals surgery for closure
of the spina bifida at age 3 days, placement of a ventricular peritoneal shunt at 1 mo
of life, and release of contractures at 6 yr of life. He is on ampicillin prophylaxis for
recurrent urinary tract infections since birth and has to be catheterized for urination.
The most likely diagnosis is:
Ampicillin hypersensitivity
Urosepsis
Status epilepticus
Latex anaphylaxis
Explanation: Latex allergy is common in children with multiple
surgical procedures and those who have required
catheterization for urinary retention. The presentation includes
urticaria, wheezing, and hypotension. Bananas may cross-
react with latex. (See Chapter 65 in Nelson Textbook
Question . 1. Autosomal dominance inheritance is characterized by all of the
following except:
Consanguinity
2-4%
6-8%
Explanation: This risk is twice the risk of an autosomal
recessive trait being manifest in non-consanguineous mating.
(See Chapter 69 in Nelson Textbook of Pediatrics, 17th edition.)
10-12%
50%
Zero
Question . 4. A disease affecting all of the daughters but none of the sons of an
affected father, and 50% of the sons or daughters of an affected mother, is most
likely:
X-linked recessive
X-linked dominant
Explanation: This is the classic pattern of an X-linked
dominant condition. These are rare conditions, which include
hypophosphatemic rickets and incontinentia pigmenti (IP). IP is
lethal to the male fetus and thus no males are born alive with
this disorder. (See Chapter 69 in Nelson Textbook of
Pediatrics, 17th ed.
Autosomal dominant
Autosomal recessive
Question . 5. A disease passed on only through the mother and affecting both sons
and daughters, with variable manifestations in the affected siblings, is most likely:
Mitochondrial inheritance
Explanation: Because mitochondria in the fetus are usually
derived only from the ovum, mitochondrial inheritance typically
passes disorders through the mother but to both her sons and
daughters. (See Chapter 69 in Nelson Textbook of Pediatrics,
17th edition.)
Multifactorial inheritance
Environmentally induced
Turner syndrome
Covers/uncovers imprinting
Physical examination
Family history
Cerebral giantism
Acromegaly
Hypothyroidism
Trisomy 21
Fragile X syndrome
Explanation: Fragile X syndrome is a common chromosomal
cause of mental retardation in boys. Affected boys have allelic
expansion of trinucleotide repeats to more than 200 (normal is
6-54 repeats). (See Chapter 70 in Nelson Textbook of
Pediatrics, 17th edition.)
Question . 11. Patients with Turner syndrome should undergo careful analysis of
their chromosomes for Y chromosome material because they may:
Become masculinized
Grow tall
Become pregnant
Experience gonadoblastoma
Explanation: Y chromosome material is present in 5-10% of
girls with Turner syndrome. Gonadoblastoma may develop in
the ovary, thus necessitating bilateral oophorectomy as a
preventive measure. (See Chapter 70 in Nelson Textbook of
Pediatrics, 17th edition.)
Question . 12. Kearns-Sayre syndrome and Leber hereditary optic neuropathy are
noted in both males and females but are inherited only through the mother. These
conditions are examples of:
Uniparental disomy
Mitochondrial inheritance
Explanation: Mitochondrial inheritance of the diseases listed in
the question involves mutation of the mitochondrial genome,
which originated solely from the ovum. (See Chapter 77 in
Nelson Textbook of Pediatrics, 17th edition.)
Anticipation
A Southern blot
A Northern blot
A Western blot
Question . 16. Trinucleotide repeats are implicated in the etiology of all of the
following except:
Fragile X syndrome
Neurofibromatosis
Explanation: Multiple repeats of trinucleotides in the coding
region and the untranslated or translated region of these genes
produce significant disease in the all of the other named
choices. (See Chapter 68 in Nelson Textbook of Pediatrics,
17th edition.)
Friedreich ataxia
Myotonic dystrophy
Mitochondrial recombination
Trisomy 13
Trisomy 18
Edwards syndrome
Trisomy 8
Trisomy 21
Explanation: Trisomy 21, or Down syndrome, is also
associated with other cardiac, gastrointestinal, and skeletal
problems. (See Chapter 70 in Nelson Textbook of Pediatrics,
17th
Hirschsprung disease
Meconium ileus
Meconium plug
Duodenal atresia
Explanation: Duodenal atresia is common in neonates with
trisomy 21 and may produce polyhydramnios. After birth,
intestinal obstruction requires that the child be NPO and
undergo intestinal decompression prior to surgery. (See
Chapter 70 in Nelson Textbook of Pediatrics, 17th edition.)
Pyloric atresia
ALLERGY
Question . 1. Which of the following are characteristic of allergens?
Lipopolysaccharides
Carbohydrates
Eosinophils
Basophils
Mast cells
Explanation: Mast cells contain or produce a diverse array
of mediators of allergic inflammation. (See Chapter 130 in
Nelson Textbook of Pediatrics, 17th ed.)
Th2 cells
Dendritic cells
Eosinophils
Basophils
Mast cells
Th2 cells
Dendritic cells
Explanation: Antigen-presenting cells (APCs) are a
heterogeneous group of cells that present antigens in the
context of the major histocompatibility complex (MHC).
Dendritic cells are actively phagocytic cells that reside in
peripheral sites such as the skin, intestinal lamina propria,
and lungs. (See Chapter 130 in Nelson Textbook of
Pediatrics, 17th ed.)
Question . 5. Which of the following statements best describes the
relationship between allergic disorders and a possible genetic basis?
Cyanosis
Pulsus paradoxus
Question . 8. A 7-yr-old boy with asthma has roughness over the extensor
surfaces of the upper arms and thighs, which is caused by keratin plugs
lodged in the openings of hair follicles. This physical finding is termed:
Keratosis pilaris
Explanation: Xerosis, or dry skin, is the most common skin
abnormality of allergic children. Keratosis pilaris, often
found on the extensor surfaces of the upper arms and
thighs, is characterized by roughness of the skin caused by
discrete follicular papules. These are the result of
hyperkeratosis with keratin plugs lodged in the openings of
hair follicles, and re-form after removal. (See Chapter 131
in Nelson Textbook of Pediatrics, 17th ed.)
Fibroepitheliosis
Hidradenitis
Xerosis
Acrochordon
Question . 9. The radioallergosorbent test (RAST) determines:
Question . 10. All of the following statements regarding skin testing for allergic
reactivity are true except:
Question . 12. Which of the following physical findings would be least likely on
examination of a child with moderate to severe asthma?
Tachypnea
Wheezing
Clubbing
Explanation: Digital clubbing (hypertrophic pulmonary
osteoarthropathy) is rarely observed in children with
uncomplicated asthma and should prompt evaluation to
exclude other potential diagnoses. (See Chapter 131 in
Nelson Textbook of Pediatrics, 17th ed.)
Keeping the cat out of the child's bedroom and other rooms
where the sensitized child spends large amounts of time
reduces cat allergen exposure
Immediately
2 days
2 wk
2 mo
6 mo
Explanation: Cat owners who remove the cat from the
home without also removing carpeting and upholstered
furniture, and thoroughly wiping down all walls and hard
surfaces, should be informed not to expect immediate
results. It may take 6 months to 1 year for the levels of cat
allergen to drop to a level found in homes without a cat.
(See Chapter 132 in Nelson Textbook of Pediatrics, 17th
ed.)
2
Explanation: Agents with greater 2-selective activity
provide effective bronchodilation with less cardiac
stimulation (e.g., increase in heart rate) than may occur
with agents with both 1 and 2 activities. (See Chapter 132
in Nelson Textbook of Pediatrics, 17th ed.)
Milk protein
Tree pollen
Grass pollen
Weed pollen
Explanation: In temperate climates, airborne pollen
responsible for SAR appears in distinct phases: trees
pollinate in the spring, grasses in the early summer, and
weeds in the late summer. (See Chapter 133 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 22. A teenage boy presents in April with symptoms consistent with
seasonal allergic rhinitis. On examination of his nose, which of the following
findings suggest the need for further evaluation to exclude another diagnosis?
Nasal polyps
Explanation: Nasal polyps and nasal septal deviation are
structural disorders that can mimic allergic rhinitis. (See
Chapter 133 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 23. A 12-yr-old presents with sneezing, clear rhinorrhea, and nasal
itching. Physical examination reveals boggy, pale nasal edema with a clear
discharge. The most likely diagnosis is:
Foreign body
Vasomotor rhinitis
Neutrophilic rhinitis
Nasal mastocytosis
Allergic rhinitis
Explanation: Allergic rhinitis is often seasonal and
associated with allergic conjunctivitis. Eosinophils
predominate in the nasal secretions.Chapter 133
Sinusitis
Explanation: Sinusitis is a possible complication of allergic
rhinitis. A change in the nature of the nasal discharge,
facial pain, and fever may all herald the onset of sinusitis.
(See Chapter 133 in Nelson Textbook of Pediatrics, 17th
ed.)
Foreign body
Rhinitis medicamentosa
Choanal stenosis
Ciliary dyskinesia
Nasal eosinophils
Ozone
Cold air
Exercise
Gelatin
Explanation: Asthma symptoms may be provoked by
numerous events or exposures.Chapter 134
Question . 28. The parents of a 3-yr-old girl with a history of several previous
coughing and wheezing exacerbations are wondering if their toddler is likely to
develop persistent asthma. Which of the following is a strong risk factor for
persistent asthma in toddlers with recurrent wheezing?
Eczema
Explanation: Only a minority of young children who
experience recurrent wheezing will go on to have persistent
asthma in later childhood. Several risk factors have been
identified. Chapter 134
Colic
Living on a farm
Female gender
Otitis media with effusion
Question . 29. A 4-yr-old boy with asthma has had mild wheezing only four
times since you began treating him 6 mo ago with theophylline (Slo-bid
Gyrocaps) twice each day. He previously experienced coughing and wheezing
at least three times each week. (A peak serum theophylline concentration 5
mo ago was 16 g/mL). For the past 4 days, he has again experienced mild
coughing and wheezing responsive to inhaled albuterol. Two days ago, an
emergency department physician began treatment with erythromycin-
sulfisoxazole (Pediazole) for otitis media. This morning the youngster began
vomiting. The likely cause of the vomiting is:
Theophylline toxicity
Explanation: The erythromycin (a macrolide antibiotic)
component of Pediazole inhibits hepatic theophylline
metabolism, thus potentially producing theophylline toxicity.
(See Chapter 134 in Nelson Textbook of Pediatrics, 17th
ed.)
Albuterol toxicity
Pediazole intolerance
Oral theophylline
Cromolyn
Oral theophylline
Close monitoring
Supplemental oxygen
Inhaled albuterol
Theophylline
Explanation: Initial emergency department management of
an asthma exacerbation includes close monitoring of
clinical status, treatment with supplemental oxygen, inhaled
-agonist every 20 min for 1 hr, and if necessary, systemic
glucocorticoids (2 mg/kg/day) given either orally or
intravenously. Inhaled ipratropium may be added to the -
agonist treatment if no significant response is seen with the
first inhaled -agonist treatment. If a child responds poorly
to intensive therapy with nebulized albuterol, ipratropium,
and parenteral glucocorticoids, then adding intravenous
theophylline could be considered.Chapter 134
Systemic glucocorticoids
Question . 33. A 7-yr-old girl has had intermittent asthma symptoms over the
past 5 yr. Her asthma symptoms have been treated with inhaled albuterol as
needed. She mostly has exercise-induced asthma symptoms, which happens
on most school days except when she uses her albuterol inhaler before going
to recess and physical education classes. In the past year, she has had two
asthma exacerbations with viral upper respiratory tract infections, and she has
used a total of 5 albuterol metered-dose inhalers. The most appropriate
management for this asthmatic girl is:
Genetic profiling
Explanation: The NAEPP guidelines were recently
adapted for childhood asthma in a joint-effort publication of
the American Academy of Allergy, Asthma & Immunology
with the U.S. National Institutes of Health's National Heart,
Lung and Blood Institute and the American Academy of
Pediatrics entitled Pediatric Asthma: Promoting Best
Practice.Chapter 134
Patient education
Lymphopenia
Explanation: Most patients with atopic dermatitis have
peripheral blood eosinophilia and elevated serum IgE level.
Nearly 80% of patients with atopic dermatitis develop
allergic rhinitis and/or asthma.
Question . 36. Major features of atopic dermatitis in children include all of the
following except:
Pruritus
Angioedema
Explanation: Angioedema is similar to urticaria but has
deeper tissue involvement. Urticaria and angioedema are
not characteristic features of atopic dermatitis
Question . 38. The most appropriate prognosis to convey to the parents of the
2-yr-old with atopic dermatitis described in Question 37 is:
Question . 39. Which of the following is the major feature of atopic dermatitis?
Pruritus
Explanation: All patients with atopic dermatitis have
pruritus. However, not all patients with atopic dermatitis
have other allergic symptoms, elevated IgE levels, or S.
aureus skin infections. (See Chapter 135 in Nelson
Textbook of Pediatrics, 17th ed.)
Chickenpox
Zoster
Eczema vaccinatum
Coxsackievirus infection
Skin biopsy
A bland diet
Oral antihistamine
Explanation: Antihistamines are usually effective for
treatment of urticaria. Diphenhydramine and hydroxyzine
are effective but also cause sedation. A nonsedating
antihistamine (e.g., Loratadine) is often the preferred
therapy for urticaria for school-aged children to minimize
the effect on learning and school performance. (See
Chapter 136 in Nelson Textbook of Pediatrics, 17th ed.)
Oral prednisone
Topical corticosteroid
Question . 43. Which of the following laboratory tests is most likely to give
abnormal results in a patient with chronic urticaria?
C4 level assay
Epinephrine
Explanation: Intramuscular epinephrine is the treatment of
choice. If the blood pressure does not respond, lactated
Ringer's solution should be administered. Benadryl,
cimetidine, and prednisone are second-line therapeutic
agents to be administered after epinephrine and fluids.
(See Chapter 137 in Nelson Textbook of Pediatrics, 17th
ed.)
Prednisone
Diphenhydramine
Albuterol
Question . 45. The most likely diagnosis for the patient described in Question
45 is:
Scarlet fever
Stevens-Johnson syndrome
Reye syndrome
Anaphylaxis
Explanation: Anaphylaxis to penicillin usually occurs within
30-90 min of administration of this drug. Anaphylactic shock
is often missed as a diagnosis unless a complete history is
obtained and there is a high index of suspicion. (See
Chapter 137 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 46. The mother of an 8-yr-old boy with acute streptococcal
tonsillitis calls to report that now, within 15 min after the first dose of oral
penicillin V that you prescribed, he is complaining of itching and has developed
hives. Which of the following should you recommend?
Question . 47. All of the following statements regarding anaphylaxis are true
except:
Diphenhydramine orally
Question . 50. The most common single cause of anaphylaxis outside of the
hospital is:
Drug allergy
Food allergy
Explanation: Food allergy is the most common cause of
anaphylaxis occurring outside of the hospital, accounting
for about one half of the anaphylactic reactions reported in
pediatric surveys. (See Chapter 137 in Nelson Textbook of
Pediatrics, 17th ed.)
Latex allergy
Inhaled albuterol
Subcutaneous epinephrine
Intramuscular diphenhydramine
Intramuscular epinephrine
Explanation: The principal treatment of choice of
anaphylaxis is aqueous epinephrine, 1:1,000, 0.01 mL/kg
(maximum 0.3 mL for a child or 0.5 mL for an adult) by
intramuscular injection, which can achieve more rapid
effective concentrations than obtainable with subcutaneous
injection. (See Chapter 137 in Nelson Textbook of
Pediatrics, 17th ed.)
Oral corticosteroids
Question . 52. Which of the following would be the optimal long-term
management of the child described in Question 51?
Immunotherapy
Explanation: Children experiencing systemic anaphylactic
reactions to an insect sting should be evaluated and treated
with immunotherapy, which is >90% protective. (See
Chapter 137 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 53. A 2-yr-old child who has completed 8 days of a 10-day course
of cefaclor presents with low-grade fever, malaise, irritability,
lymphadenopathy, and a generalized erythematous rash that is mildly pruritic.
The most likely diagnosis is:
Infectious mononucleosis
Kawasaki disease
Question . 57. A 7-yr-old boy presents with fever and otalgia. On examination,
he has a bulging right tympanic membrane. As you hand his mother a
prescription for amoxicillin, she informs you that when the child was 4 yr old,
he broke out in an itchy rash during treatment with amoxicillin. The most
appropriate approach to management of this patient would be:
Allergy to sulfamethoxazole
Stevens-Johnson syndrome
Explanation: Stevens-Johnson syndrome is a blistering
mucocutaneous disorder induced by drugs, classically
sulfonamides. Epidermal detachment of less than 10%
suggests Stevens-Johnson syndrome. (See Chapter 139 in
Nelson Textbook of Pediatrics, 17th ed.)
Asthma
Anaphylaxis
Uveitis
Explanation: Clinical findings in allergy caused by insects
are similar to those occurring with usual inhalant allergens
(e.g., rhinitis, conjunctivitis, asthma). Biting insects may
cause local reactions that do not involve IgE. Venom from
stinging insects causes IgE-mediated sensitivity that may
lead to urticaria and anaphylaxis. (See Chapter 140 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 61. All of the following statements concerning allergic reactions to
stinging insects are true except:
Ragweed allergy
A Medic-Alert bracelet
Question . 64. A 10-yr-old girl was stung on her left cheek by a yellow jacket.
She is experiencing pain. By 4 hr following the sting the left side of her face is
so swollen that her left eye is virtually closed. There are no other complaints.
The best course of action would be:
Topical antihistamines
Topical decongestants
Immunotherapy
Topical corticosteroids
Oral corticosteroids
Acute urticaria
Angioedema
Wheezing
Diarrhea
Chronic fatigue
Explanation: Chronic fatigue is not recognized to be
caused by food allergies. Acute urticaria and angioedema
(but not chronic urticaria and angioedema), acute
rhinoconjunctivitis, bronchospasm (wheezing), vomiting,
and protracted diarrhea are all manifestations of food
allergies. (See Box 142-1 and Chapter 142 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 70. All of the following foods are characteristically associated with
allergy except:
Peanuts
Tree nuts
Legumes
Explanation: Peanuts, tree nuts, eggs, and seafood all are
characteristically associated with food allergies. (See
Chapter 142 in Nelson Textbook of Pediatrics, 17th ed.)
Eggs
Seafood
Question . 71. Because of a strong family history on both sides, the parents of
a newborn baby ask for guidance about preventing their child from developing
an allergy to peanuts. Which of the following approaches is recommended?
Generalized anaphylaxis
Gastrointestinal anaphylaxis
Question . 73. Which of the following is the most definitive test for diagnosing
a food protein-induced enterocolitis?
Congenital leukemia
Kostmann syndrome
Platelet count
CH50
Explanation: The CH50 assay is a screening test for
complement defects and is not recommended for the initial
evaluation of immunodeficiency unless there is history of
infection with encapsulated organisms. The CBC, platelet
count, and immunoglobulin levels assay are cost-effective
screening tests. (See Chapter 112 in Nelson Textbook of
Pediatrics, 17th ed.)
Immunoglobulin levels
Cryptosporidium diarrhea
Isohemagglutinins
Antibodies to tetanus
Anaphylaxis
Fluid overload
Transmission of HIV
Aseptic meningitis
Explanation: AIDS has not been reported as a
complication of the use of intravenous immunoglobulin
(IVIG) prepared from human donors. Donors are screened
for human immunodeficiency virus, hepatitis B virus, and
hepatitis C virus; furthermore, preparative methods
inactivate these viruses. The remaining choices are rare
but reported complications of IVIG therapy. Nonetheless,
IVIG has been a remarkable aid in the treatment of patients
with congenital antibody deficiency states. (See Chapter
114 in Nelson Textbook of Pediatrics, 17th ed.)
Systemic reactions
Question . 9. A 1-yr-old child is found to have a normal WBC count but no
circulating B cells, small tonsils, and no palpable lymph nodes. Serum
concentrations of IgG, IgA, IgM, and IgE are below the 95% lower limits for
age. The most likely diagnosis is:
Ataxia-telangiectasia
DiGeorge syndrome
X-linked agammaglobulinemia
Explanation: X-linked agammaglobulinemia (XLA), or
Bruton agammaglobulinemia, is suggested by low
concentrations of all Ig classes. Affected patients are also
unable to respond to immunizations, unlike infants with
transient agammaglobulinemia of infancy. (See Chapter
114 in Nelson Textbook of Pediatrics, 17th ed.)
X-linked agammaglobulinemia
Ataxia-telangiectasia
Question . 11. The X-linked lymphoproliferative (XLP) syndrome is classically
associated with overwhelming infection by which of the following agents?
Epstein-Barr virus
Explanation: The genetic defect for X-linked
lymphoproliferative (XLP) syndrome also predisposes to
severe primary EBV infection, which is associated with 50%
mortality in affected patients. (See Chapter 114 in Nelson
Textbook of Pediatrics, 17th ed.)
Enteroviruses
Catalase-positive bacteria
Neisseria meningitidis
Pneumocystis carinii
Neonatal hypocalcemia
Micrognathia
Atopic dermatitis
Thrombocytopenia
Recurrent pneumonia
Pneumatoceles
Recurrent fractures
Hyperextensible joints
Gene therapy
Monthly IVIG
Dendritic cells
Microglial cells
Kupffer cells
Osteoblasts
Explanation: Tissue macrophages derived from
monocytes include osteoclasts, which are large
multinucleated cells associated with the absorption and
removal of bone. In contrast, osteoblasts arise from
fibroblasts and, when mature, are associated with the
production of bone. (See Chapters 118 in Nelson Textbook
of Pediatrics, 17th ed.)
Congenital hypogammaglobulinemia
Normal child
Question . 20. All of the following are typically associated with an eosinophilic
response and eosinophilia except:
Allergic rhinitis
Wiskott-Aldrich syndrome
Question . 21. Delayed separation of the umbilical cord after birth suggests
which of the following types of immune dysfunction?
B-cell defect
T-cell defect
Myeloperoxidase deficiency
Aspergillus pneumonia
Perianal abscess
Hypogammaglobulinemia
Explanation: Because of chronic or recurrent infections,
most patients with CGD demonstrate
hypergammaglobulinemia. (See Chapter 120 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 24. A 5-yr-old boy presents with his third episode of painful cervical
lymphadenitis. Each was treated with incision and drainage, and cultures grew
Staphylococcus aureus. At the age of 2 yr, he required surgical aspiration of a
liver abscess. The most important laboratory test is:
MAC-1 assay
Neutrophil count
Bruton agammaglobulinemia
AIDS
Kostmann disease
Cyclic neutropenia
Intravenous immunoglobulin
IFN-
Explanation: IFN- increases superoxide anion generation
in vitro and reduces the incidence of new infections. Long-
term use of trimethoprim-sulfamethoxazole may also be
effective in reducing infections. (See Chapter 120 in Nelson
Textbook of Pediatrics, 17th ed.)
IL-2
Granulocyte transfusion
Question . 27. Neutropenia is noted in children in all of the following
conditions except:
Kostmann disease
Viral infection
Maternal preeclampsia
Hunter syndrome
Explanation: Transient, benign neutropenia associated
with various non-life-threatening viral infections is the most
common cause of neutropenia in previously healthy
children. Neonatal neutropenia due to alloimmune,
autoimmune, or preeclamptic processes is often
asymptomatic and transient. (See Chapter 121 in Nelson
Textbook of Pediatrics, 17th ed.)
Shwachman-Diamond syndrome
Question . 28. A 5-mo-old girl presents with diarrhea and malabsorption, and
on initial laboratory testing has a WBC count of 900/mm3. Which of the
following is the most likely diagnosis?
Cystic fibrosis
Shwachman-Diamond syndrome
Explanation: Schwachman-Diamond syndrome is an
autosomal recessive disorder characterized by digestive
abnormalities and leukopenia. (See Chapter 121 in Nelson
Textbook of Pediatrics, 17th ed.)
Cyclic neutropenia
Shwachman-Diamond syndrome
Cartilage-hair hypoplasia
Chédiak-Higashi syndrome
AIDS
Kostmann disease
Explanation: Kostmann disease, an autosomal recessive
severe infantile form of agranulocytosis, manifests with
persistently low absolute neutrophil counts (<200/mm3) and
severe, recurrent, and at times lethal (by age 3 yr) infection.
(See Chapter 121 in Nelson Textbook of Pediatrics, 17th
ed.)
Cyclic neutropenia
Prophylactic antibiotics
IFN-
Neutrophilia
Leukocytosis
B-cell defect
T-cell defect
Autologous
Syngeneic
Familiogeneic
Allogeneic
Explanation: Cells for autologous transplantation (after
removal of cancer cells) are obtained from the patient. Cells
for syngeneic transplantation are obtained from an identical
twin. Cells for allogeneic transplantation are obtained from
a nonidentical person. (See Chapter 125 in Nelson
Textbook of Pediatrics, 17th ed.)
Xenogeneic
IFN-
HLA disparity
Explanation: HLA disparity is the most important variable
influencing graft failure and graft rejection. (See Chapter
126 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 38. A 9-yr-old boy undergoes stem cell transplantation for acute
myelogenous leukemia in remission. Approximately 4 mo after transplantation,
he has persistent maculopapular rash over 25% of his body, generalized
erythroderma, bilirubin 8.4 mg/dL, and diarrhea with >1,000 mL of feces per
day. He complains of xerostomia. The most likely diagnosis is:
Leukoencephalopathy
Secondary malignancies
Hyperthyroidism
Explanation: The use of total body irradiation (TBI) with or
without additional conventional irradiation involving the
thyroid gland, may result in hypothyroidism, not
hyperthyroidism. (See Chapter 129 in Nelson Textbook of
Pediatrics, 17th ed.)
Growth depression
Cataracts
Question . 1. A 3-yr-old girl has fever. Urine is collected by catheterization for
culture. What is the minimum concentration of bacterial growth in the culture that
would generally be considered diagnostic of a urinary tract infection in this young
girl?
1 bacterium/mL
10 bacteria/mL
103 bacteria/mL
Explanation: Urine colony counts of 103 organisms/mL or greater
are generally considered significant in urine collected by
catheterization, and of 105 organisms/mL or greater in urine collected
by clean-catch (midstream) void. Urine obtained by suprapubic
puncture should normally be sterile; any bacterial growth is
considered significant. (See Chapter 160 in Nelson Textbook of
Pediatrics, 17th ed.)
105 bacteria/mL
Relapsing disease
Syphilis
Question . 4. Amoxicillin was begun 4 days ago for treatment of otitis media
in a 4-yr-old boy. He now presents with signs of meningitis and is found to
have a pleocytosis with126 leukocytes/mm3. The diagnostic stain of the
cerebrospinal fluid that would be most useful is:
Gram stain
Explanation: The Gram stain remains the most useful
diagnostic stain for bacterial meningitis. It is a rapid,
inexpensive method for demonstrating the presence of
bacteria and fungi. (See Chapter 160 in Nelson Textbook of
Pediatrics, 17th ed.)
Kinyoun stain
Trichrome stain
Wright stain
Question 5. 5. A 12-yr-old girl has a positive throat culture for group A streptococci.
Which of the following antimicrobial susceptibility tests should be performed?
Absence of IgG antibody titer in the acute serum and IgG antibody
titer of 1:16 in the convalescent serum
Question 7. 7. Most evidence suggests that fever is an adaptive response, and that
antipyretics provide symptomatic relief but do not change the course of diseases
except in selected circumstances. Patients with which of the following underlying
conditions should be treated with antipyretics for fever as an essential part of
treatment?
Osteomyelitis
Diabetes mellitus
Cyclic neutropenia
Explanation: Periodic fever is used to narrowly describe fever
syndromes with a regular periodicity, such as cyclic neutropenia, and
the syndrome of periodic fever, aphthous stomatitis, pharyngitis, and
adenopathy (PFAPA). (See Chapter 161 in Nelson Textbook of
Pediatrics, 17th ed.)
Hectic fever
Marburg fever
Ques.9.A 4-yr-old girl has a temperature of 41.8°C. Which of the following is the most
likely cause?
Cerebellar disorders
Hypothalamic disorders
Explanation: Temperatures in excess of 41°C are most often
associated with a noninfectious cause. Causes of very high
temperatures (>41°C) include central fever (resulting from central
nervous system dysfunction involving the hypothalamus), malignant
hyperthermia, malignant neuroleptic syndrome, drug fever, or
heatstroke. (See Chapter 161 in Nelson Textbook of Pediatrics, 17th
ed.)
Excessive sweating
10. A 16-yr-old boy who has recently traveled to sub-Saharan Africa is diagnosed
with Plasmodium vivax malaria. The fever pattern is one of febrile periods every
other day. The term that best characterizes this fever pattern is:
Hectic fever
Remittent fever
Biphasic fever
Tertian fever
Explanation: Tertian fever occurs on the 1st and 3rd days (e.g.,
malaria caused by Plasmodium vivax), and quartan fever occurs on
the 1st and 4th days (e.g., malaria caused by Plasmodium malariae).
(See Chapter 161 in Nelson Textbook of Pediatrics, 17th ed.)
Periodic fever
12. An 8-yr-old boy with sickle cell disease presents with fever and symptoms of an
acute illness. You consider treating him as an outpatient with intramuscular
ceftriaxone. Which of the following findings should lead to hospitalization?
Pulmonary infiltrates
13. Pyelonephritis is a frequent cause of fever in young infants. All of the following
patient groups have an increased risk of urinary tract infections except:
Infant girls
Moraxella catarrhalis
Explanation: Occult bacteremia (bacteremia without an obvious
focus of infection) due to Streptococcus pneumoniae, H. influenzae
type b, N. meningitidis, or nontyphoidal Salmonella occurs in
approximately 4% of relatively well-appearing children between 3 and
36 mo of age with fever (rectal temperature >38.0°C). S. pneumoniae
accounts for 90% of cases of occult bacteremia. (See Chapter 162 in
Nelson Textbook of Pediatrics, 17th ed.)
Neisseria meningitidis
Salmonella
Streptococcus pneumoniae
15. A 22-day-old infant is noted by his mother to have a rectal temperature of 38.3°C.
She reports that he has been acting normal and appears generally well. He was born
at 37 wk of gestation, went home with his mother at 24 hr of life, and has done well
since. There is no known underlying illness. The physical examination is normal.
The infant's WBC count is 19,500/mm3 and the absolute band count is 850/mm3.
There are 4 WBCs/mm3 in an unspun urine sample, and results of a Gram stain of
the urine are negative. This infant fails to meet criteria for low risk of serious
bacterial infection because:
16. A 10-mo-old black male infant from an urban area presents to the emergency
department with a temperature of 39.3°C and an unremarkable physical examination.
Which of the following is a risk factor for occult bacteremia in this child?
Race
Socioeconomic status
Sex
Fever
Explanation: Socioeconomic status, race, gender, and age do not
appear to affect the risk for occult bacteremia among children 3-36
mo of age.
17. The triage history of a 9-mo-old child presenting with a temperature of 39.2°C
shows the immunization history as "up-to-date." Further review of the medical
record shows that the patient has had three doses of Hib conjugate vaccine. Of the
following immunizations, which is the most important to document before
determining any management decisions?
Hepatitis B
DTaP
IPV
18. The laboratory calls at 8:45 A.M. to inform you that a blood culture obtained in the
emergency department yesterday from a 10-mo-old febrile girl who is followed in your
practice is growing Streptococcus pneumoniae. You contact her parents, and they report
that she is "doing well." The most appropriate next step in management would be to:
Instruct the family that you will telephone a prescription for amoxicillin
to the pharmacy, and that they should pick up the prescription and
start treating their child this morning.
Inform the parents that the blood culture was positive and that they
should have the child return to your office if new symptoms develop.
Instruct the parents that they should have the child return to your
office if new symptoms develop; in addition, since the medical record
shows that she has been immunized against S. pneumoniae and has
received the three doses recommended by this age, you should
report the vaccine failure to the state health department.
Instruct the parents to call 911 and have their child taken to the
emergency department immediately.
20. A 1-yr-old child presents with a history of recurrent fevers for several weeks. On
physical examination you find that the pupils fail to constrict. This finding is associated with:
Toxoplasmosis
Ectodermal dysplasia
Hypothalamic dysfunction
Explanation: Fever of unknown origin is sometimes due to
hypothalamic dysfunction. A clue to this disorder is failure of pupillary
constriction due to absence of the sphincter constrictor muscle of the
eye. This muscle develops embryologically when the hypothalamus
is also undergoing differentiation. (See Chapter 162 in Nelson
Textbook of Pediatrics, 17th ed.)
Thyrotoxicosis
22. Thirty minutes after admission, an 18-yr-old girl with meningococcemia has just finished
receiving the last of her 60 mL/kg infusion of normal saline. The nurse tells you that the
patient's heart rate is still 120/min, that her blood pressure is 70/30 mm Hg, and that pink,
frothy material is being suctioned from the patient's endotracheal tube. The patient's
extremities are warm, with bounding pulses. The next step in the resuscitation is to:
Administer NaHCO3
Administer nitroprusside
Administer norepinephrine
Explanation: This patient is exhibiting signs of fluid overload-
pulmonary edema-and therefore should be given pharmacologic
therapy to restore her blood pressure. Because the patient's pulses
are good and she is well perfused, a pressor is indicated. (See
Chapter 163 in Nelson Textbook of Pediatrics, 17th ed.)
24. In the case described in Question 23, the most appropriate antibacterial regimen to use
until culture results are known would be:
Ceftriaxone
27. A 6-mo-old girl with streptococcal bacteremia admitted earlier to the PICU is now
unresponsive, hypotensive, and tachycardic. She is intubated, sedated, and receiving the
last part of her third 20 mL/kg normal saline bolus. Her blood pressure is 120/70 mm Hg,
and her heart rate is 120/min. Despite some improvement in peripheral pulses, her
peripheral extremities remain cool, with delayed capillary refill. The recommended next
step in management of this girl is:
29. A 4-yr-old boy who was previously well is found to have a Staphylococcus aureus
hepatic abscess. His maternal uncle died during childhood from "an infection" that was also
thought to be caused by S. aureus. Of the following, which is the most likely diagnosis?
Congenital neutropenia
Cyclic neutropenia
30. The boy described in Question 29 should receive specific antibiotic therapy directed
against S. aureus and also:
Intramuscular immunoglobulin
Cyclosporine
Amphotericin B
31. A 13-yr-old girl with hyperthyroidism has chronic infection of her skin and nails with
Candida albicans. She has never required hospitalization or had life-threatening infection.
She had chickenpox at age 11 mo from which she had an uneventful recovery, and has
received her other routine childhood vaccinations without problems. Which of the following
tests often yields an abnormal result in a child with this condition?
Neutrophil count
33. A child with fever is found to have a white blood cell count of 1,400/mm3 with a
differential count of 10% neutrophils, 2% band forms, 85% lymphocytes, and 3%
mononuclear cells. Which of the following scenarios indicate the greatest risk for this child
to have a new serious bacterial complication?
The child has leukemia and received chemotherapy 20 days ago. His
WBC count 2 days ago was 800/mm3, with 1 % neutrophils, 0% band
forms, 65% lymphocytes, and 44% mononuclear cells.
The child was recently diagnosed with a seizure disorder and was
started on carbamazepine (Tegretol) 2 weeks ago.
34. A 4-yr-old girl underwent liver transplantation 4 mo ago after liver failure from biliary
atresia. She has done relatively well, with only one episode of acute cellular rejection at 1
mo after transplantation. She is currently on cyclosporine and prednisone given orally. She
takes no other medications. She presents to your office with fever of 3 days' duration,
tachypnea, and cough. The clinical examination reveals a moderately ill child with
increased respiratory effort and perioral cyanosis. The lungs are clear on auscultation.
Chest radiograph shows a diffuse interstitial infiltrate White blood cell count is 5,400/mm3
with a differential count showing 56% neutrophils, 3% band forms, 37% lymphocytes, and
4% eosinophils. Bronchoalveolar lavage is performed, and a diagnosis is established.
Which of the following is the least likely pathogen in this patient?
Cytomegalovirus
Pneumocystis carinii
S. pneumoniae (pneumococcus)
Explanation: Although pneumococcal pneumonia can occur in both
immunocompetent and immunocompromised persons, unusual
pathogens are more likely in a post-transplantation patient receiving
immunosuppressive therapy. (See Chapter 164 in Nelson Textbook of
Pediatrics, 17th ed.)
Adenovirus
Parainfluenza virus
35. A 6-yr-old boy with acute lymphocytic leukemia has had a central venous catheter
(Hickman catheter) in place for 1 yr to facilitate administration of chemotherapy. He was
brought into the clinic with a temperature of 39°C. His mother reports that he was well until
an hour after she routinely flushed his line with heparin, when he developed the fever and
had rigors. Aside from increased heart rate, his vital signs and findings on physical
examination are normal. He is not neutropenic. The most appropriate approach to
management of this child is:
36. A 9-yr-old boy with cancer had an indwelling Broviac catheter placed 8 mo ago for
cancer chemotherapy. He presents with fever and erythema over the catheter tunnel,
without other localizing symptoms. Blood culture specimens are taken. Which of the
following antibiotics is recommended?
Nafcillin
Cephalexin
Ceftriaxone
Clindamycin
Vancomycin
Explanation: Vancomycin is the choice for empirical treatment of
indwelling line and prosthesis infections caused by coagulase-
negative staphylococci. Most coagulase-negative staphylococci are
resistant to nafcillin. (See Chapter 165 in Nelson Textbook of
Pediatrics, 17th ed.)
37. An 18-mo-old infant has a CSF shunt in place because of congenital hydrocephalus.
He underwent a surgical revision of the shunt 4 mo ago because of malfunction. He
presents to the emergency department with increased irritability and decreased appetite of
3 days' duration. The rectal temperature is 38.7°C. There are no focal signs of infection.
The most appropriate management of this child would be:
If the WBC count is normal, discharge the child with instructions to
take acetaminophen every 4 hr for the fever.
38. A 9-yr-old boy presents with fever >39°C for 4 days, myalgias, watery diarrhea,
conjunctival infection, diffuse erythroderma, strawberry tongue, blood pressure of 105/45
mm Hg, and moderately elevated hepatic transaminases. The most likely diagnosis is:
Kawasaki disease
Stevens-Johnson syndrome
39. Strains of Staphylococcus aureus can produce which of the following toxins?
Exfoliatin A and B
Hemolysins
Enterotoxins A through E
40. A 16-yr-old girl experiences abrupt onset of high fever, vomiting, and diarrhea, with a
diffuse sunburn-like rash, hyperemia of the pharyngeal and conjunctival membranes,
oliguria, and postural hypotension. The most likely diagnosis is:
Hemolytic-uremic syndrome
Kawasaki disease
Renal dialysis
IVIG
Doxycycline
An antistaphylococcal antibiotic
Explanation: Treatment of toxic shock includes an
antistaphylococcal antibiotic and aggressive intravenous fluid therapy
to prevent or treat hypotension. Corticosteroids and intravenous
immunoglobulin are reserved for severe cases. (See Chapter 166.2 in
Nelson Textbook of Pediatrics, 17th ed.)
Corticosteroids
Proteus mirabilis
Coagulase-negative staphylococci
Explanation: Slime produced by coagulase-negative staphylococci
surrounds the organism, resists phagocytosis, and enhances
adhesion to foreign surfaces, including indwelling catheters and
prostheses. (See Chapter 166.3 in Nelson Textbook of Pediatrics, 17th
ed.)
Group A streptococci
Haemophilus influenzae
Moraxella catarrhalis
43. Coagulase-negative staphylococci are commonly associated with all of the following
except:
Neonatal bacteremia
Urinary tract infection
44. A 12-yr-old child is being treated with nafcillin for Staphylococcus aureus bacteremia.
However, cultures of specimens taken 4 days after presentation remain positive. Which of
the following is the least likely cause of the positive cultures?
Antimicrobial resistance to nafcillin
Endocarditis
Septic thrombophlebitis
An undrained abscess
Penicillin allergy
Explanation: Persistent Staphylococcus aureus bacteremia
suggests the possibility of antimicrobial resistance, an endovascular
focus such as endocarditis, or focal infection that requires drainage.
45. A throat culture from a 16-yr-old boy with osteosarcoma and a Broviac catheter grows
coagulase-negative staphylococci. The recommended course of management is:
Intravenous nafcillin
Vancomycin mouthwashes
Intravenous vancomycin
Clindamycin
Azithromycin
Vancomycin
Explanation: Vancomycin is the current treatment of choice for
penicillin/cephalosporin-resistant pneumococcal infection. (See
Chapter 167 in Nelson Textbook of Pediatrics, 17th ed.)
Streptomycin
47. A 7-mo-old infant presents to your office with fever, lethargy, and a stiff neck. A lumbar
puncture reveals cloudy cerebrospinal fluid. Blood and CSF specimens are sent for culture.
Which of the following is the most appropriate next step in the management of this infant?
MRI scan
Intravenous penicillin
Intravenous ceftriaxone
48. A 26-mo-old child with sickle cell disease appears in your office for the first time. He
has a history of a prior hospitalization for pneumococcal bacteremia. Currently the child is
on penicillin prophylaxis, but he has not received either the conjugate or polysaccharide
pneumococcal vaccine. Which of the following is the optimal means for protecting this child
from developing another episode of invasive pneumococcal disease?
50. An 8-mo-old infant who has received all recommended vaccines at the appropriate age
presents to your office with a temperature of 39.5°C, increased respiratory rate, and
crackles in the left lung. A chest radiograph shows a left lower lobe infiltrate with a large
pleural effusion. The peripheral white blood cell count is 22,000/mm3, with 60% neutrophils
and 15% bands. The child is admitted to the hospital but is not thought to require intensive
care or intubation.The most appropriate next step in management would be to:
51. A 4-yr-old boy presents with well-demarcated, perianal erythema associated with anal
pruritus and blood-streaked stools. The most likely etiology is:
Lupus erythematosus
Crohn disease
Parvovirus B19
Question . 53. All of the following are features of scarlet fever except:
Pastia lines
Desquamation
Staphylococcus aureus
Group A streptococci
Group B streptococci
Explanation: Group B streptococcal organisms are the major cause
of severe systemic and focal infections in the newborn. Coagulase-
negative staphylococcal infections are the most common nosocomial
infections in the neonatal intensive care unit. (See Chapter 169 in
Nelson Textbook of Pediatrics, 17th ed.)
Escherichia coli
Question . 55. All of the following statements concerning perinatal group B streptococcal
neonatal infections are true except:
Question . 56. The recommended regimen for selective intrapartum prophylaxis for group
B streptococcal infection is:
Question . 57. Regarding early-onset versus late-onset neonatal infection, all of the
following are true except:
Question . 59. Which of the following pregnant women should receive prophylaxis against
group B streptococci?
Question . 60. All of the following infants routinely require a sepsis evaluation (at least a
complete blood count with differential, and blood culture) except:
Question . 61. A 19-yr-old freshman in college presents with signs of pharyngitis. His
throat culture is positive for group C streptococci. The recommended management is:
Oral clindamycin
Oral erythromycin
Intramuscular ceftriaxone
Question . 62. A 12-yr-old girl is hospitalized in intensive care. She has a Foley catheter,
and a urine culture is positive for Enterococcus. In addition to removing the catheter, which
antibiotic is the recommended agent for treatment of Enterococcus infections?
Penicillin
Ampicillin
Explanation: In general, in the immunocompetent person, minor
localized infections due to Enterococcus can be treated with
ampicillin alone. (See Chapter 171 in Nelson Textbook of Pediatrics,
17th ed.)
Clindamycin
Erythromycin
Vancomycin
Question . 63. As a visiting physician in a developing country, you are asked to see a 2-yr-
old child who presents with a history of fever, dysphagia, and lethargy. Physical
examination shows a gray-brown leather-like adherent membrane over the posterior
oropharynx and hypopharynx. The most likely diagnosis is:
Epiglottitis
Bacterial tracheitis
Vincent angina
Diphtheria
Explanation: The leather-like adherent membrane, extension
beyond the faucial area, relative lack of fever, and dysphagia help
differentiate diphtheria from exudative pharyngitis due to group A
streptococci and Epstein-Barr virus. (See Chapter 172 in Nelson
Textbook of Pediatrics, 17th
Question . 64. Which of the following routes of transmission has been associated with
several large outbreaks of human listeriosis?
Aerosol transmission
Person-to-person spread
Zoonotic transmission
Food-borne transmission
Explanation: Listeria monocytogenes may contaminate dairy
products (milk, cheese) and may survive, replicate, and spread in a
family's refrigerator. (See Chapter 173 in Nelson Textbook of
Question . 65. Which of the following is the recommended treatment for neonatal
listeriosis?
Ceftriaxone
Erythromycin
Vancomycin
Question . 66. All of the following represent risk factors for infection with Listeria
monocytogenes except:
Cancer chemotherapy
Question . 67. All of the following are effective in the prevention of infection due to Listeria
monocytogenes except:
Question . 68. A 16-yr-old girl presents with signs and symptoms of appendicitis. Her past
medical history is significant only for sexual activity and placement of an IUD 1 yr
previously. She undergoes an appendectomy, in which her appendix is found to be normal.
One month postoperatively, she has local pain and has an irregular, hard mass in her
ileocecal area. The most likely diagnosis is:
Yersinia pseudoappendicitis
Lymphoma
Pelvic actinomycosis
Explanation: Pelvic actinomycosis is an unusual complication of IUD
use.
Amebiasis
Involvement of bone
Question . 70. All of the following serogroups are included in the quadrivalent
meningococcus vaccine except:
B
Explanation: Meningococcal group B polysaccharide is poorly
immunogenic. There is no vaccine available for this serogroup. (See
Chapter 176 in Nelson Textbook of Pediatrics, 17th ed.)
C
W135
Y
Question . 71. Which of the following is associated with a poorer prognosis for persons
presenting with meningococcal disease?
Meningitis
Thrombocytosis
Leukocytosis
Low circulating levels of tumor necrosis factor
Question . 72. Which of the following contacts should receive rifampin chemoprophylaxis
after diagnosis of invasive Neisseria meningitidis in a child?
Question . 73. A 7-mo-old girl presents with a temperature of 103.8°F, blood pressure of
70/30 mm Hg, diffuse petechiae first noted 4 hr before presentation, platelet count of
88,000/mm3, and white blood cell count of 4300/mm3, with 23% neutrophils and 42%
bands. The infant has received all recommended vaccinations. Which of the following is the
most likely bacterial etiology of this presentation?
Staphylococcus aureus
Streptococcus pneumoniae
Neisseria meningitidis
Explanation: The presence of fever, petechiae, and hypotension
suggest meningococcemia. (See Chapter 176 in Nelson Textbook of
Pediatrics, 17th ed.)
Question . 74. A 15-mo-old child who attends a child care center 5 days per week is
diagnosed with meningococcal infection. Which of the following agents should be used for
prophylaxis for the child care classmates of this infant?
Chloramphenicol
Cefixime
Rifampin
Explanation: Rifampin or ceftriaxone is recommended for
prophylaxis of close contacts of patients with meningococcal disease.
(See Chapter 176 in Nelson Textbook of Pediatrics, 17th ed.)
Ciprofloxacin
Trimethoprim-sulfamethoxazole
Question . 75. Parents of a college-bound high school senior ask whether their child
should receive a meningococcal vaccine. Which of the following statements should
comprise part of the information that is provided to them?
Question . 76. A 6-yr-old child with meningococcal meningitis develops a swollen left knee
on the fifth day of antibiotic treatment. Which of the following is the most likely etiology of
this finding?
Question . 77. A 13-yr-old boy develops fever with petechiae and a few purpura. Mild
hypotension responds to intravenous fluids without the need for pressor support. A blood
culture yields Neisseria meningitidis. The patient improves greatly after 7 days of antibiotic
therapy and is ready for discharge. Which of the following is most likely to reveal an
abnormality that may have predisposed him to develop meningococcal disease?
Asymptomatic infection
Lymphadenitis
Explanation: Gonococcal infections range from asymptomatic
carriage to localized urogenital infections, culture-negative
tenosynovitis, suppurative arthritis, and disseminated gonococcal
infection with bacteremia. Most genital tract infections in children are
symptomatic, but as many as 80% of sexually active mature females
with urogenital gonorrhea infections are asymptomatic. Conjunctivitis
occurs in neonates born to mothers with genital tract gonorrhea. (See
Chapter 177 in Nelson Textbook of Pediatrics, 17th ed.)
Conjunctivitis
Suppurative arthritis
Question . 80. Which of the following drugs is recommended for initial therapy for
nondisseminated gonococcal disease in children and adults?
Penicillin
Tetracycline
Ceftriaxone
Explanation: Even with disseminated disease (bacteremia, arthritis,
meningitis), ceftriaxone is the drug of choice because of the high rate
of penicillin resistance. (See Chapter 177 in Nelson Textbook of
Pediatrics, 17th ed.)
Cefazolin
Erythromycin
Gonococcal meningitis
Question . 82. Which of the following contacts should receive rifampin chemoprophylaxis
after diagnosis of invasive Haemophilus influenzae type b infection in a child?
Unimmunized or partially immunized children younger than 4 yr in the
same household
Question . 84. Which of the following contacts should receive erythromycin after diagnosis
of pertussis in a child?
Question . 86. A 4-wk-old infant has the history of gagging and gasping episodes of acute
onset, with mild cough and rhinorrhea. The infant is afebrile and appears well, and findings
on lung auscultation are normal. Complete blood count reveals hemoglobin 12.0 gm/dL,
WBC count 42,000/mm3 (10% neutrophils, 3% monocytes, 87% lymphocytes), and platelet
count 650,000/mm3. The most likely etiologic agent of this illness is:
Chlamydia trachomatis
Rhinovirus
Bordetella pertussis
Explanation: Leukocytosis (15,000-100,000 cells/mm3) due to
absolute lymphocytosis is characteristic in the catarrhal stage of
pertussis. (See Chapter 180 in Nelson Textbook of Pediatrics, 17th
ed.)
Group B streptococci
Question . 87. You are advising the mother of a 2-mo-old infant about recommended
immunizations. She has read about pertussis vaccine and questions you on the acellular
pertussis vaccine you are recommending. You should advise her that compared with
whole-cell pertussis vaccine, the acellular vaccine:
Question . 88. A 6-wk-old infant is proved to have pertussis. His mother has had a bad
cough for 2 wk, and his father is well. There are also three siblings (ages 20 mo, 6 yr, and
8 yr) living in the household; all are appropriately immunized for age and are
asymptomatic. In addition to the infant, for whom erythromycin is prescribed, which of the
following household contacts should also be treated?
Mother
Question . 90. A 1-mo-old infant develops bloody diarrhea associated with fever. The most
likely agent causing this illness is:
Nontyphoidal Salmonella
Explanation: Salmonella is by far the most common cause of febrile
gastroenteritis in early infancy. Campylobacter is second in frequency
to Salmonella as a bacterial cause of enteritis in infancy. Yersinia is
rare. Shigella is rare in infancy but common in children 1-3 yr of age.
Rotavirus rarely causes bloody diarrhea. (See Chapter 181.1 in Nelson
Textbook of Pediatrics, 17th ed.)
Shigella
Campylobacter
Yersinia
Rotavirus
Question . 91. Isolation of Salmonella serotype marina from an infant suggests that:
Question . 92. A child who has recently returned from a visit to a developing country
experiences a 2-wk illness characterized by gradually increasing fever with temperature
that eventually reaches 104°F, associated with headache, malaise, cough, and abdominal
pain. The most likely diagnosis is:
Cholera
Diphtheria
Shigellosis
Typhoid fever
Explanation: Typhoid fever may or may not be associated with
diarrhea or constipation and is a prolonged, serious illness. (See
Chapter 181.2 in Nelson Textbook of Pediatrics, 17th ed.)
Tetanus
Question . 93. A 10-mo-old child presents to the emergency department with a 4-day
history of fever, with temperatures to 105°, and watery diarrhea, and has just experienced
a generalized seizure. The most likely cause of this syndrome is:
Salmonella gastroenteritis
Aeromonas gastroenteritis
Shigella gastroenteritis
Explanation: Shigella usually causes diarrhea and fever and
sometimes, particularly in young infants, seizures. (See Chapter 182 in
Nelson Textbook of Pediatrics, 17th ed.)
Rotavirus gastroenteritis
Drug ingestion
Question . 94. A 3-yr-old boy acutely develops severe abdominal pain, vomiting, fever
with temperatures to 105°F, and diarrhea that initially is watery but becomes grossly
bloody. Stool culture specimens are obtained, and oral rehydration is initiated. His 8-
yr-old sister had a similar presentation 9 days ago, including a stool culture that was
positive for Shigella flexneri. The next step in management should be to administer:
Loperamide
Ampicillin intravenously
Ceftriaxone parenterally
Explanation: Shigella infection is the most likely treatable
etiology for this acute dysenteric syndrome. Loperamide may
prolong illness. Ampicillin and TMP-SMZ are poor choices for
empirical management because of the frequency of resistant
Shigella. (See Chapter 182 in Nelson Textbook of Pediatrics, 17th
ed.)
Trimethoprim-sulfamethoxazole
Question . 95. The symptoms and fever in the child described in Question 94 resolve
over the ensuing 3 days. The boy's stool culture is reported as negative for enteric
pathogens. The recommended management is to:
Continue loperamide
Continue the antibiotic for 14 days and also obtain specimens for
culture from all other family members for Shigella
Question . 96. Hemolytic-uremic syndrome is typically a complication of infection with E.
coli O157:H7. The same process, microangiopathic hemolytic anemia with renal failure,
can also follow infection with:
Shigella flexneri
Shigella sonnei
Question . 97. A 20-mo-old child develops hemolytic anemia, anuria, azotemia, and
thrombocytopenia after a bout of febrile bloody diarrhea. The most likely etiologic agent of
this illness is:
Campylobacter jejuni
Salmonella typhi
Aeromonas
Non-typhi Salmonella
Question . 98. A 2-yr-old girl has an acute afebrile diarrheal syndrome characterized by
abdominal pain, vomiting, and grossly bloody stools. A stool culture on MacConkey sorbitol
media shows growth of bacteria that suggests E. coli O157:H7. A fecal toxin
electroimmunoassay suggests that a Shiga toxin is present. The most appropriate next
step in the management of this girl is:
Administration of loperamide
Oral antibiotic therapy, with the choice based on susceptibility of the
Shiga toxin-producing E. coli
Question . 100. Which of the following indicates a poor prognosis for cholera in children?
Acidosis
Corynebacterium diphtheriae
Clostridium botulinum
S. dysenteriae serotype 1
Campylobacter jejuni
Explanation: C. jejuni is a commonly associated pathogen in
Guillain-Barré syndrome (autoimmune polyneuropathy). (See Chapter
185 in Nelson Textbook of Pediatrics, 17th ed.)
Clostridium tetani
Question . 102. Which of the following blood products has been shown to be associated
with the greatest risk for transfusion-associated disease due to Y. enterocolitica?
Albumin
Platelet concentrates
Question . 103. Of the following diagnostic tests, which is least useful in establishing a
diagnosis of mesenteric lymphadenitis due to Yersinia pseudotuberculosis?
Stool culture
Explanation: Many patients affected by Y. pseudotuberculosis do
not have diarrhea, and thus a stool culture is not even considered as
part of the diagnostic evaluation. If the extent of infection is limited to
the mesenteric lymph nodes, the stool culture results may be
negative. (See Chapter 186.2 in Nelson Textbook of Pediatrics, 17th
ed.)
Abdominal ultrasonography
Endoscopy
Question . 104. An adolescent in rural New Mexico living in a household with domestic
cats that roam freely presents with fever and chills of sudden onset and extraordinarily
painful lymphadenopathy. He appears toxic. The most likely etiology is:
Question . 105. A 3-yr-old girl experiences mild enteritis. A stool culture identifies the
presumed etiology. Her symptoms are resolved by the time the culture result is known.
Which of the following organisms is least likely to be the cause of her illness?
Salmonella
Campylobacter jejuni
Aeromonas hydrophila
Plesiomonas shigelloides
Question . 106. A 13-yr-old girl with cystic fibrosis experiences an acute exacerbation
requiring hospitalization for antibiotic therapy. Which of the following organisms is the most
likely cause of her exacerbation?
Aeromonas
Plesiomonas
Stenotrophomonas maltophilia
Burkholderia cepacia
Explanation: Mucoid strains of P. aeruginosa are common in
persons with cystic fibrosis, causing insidious but progressive
respiratory deterioration, but are rarely encountered in other persons.
B. cepacia is an opportunist that rarely infects immunocompetent
persons but is common in persons with cystic fibrosis and causes an
acute respiratory syndrome with fever, leukocytosis, and progressive
respiratory failure. (See Chapters 188.1 and 188.2 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 107. A 12-yr-old boy with cystic fibrosis experiences an acute exacerbation and
is admitted for intravenous antibiotic therapy. Sputum culture reveals Pseudomonas
aeruginosa. The antibiotic recommended for treatment is:
Ampicillin-sulbactam
Ceftazidime
Explanation: Appropriate single agents for treatment of
Pseudomonas aeruginosa infection include ceftazidime,
cefoperazone, ticarcillin-clavulanate, and piperacillin-tazobactam.
Gentamicin or another aminoglycoside may be used concomitantly
for synergistic effect. (See Chapter 188.1 in Nelson Textbook of
Pediatrics, 17th ed.)
Cefotetan
Ceftriaxone
Ciprofloxacin
Question . 108. In which of the following patients, all age 10 yr, would isolation of
Pseudomonas aeruginosa from the sputum be likely?
Ceftazidime
Cefotaxime
Explanation: Cefotaxime does not provide coverage for
Pseudomonas aeruginosa. (See Chapter 188.1 in Nelson Textbook of
Pediatrics, 17th ed.)
Piperacillin/tazobactam
Ciprofloxacin
Ticarcillin/clavulanate
Question . 110. All of the following are means of transmission of Francisella tularensis
except:
Tick bite
Inhalation
Person-to-person spread
Explanation: F. tularensis, the cause of tularemia, can be
transmitted by many different modes, but person-to-person
transmission has not occurred. (See Chapter 189 in Nelson Textbook
of Pediatrics, 17th ed.)
Question . 111. All of the following have been shown to be routes of transmission for
tularemia except:
Person-to-person transmission
Explanation: Tularemia, an important zoonotic infection, is most
often acquired from a tick bite or directly from rabbits. Flies, fleas,
mosquitos, lice, and many animals (squirrels, beavers, birds) are
additional vectors. (See Chapter 189 in Nelson Textbook of Pediatrics,
17th ed.)
Gentamicin or streptomycin
Explanation: Gentamicin or streptomycin is the agent of choice for
treatment of tularemia. Chloramphenicol and third-generation
cephalosporins are associated with a high clinical failure rate. (See
Chapter 189 in Nelson Textbook of Pediatrics, 17th ed.)
Ceftriaxone or cefotaxime
Trimethoprim-sulfamethoxazole
Chloramphenicol
Vancomycin
Actinomyces
Bartonella henselae
Brucella
Explanation: A history of exposure to animals or ingestion of
unpasteurized dairy produces is helpful in the diagnosis of
brucellosis. (See Chapter 190 in Nelson Textbook of Pediatrics, 17th
ed.)
Francisella tularensis
Yersinia enterocolitica
Question . 114. A 16-yr-old boy is suspected of having legionellosis. Which of the following
is the most useful test for prompt diagnosis of Legionella pneumonia?
Question . 115. For the patient described in Question 114, the diagnostic test confirms
legionellosis. The recommended treatment for Legionella infection is drug therapy with:
Gentamicin or streptomycin
Ceftriaxone or cefotaxime
Trimethoprim-sulfamethoxazole
Erythromycin
Explanation: Erythromycin, with or without rifampin, has been
established empirically as effective therapy for legionellosis. The
newer macrolides (azithromycin and clarithromycin) and the
quinolones also have excellent activity in vitro. (See Chapter 191 in
Nelson Textbook of Pediatrics, 17th ed.)
Vancomycin
Systemic disease
Erythema nodosum
Oculoglandular syndrome of Parinaud
Explanation: The oculoglandular syndrome (conjunctivitis, lymph
node) is the most frequent atypical manifestation of cat-scratch
disease. (See Chapter 192.2 in Nelson Textbook of Pediatrics, 17th
ed.)
Neuroretinitis
Question . 117. All of the following statements regarding cat-scratch disease are true
except:
Question . 118. Which of the following is the characteristic incubation period for
development of cutaneous papules from Bartonella henselae after a cat bite or scratch?
<24 hr
Question . 119. All of the following statements concerning the symptomatology of cat-
scratch disease are true except:
Question . 120. A 3-yr-old presents to your office with a unilateral conjunctivitis that has
been present for 5 days. You palpate an enlarged preauricular node on the same side. She
has no history of recent travel, but her family did receive a kitten as a pet approximately 2
mo ago. The most likely etiologic agent responsible for her condition is:
Borrelia burgdorferi
Francisella tularensis
Bartonella henselae
Explanation: Bartonella henselae is the cause of Parinaud
oculoglandular syndrome (unilateral conjunctivitis accompanied by
preauricular lymphadenopathy). Direct inoculation of the eye,
perhaps by contaminated hands after contact with a cat, is the
presumed mode of spread. (See Chapter 192.2 in Nelson Textbook of
Pediatrics, 17th ed.)
Staphylococcus aureus
Toxoplasma gondii
Question . 121. A 5-yr-boy presents to your office with an enlarged axillary node that has
been present for 3 wk. He had visited the emergency department of a local hospital for the
same problem 2 wk ago and was prescribed a course of cephalexin. His family reports that
he took most of the prescribed doses, but with no change in the node. He initially had a
low-grade fever and fatigue, which has resolved. He has no known exposure to infection
although the family has 3 birds, 2 dogs, and 2 cats. Physical examination shows a large, 3-
cm left axillary node that is tender. There is no other lymphadenopathy or abnormalities
except for healing scratches on both arms. The most reasonable therapeutic approach
would be:
Question . 122. A family returns to your travel clinic after a three-week vacation to the
Peruvian Andes. Their 12-yr-old boy has become ill with fever, malaise, and a yellowish,
pale color. On physical examination, he is pale, tachycardic with mild icterus, and has
generalized lymphadenopathy. The most likely etiologic agent is:
Yersinia pestis
Rickettsia rickettsii
Bartonella bacilliformis
Explanation: Bartonellosis, caused by Bartonella bacilliformis, is
found only in the valleys of the Andes Mountains in Peru, Ecuador,
Colombia, Chile, and Bolivia. (See Chapter 192.1 in Nelson Textbook
of Pediatrics, 17th ed.)
Staphylococcus aureus
Salmonella
Penicillin G
Clindamycin
Question . 125. Which of the following findings on the history or physical examination
excludes a diagnosis of infant botulism?
Soft feces
Metabolic acidosis
Question . 126. A 2-mo-old infant is suspected of having infant botulism. Which is the best
means to confirm the diagnosis?
Lumbar puncture
CT scan
Muscle biopsy
Electromyography
Fecal specimen
Explanation: The diagnosis of botulism is unequivocally established
by demonstrating the presence of botulinum toxin in serum or of C.
botulinum toxin or organisms in wound material or feces. (See
Chapter 193 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 127. A 2-mo-old child is seen in your clinic for the first time. The child was born
at home, and this is the first well-child visit. Risk factors for infant botulism that should be
communicated to the parents include:
Gardening
Home construction
Frozen vegetables
Honey
Explanation: The one identified, avoidable source of botulinum
spores for infants is honey. Honey is an unsafe food for any child
younger than 1 yr of age. (See Chapter 193 in Nelson Textbook of
Pediatrics, 17th ed.)
Question . 128. An 18-yr-old adolescent presents to the emergency department with a nail
puncture wound of his foot. The injury occurred 1 hr ago in a school play yard. His wound
is cleansed and debrided. His last tetanus immunization was at age 12 yr, as confirmed in
his medical records. Which of the following measures is recommended?
TD
Td
DTaP
Question . 129. A 12-yr-old boy presents to the emergency department with a nail
puncture wound of his foot. The injury occurred 1 hr ago in a school play yard. His wound
is cleansed and debrided. His last tetanus immunization was at age 4 yr, as confirmed in
his medical records. Which of the following is recommended?
Td
Explanation: A tetanus toxoid booster (preferably Td) is given to all
persons with any wound if their tetanus immunization status is
unknown or incomplete. A booster is given to injured persons who
have completed their primary immunization series if (1) the wound is
clean and minor but more than 10 yr have passed since the last
booster, or (2) the wound is more serious and more than 5 yr have
passed since the last booster. With delayed wound care, active
immunization should be started at once. (See Chapter 194 and Table
194-1 in Nelson Textbook of Pediatrics, 17th ed.)
DTaP
Question . 130. An 12-yr-old boy presents to the emergency department with a nail
puncture wound of his foot. The injury occurred 1 hr ago in a school play yard. His wound
is cleansed and debrided. His parents came to the United States 4 yr ago from Mexico. He
has not had medical evaluation in the United States since, and his vaccination records from
childhood are not available, although his parents report that "all his childhood
immunizations were completed." Which of the following is recommended?
Td
Explanation: A tetanus toxoid booster (preferably Td) is given to all
persons with any wound if their tetanus immunization status is
unknown or incomplete. A booster is given to injured persons who
have completed their primary immunization series if (1) the wound is
clean and minor but more than 10 yr have passed since the last
booster, or (2) the wound is more serious and more than 5 yr have
passed since the last booster. With delayed wound care, active
immunization should be started at once. (See Chapter 194 and Table
194-1 in Nelson Textbook of Pediatrics, 17th ed.)
DTaP
Question . 131. A 15-yr-old white girl develops bloody diarrhea on her sixth day of
hospitalization for therapy of presumed bacterial pneumonia. She has been receiving
intravenous ampicillin. Her fever and tachypnea have resolved, and her oxygenation is now
normal. In fact, she was scheduled for discharge. Which of the following actions would be
most appropriate?
Discontinue ampicillin
Explanation: The first and essential step in treatment of Clostridium
difficile-associated diarrhea is the discontinuation of the current
antibiotics, if at all possible. In most instances this course combined
with appropriate fluid and electrolyte replacement is sufficient. (See
Chapter 195 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 133. All of the following are risk factors for Clostridium difficile-associated
diarrhea except:
Antibiotics that alter normal gut flora but do not affect growth of C.
difficile
Chemotherapy
Bowel surgery
Bowel stasis
Question . 134. A previously healthy 6-mo-old child who just completed antibiotic
treatment for acute otitis media and now is healthy and asymptomatic undergoes a stool
culture to check for antibiotic-associated diarrhea. The stool culture grows C. difficile. The
preferred antibiotic treatment is:
Oral clindamycin
Oral vancomycin
Intravenous vancomycin
Oral metronidazole
Question . 135. Which of the following best describes the pathogenesis of Clostridium
difficile-associated diarrhea?
Production of toxins
Explanation: Clostridium difficile strains may produce two toxins, A
and B. Both toxins are internalized and act within cells to modify
proteins, resulting in cell death. (See Chapter 195 in Nelson Textbook
of Pediatrics, 17th ed.)
Question . 136. All of the following may be clues to anaerobic infection except:
Sweet-smelling odor
Explanation: Anaerobic infections should be suspected with foul-
smelling pus, which is present in half of anaerobic infections. In
addition, the culture may be negative if the specimen is not handled
properly under anaerobic conditions. (See Chapter 196 in Nelson
Textbook of Pediatrics, 17th ed.)
Tissue necrosis
Question . 137. All of the following antimicrobials can provide good anti-anaerobic
coverage except:
Clindamycin
Cefoxitin
Meropenem
Gentamicin
Explanation: Antibiotics that are active against anaerobic organisms
include metronidazole, penicillins combined with -lactamase
inhibitors (ampicillin-sulbactam, ticarcillin-clavulanate, and
piperacillin-tazobactam), carbapenems (imipenem and meropenem),
clindamycin, cefoxitin, and chloramphenicol. Penicillin and
vancomycin are active against the gram-positive anaerobes. (See
Chapter 196 in Nelson Textbook of Pediatrics, 17th ed.)
Metronidazole
Question . 138. A 10-yr-old boy who presents with right lower quadrant pain is found to
have a ruptured appendix. Which of the following organisms are most likely to cause
postoperative infection in such cases?
Question . 139. In the patient described in Question 138, which of the following specimens
is most likely to yield the responsible pathogen?
Blood
Stool
Throat swab
Peritoneal fluid
Explanation: Rupture of the gut leads to spillage of gut flora into the
peritoneal cavity, and thus the peritoneal fluid is the best source for a
culture specimen. Anaerobic bacteremia is uncommon but may
occur. (See Chapter 196 in Nelson Textbook of Pediatrics, 17th ed.)
Urine
Question . 140. Which of the following infections is most likely to involve anaerobes?
Neonatal meningitis
Tubo-ovarian abscess
Explanation: Pelvic inflammatory disease and tubo-ovarian
abscesses are frequently due to mixed aerobes and anaerobes. (See
Chapter 196 in Nelson Textbook of Pediatrics, 17th ed)
Pharyngitis
Otitis media
Paronychia
Question . 141. A 9-yr-old child is found to have a positive PPD test result on routine
screening. There are no symptoms. Laboratory tests, including chest film, are normal.
Which of the following is the best interpretation of this finding?
Question . 142. In the child described in Question 141, the risk of developing clinical and
radiographic evidence of tuberculosis without institution of therapy is:
<1%
5-10%
Explanation: Without appropriate treatment, 5-10% of asymptomatic
persons with M. tuberculosis infection will experience disease in the
future. (See Chapter 197 in Nelson Textbook of Pediatrics, 17th ed.)
50%
90-95%
Almost 100%
Question . 144. A true statement concerning the 5-unit PPD skin test for tuberculosis is:
Question . 145. A 3-yr-old child in whose mother tuberculosis was just diagnosed has a
positive PPD skin test result. A chest film shows a localized, nonspecific infiltrate in the
peripheral segments of the right lower lobe. The most appropriate course of action to
confirm the diagnosis of tuberculosis disease in this child is:
Culture of sputum
Question . 147. All of the following statements concerning isoniazid are true except:
Question . 148. The recommended treatment for active pulmonary tuberculosis in children
is:
Isoniazid for 9 mo
Isoniazid and rifampin for 6 mo, with ethambutol during the first 2 mo
Question . 149. A 2-wk-old neonate experiences high fever, severe respiratory distress,
and hepatomegaly. The chest film shows a fine, nodular infiltrate throughout both lungs,
and congenital tuberculosis is suspected. All of the following are expected additional
findings in this newborn except:
Meningitis
Hepatitis
Treat the mother and isolate her from the newborn until she has been
treated for 2 wk.
Treat the mother and isolate her from the newborn until she has three
consecutive negative sputum smears and cultures.
Treat the mother; no isolation is necessary.
Treat the mother and treat the infant with isoniazid and rifampin for 6
mo, with pyrazinamide during the first 2 mo; no isolation is
necessary.
Treat the mother and treat the infant with isoniazid until the
mother is sputum culture-negative for 3 mo; no isolation is
necessary.
Explanation: Isoniazid therapy for newborns has been so effective
that separation of the mother and infant is no longer mandatory
unless the mother is ill enough to require hospitalization or is
expected not to adhere to her treatment regimen. (See Chapter 197 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 151. The form of leprosy characterized by a single large lesion that slowly
enlarges, heavy cellular infiltration in the dermis, destruction of the cutaneous nerve fibers,
a vigorous and specific cell-mediated immune response, and granulomas composed of
epithelioid cells and lymphocytes, but few or absent bacilli, is:
Lepromatous leprosy
Explanation: Tuberculoid and lepromatous leprosy constitute the
ends of the spectrum of leprosy. Tuberculoid leprosy responds well to
treatment, but complete resolution may take 8-12 mo. Response of
lepromatous leprosy to therapy may take 2-5 yr. (See Chapter 198 in
Nelson Textbook of Pediatrics, 17th ed.)
Borderline leprosy
Tuberculoid leprosy
Question . 152. The disease associated most frequently with atypical mycobacteria in
children is:
Cellulitis
Lymphadenitis
Explanation: Lymphadenitis of the superior or anterior cervical or
submandibular areas is the most frequent manifestation of atypical
mycobacterial infections in children. (See Chapter 199 in Nelson
Textbook of Pediatrics, 17th ed.)
Skeletal infections
Pneumonia
Question . 153. The recommended treatment for cervical lymphadenitis caused by atypical
mycobacteria is:
Isoniazid and rifampin for 6 mo, with pyrazinamide during the first 2
mo
Question . 154. Which of the following therapeutic options is the optimal method to
manage symptomatic nontuberculous mycobacterial lymphadenitis?
Question . 155. A 16-yr-old adolescent developed a nontender, solitary nodule that slowly
enlarged over several weeks. It began at the site of an abrasion that he incurred while
cleaning his fish aquarium. The most likely infecting organism in this case is:
Sporothrix schenckii
Mycobacterium avium complex
Mycobacterium marinum
Explanation: "Swimming pool granuloma" or "fish tank granuloma" is
caused by M. marinum and develops after inoculation of the
organism at the site of a minor abrasion. (See Chapter 199 in Nelson
Textbook of Pediatrics, 17th ed.)
Mycobacterium leprae
Question . 156. Which of the following serologic patterns is most consistent with
successful treatment of primary syphilis in an adolescent 2 yr previously?
Question . 157. In a newborn whose mother was treated for syphilis during pregnancy, all
of the following are risk factors for congenital syphilis except:
Question . 158. A full-term male newborn whose mother had reactive Venereal Disease
Research Laboratory (VDRL) and microhemagglutination assay-Treponema pallidum
(MHA-TP) results at the time of delivery was evaluated. He was anemic and had
thrombocytopenia and mild hepatomegaly. He also had a desquamative skin rash
consistent with congenital syphilis. His CSF was clear, with 5 white blood cells (WBCs), 0
RBCs, protein of 80 mg/dL, and glucose of 49 mg/dL; the CSF VDRL result was
nonreactive. Based on this examination, which of the following is true?
Question . 159. A sexually active adolescent who has never been treated for syphilis is
found to have a negative result on a VDRL test and a positive result on an MHA-TP. The
most likely explanation is:
Primary syphilis
Secondary syphilis
Latent syphilis
Lyme disease
Explanation: There is limited cross-reactivity of the treponemal test
(MHA-TP, FTA-ABS) material with other spirochetes. Only T.
pallidum and Borrelia burgdorferi, the causative organism of Lyme
disease, are endemic in the United States. Th nontreponemal tests
(VDRL, RPR) are uniformly nonreactive in Lyme disease. (See
Chapter 200 in Nelson Textbook of Pediatrics, 17th ed.)
False-negative results on VDRL testing
Question . 160. The radiologist calls to report that a plain x-ray that you ordered to
evaluate a hip-click shows periostitis. This finding suggests congenital infection by which of
the following agents?
Toxoplasma gondii
Syphilis
Explanation: Periostitis, occurring in the long bones, is most typical
of congenital syphilis. Osteochondritis is a common finding in
congenital cytomegalovirus, rubella, and syphilis infections. (See
Chapter 200 in Nelson Textbook of Pediatrics, 17th ed.)
Parvovirus B19
Question . 161. A sexually active adolescent who lives in a rural area with contact with
farm animals presented 1 wk ago with an acute febrile illness associated with headache,
emesis, and myalgias, which all resolved briefly. He now returns with hematuria,
proteinuria, hepatomegaly, and icterus. Which diagnosis is most likely?
Relapsing fever
Leptospirosis
Explanation: A biphasic course is characteristic of icteric
leptospirosis (Weil syndrome). Hepatorenal dysfunction follows
anicteric leptospirosis in less than 10% of cases. (See Chapter 202 in
Nelson Textbook of Pediatrics, 17th ed.)
Infection mononucleosis
Question . 162. A 6-yr-old child is brought to your office because a tiny tick was found and
removed from his forearm. The parents are unsure how long the tick had been attached,
although they thought that it probably had not been there for more than 1 day. They live in
an area in which Lyme disease is common. The next step in the proper treatment of this
patient should be to:
Question . 163. The preferred agent for treatment of Lyme disease in a child 13 yr of age
is:
Doxycycline
Amoxicillin
Explanation: Doxycycline (for 14-21 days) is the treatment of choice
for Lyme borreliosis in children older than 8 yr of age, but amoxicillin
(for 14-21 days) is the treatment of choice in children younger than 8
yr. Where effective alternatives are available, children younger than 8
yr should not be treated with doxycycline because it may cause
permanent discoloration of the teeth. Erythromycin is an alternative
for persons who cannot take either doxycycline or amoxicillin. (See
Chapter 204 in Nelson Textbook of Pediatrics, 17th ed.)
Ceftriaxone
Erythromycin
Trimethoprim-sulfamethoxazole
Question . 164. A 4-yr-old boy is brought to your office because of a circular reddish rash
on the right side of his chest. The child has been afebrile and has had no other systemic
symptoms. The rash is not pruritic. The child's parents state that they have recently
returned from a vacation in Massachusetts on Cape Cod and that a small tick had been
removed from the same area where the rash is now. The only abnormality on the
examination is the circular, flat, erythematous rash, which is about 6 cm in diameter and is
not tender. The most appropriate next step in treating this patient is to:
Question . 165. The mother of a 5-yr-old boy notices a new "mole" on her child's neck.
Upon closer inspection, she realizes that it is actually a small tick. She removes it with
tweezers and brings both the tick and the child to your office. They live in northern
Westchester County, New York, in a house surrounded by woods. She is not sure how
long the tick might have been on the child. The most appropriate next step in management
would be to:
Reassure the mother and order a serologic test for antibodies against
B. burgdorferi on the child in 1 mo.
Question . 166. A 13-yr-old boy comes to your office with a chief complaint of fatigue and
intermittent arthralgia and headache for 8 mo. His mother is concerned about Lyme
disease (they live in Connecticut and she recently heard a lecture about Lyme disease at
the public library). She denies any stress at home or at school. There has been no weight
loss. She has not seen any ticks on her son, although he does spend time outdoors. The
child is quiet and answers your questions in monosyllables. Findings on physical
examination are entirely normal, with no evidence of synovitis. The most appropriate next
step in management would be to:
Reassure the mother and order a serologic test for antibodies against
B. burgdorferi.
Reassure the mother and explain that the child is completely normal.
Reassure the mother and explain why it is very unlikely that her
child has Lyme disease in the absence of any objective findings.
Explanation: There is no evidence of Lyme disease. It would be
advisable to discuss other possible non-organic causes for the
symptoms. (See Chapter 204 in Nelson Textbook of Pediatrics, 17th
ed.)
Question . 167. A 10-yr-old boy comes to your office with a chief complaint of facial nerve
palsy. He lives in an area of New Jersey in which Lyme disease is endemic but has not had
any recognized tick bites. He has never had fever blisters or cold sores. He has been
afebrile and otherwise asymptomatic. On physical examination, there is a large (8-cm)
erythematous annular rash on his upper back and a unilateral peripheral palsy of the facial
nerve. The neck is supple, and the child appears otherwise well. The most appropriate next
step in management would be to:
question . 168. You have just diagnosed erythema migrans in a 14-yr-old boy. His parents
are concerned about his prognosis because of Lyme disease in a cousin that seems to be
untreatable. Which of the following is the most accurate characterization of the prognosis
for Lyme disease?
Lyme disease is difficult to treat and may require therapy with the
same antibiotic for several months.
Amoxicillin or ampicillin
Gentamicin or kanamycin
Trimethoprim-sulfamethoxazole
Question . 170. An 18-yr-old sexually active boy complains of penile discomfort and
dysuria that has developed slowly over the past 12 days. Physical examination reveals a
scanty, mucoid white urethral discharge. A Gram stain is most likely to reveal:
Question . 171. For the patient described in Question 170, which of the following is a
recommended treatment?
Azithromycin
Explanation: Nongonococcal urethritis in adolescents and adults is
treated with azithromycin (1 g PO as a single dose) or doxycycline
(100 mg bid PO for 7 days). Sexual partners should also be treated
to avoid recurrent disease. (See Chapter 206 in Nelson Textbook of
Pediatrics, 17th ed.)
Cefotetan
Ceftriaxone
Gentamicin
Question . 172. A 2-mo-old infant presents with conjunctivitis, tachypnea, and a mild
cough. There is no fever. Physical examination reveals the presence of crackles bilaterally.
The most likely etiologic agent is:
Influenza virus
Parainfluenza virus
Adenovirus
Chlamydia trachomatis
Explanation: C. trachomatis infection is characterized by insidious
onset of persistent cough and tachypnea, with the notable absence of
fever. Rales are common, but wheezes are uncommon, which helps
distinguish C. trachomatis from RSV pneumonia. (See Chapter 208.3
in Nelson Textbook of Pediatrics, 17th ed.)
Fever
Explanation: C. trachomatis pneumonia is not associated with fever.
(See Chapter 208.3 in Nelson Textbook of Pediatrics, 17th ed.)
Conjunctivitis
Cough
Tachypnea
Eosinophilia
Question . 175. A 15-yr-old boy presents to your office with complaint of fever, malaise,
headache, cough, and shortness of breath. A chest radiograph reveals left upper and lower
lobe infiltrates. His WBC count is elevated. He states that he recently received a pet
cockatiel that became ill and died. The most likely diagnosis is:
Mycoplasma pneumonia
Pneumococcal pneumonia
Psittacosis
Explanation: Psittacosis, a bird-borne chlamydial disease, produces
severe pneumonia with systemic manifestations similar to those of
Mycoplasma pneumoniae or Legionnaires' disease. (See Chapter 209
in Nelson Textbook of Pediatrics, 17th ed.)
Q fever
Legionnaires' disease
Question . 176. The most appropriate next step in diagnosis for the case described in
Question 175 is:
Blood culture
Throat culture
Serologic testing
Explanation: Culture is of poor value, but serologic studies are the
diagnostic tests of choice for psittacosis. (See Chapter 209 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 177. All of the following laboratory findings are suggestive of Rocky Mountain
spotted fever except:
Reticulocytopenia
Explanation: Early laboratory clues to Rocky Mountain spotted fever
include normal to slightly low leukocyte count, a shift to the left
(increased bands), thrombocytopenia, and low serum sodium. (See
Chapter 210.1 in Nelson Textbook of Pediatrics, 17th ed.)
Thrombocytopenia
Question . 178. An 8-yr-old child presents with headache, fever, anorexia, and myalgias
with onset 3 days ago, now accompanied by a petechial rash that is prominent on the
extremities, including the palms and soles (Figure). The most likely diagnosis is:
Infective endocarditis
Meningococcemia
Question . 179. The recommended agent for treatment of Rocky Mountain spotted fever in
a child younger than 8 yr is:
Ceftriaxone
Chloramphenicol
Doxycycline
Explanation: Chloramphenicol and tetracyclines have proven
efficacy against Rocky Mountain spotted fever, but chloramphenicol
may be associated with higher mortality. Dental staining is unlikely
with a single course of a tetracycline. Doxycycline is recommended
because the risk of dental staining is less than with other
tetracyclines. (See Chapter 210.1 in Nelson Textbook of Pediatrics,
17th ed.)
Clindamycin
Quinidine
Question . 180. All of the following may be characteristic of Rocky Mountain spotted fever
except:
Ceftriaxone
Chloramphenicol
Doxycycline
Explanation: Unlike with Rickettsia rickettsii, the cause of Rocky
Mountain spotted fever, chloramphenicol is not effective against
Ehrlichia spp. Dental staining is unlikely with a single course of a
tetracycline. Doxycycline is recommended because the risk of dental
staining is less than with other tetracyclines. (See Chapter 213 in
Nelson Textbook of Pediatrics, 17th ed.)
Clindamycin
Quinidine
Question . 182. A 5-yr-old boy has had fever, headache, abdominal pain, and muscle
aches for the preceding 3 to 4 days. His temperature is 103.4°F, heart rate is 130/min, and
respiratory rate is 40/min. He appears acutely ill and dehydrated. He has no rash. His
family had recently been camping in rural Wisconsin, but there is no history of tick bite.
Laboratory findings include WBC count of 2,300/mm3, 24% segmented neutrophils, 65%
bands, and 8% lymphocytes, and platelet count of 57,000/mm3. The AST level is 465 IU/L.
A peripheral blood smear reveals small blue clusters of bacteria-like bodies in an
aggregate within the cytoplasm of 1% of circulating mononuclear leukocytes. The most
likely diagnosis is:
Meningococcemia
Staphylococcal septicemia
Rocky Mountain spotted fever
Ehrlichiosis
Explanation: Human ehrlichiosis is a rickettsial multisystem illness,
which may be accompanied by a rash. It is endemic and probably is
more common than reported. (See Chapter 213 in Nelson Textbook of
Pediatrics, 17th ed.)
Hemolytic-uremic syndrome
Question . 183. A 17-yr-old adolescent who works on his family's sheep ranch presents in
August with an influenza-like illness with interstitial pneumonitis. There is no history of a
tick bite. Laboratory tests reveal leukopenia and elevated serum transaminase levels.
Which of the following pathogens is the most likely cause of this illness?
Bartonella henselae
Leptospira
Coxiella burnetii
Explanation: Acute Q fever is transmitted by inhalation of infectious
aerosols; arthropod vectors are rarely implicated in human cases.
(See Chapter 214 in Nelson Textbook of Pediatrics, 17th ed.)
Ancylostoma
Echinococcus
Question . 184. What is the most appropriate next step in diagnosis for the case described
in Question 183?
Blood culture
Throat culture
Serologic testing
Explanation: The diagnosis of Q fever is most easily confirmed
serologically by testing acute and convalescent sera (2-4 wk apart),
which should show a fourfold increase in indirect fluorescent antibody
titers to phase I and phase II antigens. (See Chapter 214 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 185. Which of the following is the most significant risk factor for fungal sepsis in
a premature infant?
Meconium aspiration
Postconceptional age
Question . 186. The recommended treatment of a central line infection due to Candida is:
Amphotericin B therapy
Flucytosine therapy
Question . 188. The microbiology laboratory calls to report that an organism has been
detected in a blood culture, and the rapid germ tube test is positive. Which of the following
organisms has been identified?
Aspergillus
Candida albicans
Explanation: Candida albicans is the only species that forms a germ
tube when suspended in rabbit or human serum and incubated for 1-
2 hr. (See Chapter 215 in Nelson Textbook of Pediatrics, 17th ed.)
Candida krusei
Cryptococcus
Malassezia furfur
Question . 189. An otherwise healthy 5-yr-old girl presents with focal back pain of insidious
onset. Her father is a pigeon fancier, and the child helps him care for the pigeons. Her past
medical history is also remarkable for an episode of "bronchitis" 1 yr ago. A plain film of the
back reveals destruction of the T8 vertebral body. The most likely diagnosis is:
Aspergillosis
Blastomycosis
Cryptococcosis
Explanation: Pigeon breeders and laboratory personnel who work
with Cryptococcus are at greatest risk for cryptococcosis. (See
Chapter 216 in Nelson Textbook of Pediatrics, 17th ed.)
Histiocytosis
Histoplasmosis
Question . 190. The use of intravenous lipids predisposes most significantly to catheter-
related infections and fungemia due to which of the following organisms?
Aspergillus
Candida albicans
Cryptococcus
Histoplasma
Malassezia furfur
Explanation: Catheter-related infections and fungemia with
Malassezia furfur occur almost exclusively in patients receiving
intravenous lipids. The use of lipid emulsions containing medium-
chain triglycerides inhibits the growth of Malassezia. (See Chapter 217
in Nelson Textbook of Pediatrics, 17th ed.)
Question . 191. A newborn in the NICU is intubated and on total parenteral nutrition,
including lipid emulsions. A blood culture yields Malassezia furfur. The most important
element of treatment for this infection is:
Intravenous itraconazole
Intravenous amphotericin B
Oral fluconazole
Question . 192. A 17-yr-old boy with cystic fibrosis develops recurrent bronchospasm and
transient pulmonary infiltrates. Laboratory testing reveals mycelia in the sputum, and a
peripheral eosinophilia. The most likely causative organism is:
Burkholderia cepacia
Stenotrophomonas maltophilia
Aspergillus
Explanation: Allergic bronchopulmonary aspergillosis complicates
chronic pulmonary disease in approximately 10% of persons with
cystic fibrosis. (See Chapter 218.1 in Nelson Textbook of Pediatrics,
17th ed.)
Histoplasma
Malassezia furfur
Question . 193. All of the following are requirements for the diagnosis of allergic
bronchopulmonary aspergillosis except:
Asthma
Peripheral eosinophilia
Question . 194. A 16-yr-old boy is brought to your office for a second opinion. He was well
until 2 wk ago when he developed a fever and cough. He was seen at a local urgent care
center, where a chest film demonstrated focal calcifications throughout both lungs with
some hilar calcifications noted bilaterally. A 5 U PPD placed at that time was negative;
Candida controls were positive. His history is remarkable for an episode of "bronchitis" 2 yr
ago following a spelunking adventure in Kentucky. The most likely diagnosis is:
Aspergillosis
Blastomycosis
Cryptococcosis
Histiocytosis
Histoplasmosis
Explanation: Histoplasma capsulatum thrives in soil rich in nitrates
such as areas heavily contaminated with bird droppings, and with bat
guano in caves and along bridges frequented by bats. (See Chapter
219 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 195. Which of the following organisms is the most likely cause of fungal
pneumonia in immunocompetent persons living in the Ohio and Mississippi River valleys?
Aspergillus
Blastomyces dermatitidis
Coccidioides immitis
Cryptococcus neoformans
Histoplasma capsulatum
Explanation: H. capsulatum is found in the soil throughout the
Midwestern United States. Blastomyces is found in the same areas
but is less common except in the northern Midwestern states (e.g.,
Wisconsin). (See Chapter 219 in Nelson Textbook of Pediatrics, 17th
ed.)
Question . 196. An adolescent with a history of spelunking presents with weight loss,
fatigue, dyspnea, and fever of onset 2 wk previously. Chest film shows evidence of
pneumonia. The most likely causative organism is:
Aspergillus
Blastomyces dermatitidis
Coccidioides immitis
Cryptococcus neoformans
Histoplasma capsulatum
Explanation: H. capsulatum thrives in soil rich in nitrates such as
areas heavily contaminated bat guano, in caves and along bridges
frequented by bats. (See Chapter 219 in Nelson Textbook of
Pediatrics, 17th ed.)
Question . 197. The most likely cause of fungal pneumonia in immunocompetent persons
living in arid areas of California, Arizona, and southwestern Texas is:
Aspergillus
Blastomyces dermatitidis
Coccidioides immitis
Explanation: C. immitis is found in arid areas of California's San
Joaquin Valley (Valley fever), central and southern Arizona, and
southwestern Texas. (See Chapter 221 in Nelson Textbook of
Pediatrics, 17th ed.)
Cryptococcus neoformans
Histoplasma capsulatum
Question . 198. A 4-yr-old girl develops nodular lymphangitis after being bitten by a cat.
The most likely etiologic agent is:
Aeromonas hydrophila
Mycobacterium marinum
Nocardia brasiliensis
Pasteurella multocida
Sporothrix schenckii
Explanation: Sporothrix thrives in decaying vegetation but also can
be transmitted by bites and scratches of animals, most frequently
cats and armadillos. (See Chapter 223 in Nelson Textbook of
Pediatrics, 17th ed.)
Question . 199. Which of the following statements concerning measles virus is true?
There is no vector
Question . 200. All of the following vaccines may be given to children with severe
combined immunodeficiency syndrome except:
Diphtheria, tetanus, pertussis (DTaP) vaccine
Pneumococcal vaccine
Question . 201. Which of the following statements concerning measles and vitamin A is
true?
Question . 202. All of the following are characteristic manifestations of congenital rubella
syndrome except:
Snuffles
Explanation: Congenital rubella affects virtually all organ systems.
Snuffles is a sign of congenital syphilis. (See Chapter 226 in Nelson
Textbook of Pediatrics, 17th ed.)
Arthritis
Meningoencephalitis
Explanation: Meningoencephalitis is the most common complication
of mumps in childhood, but appears to occur in more than two-thirds
of cases, with clinical symptoms in more than 10% of cases. (See
Chapter 227 in Nelson Textbook of Pediatrics, 17th ed.)
Myocarditis
Orchitis
Pancreatitis
Question . 204. A 14-yr-old boy and his twin sister each developed mumps. Their parents
had repeatedly declined for them to receive MMR vaccination. They ask about the
prognosis for this disease in their children, especially the possibility of infertility. Which of
the following statements most accurately describes the relationship between mumps and
infertility?
Question . 205. The percentage of poliovirus infections that are inapparent is:
5-10%
20-25%
50%
75-80%
90-95%
Explanation: Approximately 90-95% of poliovirus infections are
inapparent, causing no paralytic disease and no sequelae. (See
Chapter 228 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 206. Most infections with poliovirus result in illness that is best characterized
as:
Subclinical illness
Explanation: Approximately 90-95% of poliovirus infections are
inapparent, causing no paralytic disease and no sequelae. (See
Chapter 228 in Nelson Textbook of Pediatrics, 17th ed.)
Aseptic meningitis
Paralytic poliomyelitis
Question . 207. Which of the following features distinguishes paralytic polio from Guillain-
Barré syndrome?
Question . 208. All of the following statements concerning the risk of vaccine-associated
paralytic poliomyelitis (VAPP) are true except:
The risk is higher after the second and third doses than after the
first dose
Explanation: Vaccine-associated paralytic poliomyelitis (VAPP),
which follows reversion of the OPV strain to a neurovirulent strain,
has accounted for all cases of polio in the United States since 1979.
The risk is higher in vaccinees than in contacts, after the first dose,
and in immunocompromised persons. (See Chapters 228 and 282 in
Nelson Textbook of Pediatrics, 17th ed.)
The risk for VAPP in the United States has exceeded the risk for wild-
type polio since 1979
Question . 209. A 5-yr-old boy who lives in an urban area is hospitalized because of low-
grade fever, flaccid paralysis of both legs, sensory changes, and absent ankle deep tendon
reflexes. The child received only two immunizations with OPV, at the ages of 2 and 6 mo.
The most probable diagnosis is:
Vaccine-associated poliomyelitis
Guillain-Barré syndrome
Explanation: Guillain-Barré syndrome, or autoimmune peripheral
neuropathy, is symmetric and involves sensory but more so motor
nerves. Polio is an anterior horn cell disease and is purely motor.
(See Chapter 229 in Nelson Textbook of Pediatrics, 17th ed.)
Tick-bite paralysis
Question . 210. All of the following may be manifestations of enterovirus infection except:
Aseptic meningitis
Herpangina
Aphthous stomatitis
Explanation: Infections due to enteroviruses have a wide spectrum
of clinical manifestations. Herpangina is usually caused by echovirus
type 9. Hand-foot-and-mouth disease is usually caused by
coxsackievirus A16. Diarrhea is probably less common than is
taught. (See Chapter 229 in Nelson Textbook of Pediatrics, 17th ed.)
Oral administration
Question . 212. Which of the following factors is associated with increased risk of
enterovirus infection?
Young age
Explanation: Factors associated with increased incidence and/or
severity of enterovirus infection include young age, male sex, poor
hygiene, overcrowding, and low socioeconomic status; >25% of
symptomatic enterovirus infections occur in children younger than 1
yr of age. Breast-feeding reduces the risk of infection in infants. (See
Chapter 229 in Nelson Textbook of Pediatrics, 17th ed.)
Breast-feeding
Question . 214. All of the following are infections typically caused by enteroviruses except:
Neonatal sepsis
Osteomyelitis
Explanation: Although more than 60 different serotypes of
enteroviruses have been identified, 11 account for the majority of
disease. No enterovirus disease is uniquely associated with any
specific serotype; however, certain manifestations are preferentially
associated with specific serotypes. Osteomyelitis is not associated
with enteroviruses. (See Chapter 229 in Nelson Textbook of
Pediatrics, 17th ed.)
Myocarditis
Meningitis
They are much less common than infections due to herpes simplex
virus and cytomegalovirus
Question . 217. Which of the following statements regarding the diagnosis of enterovirus
infections is true?
Question . 218. All of the following may be manifestations of parvovirus B19 infection
except:
Arthritis
Reticulocytopenia
Question . 220. All of the following statements regarding herpes simplex virus (HSV)
infections in neonates are true except:
Women with primary HSV genital tract infection are more likely to
transmit infection to their offspring than women with recurrent HSV
infection
Most cases are transmitted at delivery and are not true congenital
infections
Question . 221. Recommended management for a mother with active genital HSV
infection during labor is:
Staphylococcus aureus
Mucocutaneous candidiasis
Coxsackievirus
Adenovirus
Question . 223. A 13-mo-old previously healthy child presents on New Year's Eve with a
2-day history of fever, lethargy, and irritability. Earlier this afternoon he began to have
twitching movements of his left arm and on the left side of his face. His immunizations are
up-to-date. Physical examination reveals fever with a temperature of 39°C and left-sided
weakness, with no rashes. Examination of the cerebrospinal fluid (CSF) reveals 70
WBCs/mm3 with 85% lymphocytes, 400 RBCs/mm3, protein of 140 mg/dL, glucose 80
mg/dL, and negative results on Gram stain. MRI scan reveals right temporal abnormalities.
The diagnostic study most likely to identify a treatable illness in a timely fashion is:
Question . 224. For the patient described in Question 223, the most appropriate empirical
therapy to begin while awaiting definitive diagnosis is:
Ceftriaxone
Acyclovir
Explanation: The focal seizure, focal physical findings, the CSF
profile, and temporal lobe lesion on MRI are highly suggestive of
herpes simplex virus encephalitis. Acyclovir must be included in the
initial treatment. (See Chapter 231 in Nelson Textbook of Pediatrics,
17th ed.)
Amphotericin B
Question . 225. Most infants with localized neonatal herpes encephalitis become
symptomatic at the age of:
0-2 days
2-8 days
8-12 days
Explanation: Localized skin, eye, and mouth infection and also
disseminated infection occur at a mean of 5-6 days post partum,
whereas localized CNS infection occurs later at a mean of 8-12 days
post partum. (See Chapter 231 in Nelson Textbook of Pediatrics, 17th
ed.)
13-21 days
Question . 226. At 6 mo after stem cell transplantation, a 4-yr-old boy has had several
episodes of recurrent oral herpes simplex virus infection, each responsive to episodic
acyclovir treatment. For the past 2 wk he has been experiencing progressive oral and lip
lesions that have spread to his face and neck, in spite of first oral and then high-dose
intravenous acyclovir. The viral culture is positive for herpes simplex virus. The most
appropriate treatment to begin during the wait for results of further studies on the virus is:
Valacyclovir
Famciclovir
Ganciclovir
Foscarnet
Explanation: The repeated antiviral treatment of herpes simplex
virus disease in an immunocompromised person promotes the
development of resistant HSV. Foscarnet should be used during the
wait for results of viral susceptibility testing. (See Chapter 231 in
Nelson Textbook of Pediatrics, 17th ed.)
Gamma interferon
Addition of amphotericin
Addition of vancomycin
Addition of ribavirin
Addition of acyclovir
Explanation: The history, inability to confirm bacterial infection, and
worsening clinical condition are suggestive of neonatal herpes
simplex virus infection. Acyclovir therapy should be initiated. Repeat
cerebrospinal fluid analysis or MRI might also be recommended.
(See Chapter 231 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 228. An otherwise healthy 16-yr-old high school wrestling star presents with a
6-mo history of a recurrent vesicular eruption on one side of his face. He has no other
history of unusual infections and is HIV negative. His immunizations are appropriate for his
age, and he has never had chickenpox. The most likely diagnosis is:
Shingles
Traumatic candidiasis
Question . 229. A 10-mo-old girl is presented in January with a 2-day history of fever with
temperatures to 103.5°F and refusal to eat. Physical examination reveals a temperature of
40°C, general irritability, and numerous ulcers on the anterior portion of her buccal
mucosa, gums, and tongue. Appearance of the throat is unremarkable. There are bilateral
tender enlarged cervical lymph nodes. The recommended therapeutic agent is:
Acyclovir
Explanation: The fever, irritability, and mucosal ulcerations suggest
acquired herpes simplex virus infection. Acyclovir therapy is the
treatment of choice. (See Chapter 231 in Nelson Textbook of
Pediatrics, 17th ed.)
Azithromycin
Nystatin
Penicillin
Pleconaril
Question . 231. A 12-yr-old girl develops varicella. Her parents ask about the risk for
herpes zoster. Which of the following statements regarding herpes zoster is/are true?
Increasing age and altered cell-mediated immunity are risk factors for
herpes zoster
Question . 232. A 2-yr-old healthy girl presents to your office for the first time. She was
seen by another physician 2 wk ago and was told at that time that she was behind in her
immunizations. Review of available records confirms that she has still not received varicella
vaccine. All of the following are contraindications to varicella vaccine except:
Question . 233. Which of the following sets of serologic titers is most consistent with acute
primary Epstein-Barr virus infection?
Question . 234. All of the following tumors are associated with Epstein-Barr virus except:
Burkitt lymphoma
Kaposi sarcoma
Explanation: EBV is associated with several malignancies, including
nasopharyngeal carcinoma, Burkitt lymphoma, Hodgkin disease, and
lymphoproliferative diseases and leiomyosarcomas in
immunocompromised persons. Kaposi sarcoma is associated with
HHV-8. (See Chapter 233 in Nelson Textbook of Pediatrics, 17th ed.)
Leiomyosarcoma
Nasopharyngeal carcinoma
Question . 235. All of the following organisms are recognized as potential causes of an
infectious mononucleosis-like syndrome except:
Cytomegalovirus
Epstein-Barr virus
Parvovirus B19
Explanation: Infectious mononucleosis-like illnesses may also be
caused by primary infection with cytomegalovirus, T. gondii,
adenovirus, hepatitis virus, HIV, and possibly rubella virus. (See
Chapter 233 in Nelson Textbook of Pediatrics, 17th ed.)
Toxoplasma gondii
Visual loss
Hearing loss
Explanation: Sensorineural hearing loss is a risk after asymptomatic
congenital CMV infection. The incidence of neonatal CMV-positive
urine is much greater than the incidence of symptomatic neonatal
CMV inclusion disease (e.g., microencephaly, retinitis, being small for
gestational age, petechiae). (See Chapter 234 in Nelson Textbook of
Pediatrics, 17th ed.)
Cirrhosis
Immunoglobulin deficiency
Question . 238. Which of the following newborns is at greatest risk for symptomatic
cytomegalovirus (CMV) infection?
Question . 239. An 18-yr-old male patient is followed in the infectious diseases clinic for
human immunodeficiency virus infection. His most recent CD4 lymphocyte count is
97/mm3. Over the last week he has developed increasing dyspnea and coughing, visual
changes, diarrhea, and fever. You suspect that cytomegalovirus infection is responsible for
these symptoms. Which of the following laboratory tests would be most helpful in
establishing the diagnosis?
Glycoprotein H epitopes
Perinatal listeriosis
Question . 241. The patient described in Question 240 is discharged from the neonatal
intensive care unit at 9 mo of age. His discharge diagnoses include chronic lung disease,
cerebral palsy, a seizure disorder, resolved necrotizing enterocolitis, and retinopathy of
prematurity. Because of the infection that was present at birth, the primary care physician
should regularly order which of the following screening tests?
Lymphocyte subsets
Neural imaging
Platelet counts
Acyclovir and CMV IVIG constitute the regimen of choice for life-
threatening CMV infections
Explanation: Ganciclovir combined with immune globulin, either
standard intravenous immunoglobulin (IVIG) or hyperimmune CMV
IVIG, has been used to treat life-threatening CMV infections in
immunocompromised hosts (e.g., bone marrow, heart, and kidney
transplant recipients and patients with AIDS). (See Chapter 234 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 243. The peak incidence of HHV-6 infection is seen in which of the following
age groups?
Children 0-5 yr
Explanation: Approximately 60-90% of children 12 mo of age and
80-100% of children 3-5 yr of age have antibodies to HHV-6. Most
newborns are seropositive as a result of transplacental transfer of
maternal antibodies. (See Chapter 235 in Nelson Textbook of
Pediatrics, 17th ed.)
Children 5-10 yr
Children 10-15 yr
Question . 244. A 7-mo-old child presents in late October with 3 days of fever with
temperatures to 103.5°F, a mildly injected pharynx, mild cervical lymphadenopathy, and
diarrhea. The child has been behaving normally and eating well and has no other
symptoms. On the fourth day of the illness the fever resolves, and a generalized measles-
like rash appears 12 hr later. The child appears normal on physical examination. The most
likely diagnosis is:
Measles
Rubella
HHV-6 infection
Explanation: HHV-6 is the agent of roseola (erythema subitum), the
childhood exanthem present in the infant described in the question.
(See Chapter 235 in Nelson Textbook of Pediatrics, 17th ed.)
Enteroviral infection
Question . 245. For the patient described in Question 244, the most appropriate next step
in management would be to:
Administration of acyclovir
Administration of ganciclovir
Administration of famciclovir
Administration of foscarnet
Question . 247. A 2-yr-old child of an African mother is noted to have poor weight gain,
with development of Pneumocystis carinii pneumonia (PCP), oral candidiasis, and
cutaneous Kaposi sarcoma lesions. Further evaluation reveals that the child is HIV
seropositive, with an HIV viral load of 100,000 copies/mL and a CD4 cell count of 150
cells/ L. Treatment for PCP and candidiasis is initiated. The most appropriate next step in
management of the Kaposi sarcoma lesions would be:
Surgical excision
Combination chemotherapy
Local radiation
Pneumonia
Otitis media
Reye syndrome
Hemolytic-uremic syndrome
Explanation: Otitis media and pneumonia, either viral or bacterial,
are common complications of influenza in children. Reye syndrome
may follow influenza, usually if salicylates are given for antipyresis,
which is why salicylates are not recommended for persons with
influenza or flulike illnesses. (See Chapter 237 in Nelson Textbook of
Pediatrics, 17th ed.)
Acute myositis
Question . 249. A 4-yr-old child is brought to your clinic for well child care. Indications for
influenza vaccine include all of the following except:
Question . 250. Which of the following is true concerning rimantadine and amantadine for
treatment of influenza?
Question . 251. Patient groups that should be targeted for annual influenza vaccination
include:
quastion . 252. A 5-mo-old boy and an 18-mo-old girl, both healthy, are presented to your
office in November for physical examination prior to entry to daycare. Which of the
following is true concerning the recommendation for influenza vacation of these children?
Influenza vaccine is recommended for the 5-mo-old but not the 18-
mo-old
Question . 253. A 4-yr-old child has an acute illness with coryza, barky cough,
hoarseness, and anorexia. There is no fever, and lower respiratory tract findings are
normal. The most likely etiologic agent is:
Influenza virus
Parainfluenza virus
Explanation: Parainfluenza viruses account for approximately half of
cases of croup and, unlike influenza virus and RSV infections, are not
usually associated with fever or lower respiratory tract symptoms.
(See Chapter 238 in Nelson Textbook of Pediatrics, 17th ed.)
Calicivirus
Adenovirus
Question . 254. Following your request for a plain x-rays of the neck of a 2-yr-old child, the
radiologist calls you to report finding a steeple sign. The most likely etiologic agent is:
Influenza virus
Parainfluenza virus
Explanation: The steeple sign is visible on an anteroposterior
radiograph of the neck. It is the progressive narrowing of the
subglottic region that has the appearance of a tall, tapering church
steeple. It is a sign of the subglottic edema that is typical of croup,
which is most frequently caused by parainfluenza viruses. (See
Chapter 238 in Nelson Textbook of Pediatrics, 17th ed.)
Adenovirus
Chlamydia trachomatis
Question . 255. A 7-mo-old infant has rhinorrhea, cough, audible wheezes, and chest
retractions. There is a low-grade fever and irritability. The most likely etiologic agent is:
Influenza virus
Parainfluenza virus
Adenovirus
Chlamydia trachomatis
Conjunctivitis
Acute diarrhea
Question . 258. Hemorrhagic cystitis, conjunctivitis, pneumonia, and diarrhea all have
been linked to:
Respiratory syncytial virus
Adenovirus
Explanation: Adenovirus 11 or 21 is probably the cause. (See
Chapter 240 in Nelson Textbook of Pediatrics, 17th ed.)
Rhinovirus
Parainfluenza virus
ICAM-1
Explanation: ICAM-1 (intercellular adhesion molecule 1) is present
on the epithelium covering the lymphoepithelium of the adenoids and
other epithelial cells of the nose and is the cell receptor for most
rhinoviruses. (See Chapter 241 in Nelson Textbook of Pediatrics, 17th
ed.)
CD23
IL-10
IFN-
Question . 260. All of the following viruses may be associated with gastroenteritis except:
Rotavirus
Polyomavirus
Explanation: Rotaviruses, astrovirus, adenoviruses, and
caliciviruses (e.g., Norwalk virus) are the medically important
pathogens of human viral gastroenteritis. (See Chapter 242 in Nelson
Textbook of Pediatrics, 17th ed.)
Astrovirus
Adenovirus
Calicivirus
Laryngeal papillomatosis
Condylomata acuminata
Cervical cancer
Question . 262. Which of the following statements regarding treatment for papillomavirus
infection is true?
Question . 263. Which of the following statements concerning eastern equine encephalitis
is true?
Question . 264. This morning an 8-yr-old boy experienced the abrupt onset of fever,
irritability, and headache, followed by lethargy, confusion, seizures, and coma. He had
accompanied his parents on a picnic and boating outing in the saltwater marshes along the
New Jersey coastline 1 wk earlier, on September 3. The peripheral white blood cell count
demonstrates a marked leukocytosis. Which of the following is the most likely diagnosis?
Meningococcal meningitis
Tuberculous meningitis
Lyme disease
Question . 265. A 4 yr-old boy attends the clinic with a minor upper respiratory tract
infection. During the interview the mother tells you that the family shortly will leave the
United States for several years' residence in northern Thailand. His vaccinations are up to
date for his age. What is your recommendation with regard to travel immunization?
Question . 266. An 8-yr-old girl presents with high fever of 5 days' duration, cool
extremities, a rapid and weak pulse, and a petechial rash. Pulse pressure is less than 20
mm Hg, and a small effusion is detected in the right pleural space. The child lived in
Thailand for 2 yr prior to immigrating to the United States and has just returned from
Thailand after visiting to see her grandparents. The most likely diagnosis is:
Hepatitis A
Relapsing fever
Typhoid fever
Yellow fever
Question . 267. All of the following are typical symptoms of dengue fever except:
Headache
Arthralgias
Question . 268. All of the following may be features of dengue hemorrhagic fever except:
Hypoalbuminemia
Thrombocytopenia (<=100,000/mm3)
Fever
Question . 269. A 16-yr-old female high school student is seen for pretravel counseling.
Departing next month with a group of classmates, she will spend 7 days on a bird-watching
excursion in the Amazonian portion of Peru. Your recommendation with regard to travel
immunization is:
Yellow fever
Borreliosis
Question . 271. Which of the following is a risk factor for hantavirus pulmonary syndrome
caused by Sin Nombre virus?
Tick bites
Mosquito bites
Contaminated food
Question . 272. A child suffers a provoked bite from a stray dog that was captured by
animal control and appears healthy. The most appropriate action would be to:
Confine and observe the dog for 10 days for signs suggestive of
rabies
Explanation: Healthy dogs, cats, and ferrets should be held for a 10-
day observation. Postexposure prophylaxis for rabies should be
given to the bitten person at the first sign of rabies in the animal,
which should be euthanized immediately and tested. (See Chapter 251
in Nelson Textbook of Pediatrics, 17th ed.)
Submit the dog's head for examination for rabies
Question . 273. Which of the following describes the recommended use of HRIG for
postexposure rabies prophylaxis in the United States?
Administer one half of the HRIG dose at the exposure site and the
remainder at another site intramuscularly, always with rabies vaccine
Administer one half of the HRIG dose at the exposure site and the
remainder at another site intramuscularly, with rabies vaccine for
high-risk bites
Question . 274. Animals that should be regarded in the United States as rabid include:
Bats
Explanation: Bats, skunks, raccoons, foxes, and most other
carnivores should be regarded as rabid unless the animal is proved
rabies-negative by laboratory testing. Bites of squirrels, hamsters,
guinea pigs, gerbils, chipmunks, rats, mice, other small rodents,
rabbits, and hares almost never require prophylaxis; local public
health officials should be consulted. (See Chapter 251 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 275. An 18-yr-old patient with AIDS develops motor weakness, visual field
defects, and speech and cognitive impairment with dementia, confusion, and personality
change. The most likely etiologic agent is:
Pneumocystis carinii
Cryptococcus
Cytomegalovirus
JC virus
Explanation: Progressive multifocal leukoencephalopathy (PML) is
caused by JC virus. More than half of cases occur in HIV-infected
individuals. (See Chapter 252 in Nelson Textbook of Pediatrics, 17th
ed.)
Question . 276. All of the following are features of prion proteins except:
Question . 277. All of the following statements regarding the spongiform encephalopathies
are true except:
Creutzfeldt-Jakob disease (CJD) is the most common human
spongiform encephalopathy
Question . 278. All of the following statements regarding HIV gp120 are true except:
It is a transmembrane glycoprotein
It is highly immunogenic
Question . 280. An HIV-seropositive woman comes to her physician for advice because
she is pregnant. She has never been on any antiviral medication because she has
remained healthy without symptoms of AIDS. However, she wonders whether antiviral
treatment might diminish the likelihood of fetal HIV infection. Which of the following
statements regarding such treatment is correct?
Question . 281. All of the following statements about HIV infection are true except:
Question . 282. Mechanisms responsible for vertical transmission of HIV infection include:
Breast-feeding
Question . 284. All of the following statements concerning HIV infection are true except:
Question . 285. All of the following statements concerning treatment of HIV infection are
true except:
Question . 286. Which of the following infants born to HIV-infected mothers should receive
prophylaxis for Pneumocystis carinii?
Infants with a positive result on HIV culture, DNA or RNA PCR assay,
or p24 antigen assay
Antiretroviral therapy
Question . 289. The rate of transmission of maternal HIV infection to offspring without any
antiretroviral treatment is:
1%
4%
12-30%
Explanation: Most large studies in the United States and Europe
have documented vertical transmission rates in untreated women of
12-30%. Transmission rates in Africa and Haiti are higher (25-52%).
(See Chapter 254 in Nelson Textbook of Pediatrics, 17th ed.)
50-60%
70-90%
Question . 290. The role of elective cesarean section in preventing perinatal HIV
transmission can best be described as:
Question . 291. Factors that may affect the perinatal HIV transmission rate include:
Preterm delivery
Question . 292. All of the following statements regarding infection with human T-cell
lymphotrophic virus type I (HTLV-I) are true except:
Question . 293. An 8-yr-old child presents with meningitis and encephalitis of acute onset
in late summer after swimming in a pond of stagnant water. The most likely etiology is:
Mucor infection
Naegleria infection
Explanation: Naegleria organisms are found in many freshwater
sources, including ponds, lakes, and stagnant pools. Therapy is often
difficult, and morbidity and mortality are high. (See Chapter 256 in
Nelson Textbook of Pediatrics, 17th ed.)
Malaria
Question . 294. Which of the following statements concerning Naegleria infection of the
central nervous system is true?
Question . 296. A 4-yr-old child presents with colicky abdominal pain, blood-stained
diarrhea, and tenesmus, all of acute onset. There is no fever. Trophozoites are seen in the
stool. The family has recently returned from a trip to Mexico. The most likely etiologic agent
is:
Giardia lamblia
Entamoeba dispar
Entamoeba histolytica
Explanation: The highest incidence of amebic colitis caused by
Entamoeba histolytica is in children 1-5 yr of age. E. dispar is
associated only with an asymptomatic carrier state. Giardia lamblia
does not cause bloody colitis. Amebiasis is uncommon in temperate
climates. (See Chapter 257 in Nelson Textbook of Pediatrics, 17th ed.)
Naegleria
Cryptosporidium
Question . 297. All of the following statements concerning the treatment of Entamoeba
histolytica amebiasis are true except:
Serologic testing
Explanation: The clinical presentation suggests amebic abscess.
The diagnosis is established by the characteristic CT or MRI findings
and positive serologic results for antibodies to Entamoeba. (See
Chapter 257 in Nelson Textbook of Pediatrics, 17th ed.)
Swimming pools
Mountain streams
Food
question . 300. All of the following statements concerning the treatment of Giardia lamblia
infections are true except:
Question . 301. All of the following are spore-forming intestinal protozoans except:
Giardia lamblia
Explanation: G. lamblia is a flagellated protozoan. (See Chapter 259
in Nelson Textbook of Pediatrics, 17th ed.)
Cryptosporidium parvum
Isospora belli
Cyclospora cayetanensis
Microsporidia
Question . 303. An 18-mo-old boy who attends out-of-home daycare develops intermittent
watery diarrhea. There is no blood present in the stool, and there is no fever. Several of the
other toddlers and adult workers in the center have also had diarrhea, but the daycare staff
report that most have had negative bacterial stool cultures. The most appropriate next step
in diagnosis would be to:
Request bacterial stool culture and also routine ova and parasite
testing
Question . 304. A sexually active adolescent girl presents with copious malodorous yellow
vaginal discharge with vulvovaginal irritation. The most likely etiologic agent is:
Candida albicans
Trichomonas vaginalis
Explanation: Trichomoniasis is characterized by copious
malodorous vaginal discharge, vulvovaginal irritation, dysuria, and
dyspareunia. (See Chapter 260 in Nelson Textbook of Pediatrics, 17th
ed.)
Giardia lamblia
Haemophilus ducreyi
Enterobius vermicularis
Question . 306. Which of the following Plasmodium species causes the most severe form
of malaria and is associated with the highest fatality rate?
P. falciparum
Explanation: P. falciparum malaria is the most severe form and
carries fatality rates of 25-35% in untreated persons. (See Chapter 264
in Nelson Textbook of Pediatrics, 17th ed.)
P. malariae
P. ovale
P. vivax
None of the above: all malaria species are similar in disease severity
Question . 307. The most useful method for the diagnosis of malaria is:
Question . 308. A 12-yr-old girl who recently visited Haiti with her family presents with
signs suggestive of cerebral malaria. She did not take malaria prophylaxis. The
confirmatory procedure that should be performed immediately is:
Question . 309. A child who returned 2 wk ago from equatorial Africa is admitted to the
hospital in a coma, with high fever and a palpable spleen. The liver is not enlarged.
Laboratory studies reveal hypoglycemia, but the cerebrospinal fluid is normal. The most
likely diagnosis is:
Pancreatic neoplasm
Pneumococcal meningitis
Falciparum malaria
Explanation: Malaria is the first diagnosis to be considered in this
patient, who had the unfavorable prognostic features of
hypoglycemia and coma. (See Chapter 264 in Nelson Textbook of
Pediatrics, 17th ed.)
Visceral leishmaniasis
Question . 310. All of the following are recognized routes of malaria transmission except:
Blood transfusion
Mosquito bite
Out-of-home daycare
Explanation: Malaria is transmitted principally via blood mosquito
bites, but has also been transmitted by blood transfusion,
contaminated needles, and vertical transmission. (See Chapter 264 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 311. A 13-yr-old adolescent boy presents with unexplained febrile illness. He
had traveled to India with his parents 6 mo previously, and both he and his parents confirm
complete adherence to the prescribed malaria prophylaxis regimen. Which of the following
is true concerning the need for investigation for malaria as the cause of his illness?
Question . 312. The use of quinidine gluconate should be considered in any child
experiencing malaria associated with:
Neurologic dysfunction
Pulmonary edema
Begin prophylaxis with any fever while traveling, and seek medical
attention immediately
Question . 314. A 19-yr-old boy in Rhode Island presents with high fever, chills, and
myalgias. He recalls a tick bite about 2 wk previously, and you consider a diagnosis of
babesiosis. Which of the following methods is useful to establish this diagnosis?
Question . 315. For the patient described in Question 314, the recommended treatment is:
Ceftriaxone with or without streptomycin
Ciprofloxacin
Erythromycin
Tetracycline
Question . 316. All of the following statements concerning congenital toxoplasmosis are
true except:
Question . 317. Which of the following causes of congenital infections is associated with
cats?
Cytomegalovirus
Rubella
Toxoplasma gondi
Explanation: Cats ingest Toxoplasma oocysts in infected meat or
from the feces of other infected cats. Cats that are strictly kept
indoors, maintained on prepared diets, and not fed fresh, uncooked
meat should not contact encysted T. gondii or shed oocysts.
Pregnant women who are seronegative for T. gondii should avoid
contact with cat feces. (See Chapter 266 in Nelson Textbook of
Pediatrics, 17th ed.)i
Syphilis
Parvovirus B19
Question . 318. Toxoplasma gondii may be acquired by all of the following means except:
Question . 319. Which is the most common result of primary Toxoplasma gondii infection
in children?
Cellulitis
Lymphadenitis
Meningitis
Pneumonia
No specific symptoms
Explanation: Most immunologically normal children who acquire T.
gondii have no clinically recognizable disease. (See Chapter 266 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 320. Toxoplasmosis causes all of the following patterns of disease except:
Question . 321. A pregnant woman, at 15 wk of gestation, brings her 5-yr-old son for
evaluation of fever and cervical lymphadenopathy. The lymph nodes are nontender and
have not suppurated. The child was given a new kitten 3 mo ago that frequently caught
mice in their barn. The child and the mother regularly cleaned the kitten's litter pan
together, and gardened and played in the backyard sandbox, where the kitten also
defecated. All of the following diagnostic tests to identify family members with or at risk for
toxoplasmosis are indicated except:
Question . 322. An infant is born small for gestational age at 34 wk of gestation with a
"blueberry muffin" rash, hepatosplenomegaly, 100,000 platelets/mm3, 15% eosinophils,
and 10% atypical lymphocytes. His serum has a Sabin Feldman dye test titer of 1:4096. All
of the following may be helpful in establishing the diagnosis of congenital toxoplasmosis for
this infant except:
Serum amylase
Explanation: Serologic tests are the best means to confirm infection
with T. gondii. (See Chapter 266 in Nelson Textbook of Pediatrics,
17th ed.)
Question . 323. All of the following statements concerning Pneumocystis carinii infections
are true except:
Question . 323. All of the following statements concerning Pneumocystis carinii infections
are true except:
Question . 324. Patients who should receive prophylaxis for Pneumocystis carinii
pneumonia include those with:
X-linked agammaglobulinemia
Congenital neutropenia
Question . 326. A 5-yr-old boy with AIDS and who is receiving zidovudine, lamivudine, and
ritonavir presents with rapid respiratory rate and progressive dyspnea of 2 days' duration.
There is no fever. The chest radiograph reveals bilateral diffuse alveolar disease. The most
important diagnostic test would be:
Fansidar
Pentamidine isethionate
Explanation: The recommended therapy for P. carinii pneumonia is
trimethoprim-sulfamethoxazole administered intravenously, or orally if
there is mild disease and no malabsorption or diarrhea. For patients
who cannot tolerate or fail to respond to trimethoprim-
sulfamethoxazole after 5-7 days, pentamidine isethionate may be
used. (See Chapter 267 in Nelson Textbook of Pediatrics, 17th ed.)
Trimethoprim-sulfamethoxazole
Dapsone
Question . 328. A previously healthy 7-yr-old girl living in rural South Carolina presents
with a 1-wk history of fever, cough, and shortness of breath. Her temperature is 37.5oC,
pulse 80/min, respiratory rate 30 breaths/min, and blood pressure 95/60 mm Hg. Chest film
reveals bilateral pulmonary infiltrates. The complete blood count is normal except for
eosinophilia. Which of the following organisms is the most likely cause of the patient's
illness?
Trichuris trichiura
Ascaris lumbricoides
Explanation: The presentation is characteristic of L ffler syndrome,
caused by Ascaris lumbricoides. (See Chapter 268 in Nelson Textbook
of Pediatrics, 17th ed.)
Enterobius vermicularis
Mycobacterium tuberculosis
Streptococcus pneumoniae
Question . 329. A 6-yr-old girl who was previously healthy presents with a 1-wk history of
nocturnal perianal itching. There are no other symptoms, and findings on physical
examination are normal. The most appropriate therapy is:
Question . 330. An 8-yr-old boy from Tennessee received a liver transplant 6 mo ago and
is on corticosteroids and azathioprine. He presents to the emergency department with a 2-
day history of cough and wheezing. Hemoptysis was observed within the previous 12 hr. A
stool specimen is most likely to reveal which of the following microorganisms?
Salmonella enteritidis
Histoplasma capsulatum
Toxocara canis
Pneumocystis carinii
Strongyloides stercoralis
Explanation: This is a characteristic presentation of hyperinfection
syndrome with Strongyloides stercoralis. (See Chapter 272 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 331. A 4-yr-old boy who recently moved from Puerto Rico to a northern city in
the continental United States presents with a 1-wk history of fever and malaise. Physical
examination is notable for temperature 38.5oC, pulse 130/min, respiratory rate 22
breaths/min, blood pressure 100/60 mm Hg, and hepatomegaly. Laboratory findings
include a white blood cell count of 60,000/mm3 with 66% eosinophils. His past history
includes extensive use of community playground facilities. The most likely diagnosis is:
Eosinophilic gastroenteritis
Question . 332. A child presents with several days of increasing myalgias, especially while
chewing and with breathing, and fever. There is a history of eating undercooked meat.
Laboratory testing shows 8% eosinophilia. The most likely etiologic agent is:
Trichuris trichiura
Trichinella spiralis
Explanation: In trichinosis, migrating larvae of Trichinella spiralis
cause symptoms of fever and myalgias and elicit an eosinophilic
response. (See Chapter 276 in Nelson Textbook of Pediatrics, 17th
ed.)
Strongyloides stercoralis
Toxocara canis
Ascaris lumbricoides
Question . 333. A 13-yr-old girl presents with a 1-wk history of fever, myalgias, and
periorbital edema. She emigrated with her family from a rural area of China to the United
States 4 wk ago. A communal meal that included a locally butchered pig was part of the
family's farewell party. Her 16-yr-old brother had similar symptoms, which have now
resolved. The most likely cause of the patient's condition is:
Typhoid fever
Trichuriasis
Cysticercosis
Trichinosis
Explanation: This is a characteristic presentation of trichinosis,
caused by Trichinella spiralis. (See Chapter 276 in Nelson Textbook of
Pediatrics, 17th ed.)
Question . 334. The 12-yr-old son of diplomat parents presents with crampy abdominal
pain, fever, migratory arthralgias, and hepatosplenomegaly. During the past 5 yr his family
has lived in the Philippines, Kampuchea, Senegal, and Mali. Ultrasound examination of his
abdomen shows periportal fibrosis consistent with schistosomiasis. His kidneys and
bladder are normal. Which of the following schistosome species is unlikely to be the cause
of his illness?
Schistosoma mansoni
Schistosoma japonicum
Schistosoma intercalatum
Schistosoma haematobium
Explanation: Schistosoma haematobium is not endemic to the areas
visited. It also does not affect the portal circulation, preferring the
ureteral and bladder veins. (See Chapter 277 in Nelson Textbook of
Pediatrics, 17th ed.)
Schistosoma mekongi
Question . 335. The most useful test for diagnosis of neurocysticercosis is:
Serologic testing
Stool examination
Rapid antigen testing
Question . 336. In S o Paulo, Brazil, a head CT study was performed on a 9-yr-old boy for
evaluation of headache following a fall. The CT shows a single calcified lesion in the left
hemisphere. On physical examination, the boy's headache is noted to increase on
standing, and he has poor coordination and intention. The most appropriate next step in
management would be to:
Perform MRI
Administer albendazole
Explanation: The cyst stage of T. solium infection (cysticercosis)
comes from ingestion of eggs excreted by infected humans and
cannot be directly related to pigs. (See Chapter 280 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 337. A mother and son from a Midwestern community, who have never traveled
outside of the United States or Canada, were found to have cysticercosis. The four other
household members have normal findings on imaging studies. To establish the source of
this infection and the risk to others in the community, the single best investigation would be
to:
Check pork in the grocery and meat stores frequented by the family
Examine the stool of anyone who has prepared meals for the family.
Question . 338. A 15-yr-old girl wishes to play soccer in school and needs medical
clearance. On physical examination, her liver edge is palpable and seems minimally
enlarged. Ultrasonography of the liver shows one cyst approximately 3 cm in diameter. Her
menstruation is normal. Results on serologic testing for Echinococcus and hepatitis are
negative, and liver enzyme values are normal. She has lived her whole life in Salt Lake
City, Utah, and has never traveled abroad. The most important factor in allowing her to play
this sport is:
Question . 339. Praziquantel is effective in the treatment of all of the following infections
except:
Hydatid cysts
Explanation: Hydatid disease (echinococcosis) does not respond to
praziquantel, probably due to failure to penetrate the liver cyst.
Except for Fasciola hepatica, all other trematode and cestode
infections (flukes and tapeworms) will respond to praziquantel. (See
Chapter 281 in Nelson Textbook of Pediatrics, 17th ed.)
Cysticercosis
Schistosomiasis
Date of administration
Site of administration
Explanation: The National Childhood Vaccine Injury Act requires
that, for vaccines mandated in childhood, health care providers
document the date of administration, manufacturer, lot number, and
name of the health care provider administering the vaccine. (See
Chapter 282 in Nelson Textbook of Pediatrics, 17th ed.)
Manufacturer
Lot number
Question . 341. Vaccines against the same infectious agent but produced by different
manufacturers are considered interchangeable with the exception of:
Hepatitis A vaccines
Hepatitis B vaccines
Question . 342. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
should be administered to healthy children at which ages?
2 and 4 mo and 1-6 yr
History of thrombocytopenia
Question . 344. Preterm, low birthweight infants should be vaccinated at the same
chronological age as for full-term infants and in accordance with the routine childhood
immunization schedule, with the following exception:
DTaP
Pneumococcal conjugate
Hepatitis B
Explanation: Preterm infants, including those of very low birthweight,
should be vaccinated at the same chronological age as for full-term
infants and according to the routine childhood immunization
schedule. One exception to this recommendation is hepatitis B
vaccination of those born of HBsAg-negative mothers with low
birthweights (i.e., <2 kg). Initiation of vaccination in this case should
be delayed until the infant is 1 mo of age. (See Chapter 282 in Nelson
Textbook of Pediatrics, 17th ed.)
IPV
Question . 345. For which of the following infections is an immune globulin product
available that is a monoclonal antibody?
Tetanus
Hepatitis B
Varicella
Hepatitis A
Measles vaccination
Mumps vaccination
Rubella vaccination
Question . 349. All of the following are risk factors for hospital-acquired infection except:
Surgical procedures
Foley catheters
Intravascular catheters
Immunizations
Explanation: Immunizations are not a risk factor for hospital-
acquired infections. (See Chapter 283 in Nelson Textbook of
Pediatrics, 17th ed.)
Antibiotic therapy
Question . 350. The most common route of transmission of nosocomial infection is:
Hands
Explanation: Transmission of infectious agents occurs by various
routes, but by far the most common and important route is via the
hands. (See Chapter 283 in Nelson Textbook of Pediatrics, 17th ed.)
Needle stick
Food
Water
Question . 351. You are asked to investigate an outbreak among children with profuse
watery diarrhea in a daycare center. Likely etiologic agents that you should consider
include all of the following except:
Cryptosporidium parvum
Giardia lamblia
Rotavirus
Ascaris lumbricoides
Explanation: Ascaris is not a known cause of daycare-associated
diarrheal epidemics, but choices A-C are. (See Chapter 284 in Nelson
Textbook of Pediatrics, 17th ed.)
Calicivirus
Question . 352. All of the following infections are readily transmissible among children
attending child daycare except:
Cytomegalovirus infection
Rhinoviral infections
Pharyngitis
Question . 1. A blonde, blue-eyed girl was admitted at 2.5 mo of age with severe
emesis to rule out pyloric stenosis. She had poor development, eczema, and a
musty odor. The most likely diagnosis is:
Wiskott-Aldrich syndrome
Galactosemia
Cystinosis
Phenylketonuria
Explanation: This is a classic picture of phenylketonuria
(PKU). Fair complexion, eczema, emesis, and mental
retardation are common features. The musty-mousy odor is
phenylacetate, a metabolic by-product of the blocked pathway
due to deficiency of phenylalanine hydroxylase. (See Chapter
74 in Nelson Textbook of Pediatrics, 17th edition.)
Biotinidase deficiency
Microcephaly
Mental retardation
Cataracts
Explanation: Adults who have the autosomal recessive
disease PKU are at risk for mild to moderate neurointellectual
problems if they are on an unrestricted diet. If a woman with
poorly controlled PKU becomes pregnant, her high
phenylalanine levels will be reflected in the fetus, who is at risk
for congenital heart disease, microcephaly, and developmental
delay. The baby will also be a carrier. (See Chapter 74 in
Nelson Textbook of Pediatrics, 17th edition.)
Hepatic carcinoma
Coagulopathy
Hepatomegaly
Mental retardation
Iridodonesis
Ectopia lentis
Short arms
Explanation: This autosomal recessive disorder, due to a
deficiency of cystathionine synthase activity, resembles Marfan
syndrome. Treatment with vitamin B6 is helpful in the subgroup
of patients who are responsive. (See Chapter 74 in Nelson
Textbook of Pediatrics, 17th edition.)
Scoliosis
Hartnup disease
Phenylketonuria
Homocystinuria
Galactosemia
Question . 6. A 6-wk-old girl has had feeding problems, hypotonia, and emesis for 3
wk. During the last week she developed an erythematous exfoliative generalized
rash and partial alopecia. Laboratory data reveal metabolic acidosis, ketosis, and
hyperammonemia. The most likely diagnosis is:
Acrodermatitis enteropathica
Phenylketonuria
Pellagra
Vitamin B1 deficiency
Biotin
Explanation: Treatment with biotin will result in rapid
improvement. Biotin is an important cofactor for the four-
carboxylase enzymes in this disorder. (See Chapter 74 in
Nelson Textbook of Pediatrics, 17th edition.)
Vitamin B1
Vitamin B6
Vitamin B12
Ascorbic acid
Question . 8. A 2-day-old boy manifests poor feeding, vomiting, and lethargy leading
to coma. Laboratory data reveal respiratory alkalosis and hyperammonemia. The
urine orotic acid level is also elevated. The most likely diagnosis is:
Methylmalonic acidemia
Galactosemia
Reye syndrome
Question . 9. An 8-mo-old girl is brought to your office with the complaint that she
has developmental delay. Her head is enlarged, and she feeds poorly and does not
focus. You examine the baby and find her hypotonic and unable to sit. She has
considerable head lag, and her head circumference is above the 95th percentile.
Which of the following diseases would you consider in the diagnosis?
Birth asphyxia
Familial hydrocephalus
Canavan disease
Explanation: Answers B, D, and E are possibilities, but the
presence of visual problems and a large head suggest
Canavan disease. The poor vision is due to optic atrophy in this
autosomal recessive disorder, seen most often in Ashkenazi
Jews. (See Chapter 74 in Nelson Textbook of Pediatrics, 17th
edition.)
Hurler disease
Question . 10. At the age of 1 yr, a patient is brought to you with increased
spasticity, which was not present at birth or at 6 mo of age. The patient has a large
head circumference, above the 95th percentile, and an MRI shows diffuse white
matter disease. Which of the following tests would be most likely to be relevant in
this case?
Thyroid profile
Hypoketotic hypoglycemia
Cardiomyopathy
Explanation: Muscle weakness or cardiomyopathy is not seen
in medium-chain acyl-CoA deficiency (MCAD). This disorder is
the most common disorder of fatty acid oxidation defects and is
best treated by avoiding prolonged periods of fasting or
catabolic states. (See Chapter 75 in Nelson Textbook of
th
Pediatrics, 17 edition.)
Carnitine deficiency
Usher syndrome
Familial hypercholesterolemia
Polygenic hyperlipidemia
Unknown
Dysbetalipoproteinemia
Question . 16. A 15-yr-old girl is found to have an LDL-C level of 191 mg/dL;
triglyceride, 50 mg/dL; HDL-C, 41 mg/dL; and total cholesterol, 242 mg/dL. The
child's father had a heart attack at age 45 yr. He takes one of the so-called statin
medications (HMG-CoA reductase inhibitor), and wants his daughter to be given the
same medication. How do you respond?
Question . 18. A 5-yr-old child has a paternal grandmother who had a heart attack
at the age of 45 yr. The child's father has hypercholesterolemia and takes
medication to lower his cholesterol level. How should the child be screened?
Psychomotor retardation
Angiokeratomata
Hepatosplenomegaly
Frontal bossing
Peripheral neuropathy
Explanation: This lethal lipidosis disorder is a progressive
neurovisceral storage disease that has some features similar to
those of some severe mucopolysaccharidoses. In addition to
dysmorphic features (coarsened facies), deafness, blindness,
seizures, and hepatosplenomegaly occur. (See Chapters 74.4
and 74.5 in Nelson Textbook of Pediatrics, 17th edition.)
Question . 20. A 4-mo-old girl presents with developmental delay, an exaggerated
startle response to loud noise, and macrocephaly. On physical examination, the
child has decreased eye contact and a cherry red spot in each retina. The most
likely diagnosis is:
GM2 gangliosidosis
Explanation: Also known as Tay-Sachs disease, this lethal
autosomal recessive lipidosis manifests with progressive
neurologic deterioration. There is no treatment, but prenatal
diagnosis is possible. (See Chapters 74.4 and 74.5 in Nelson
Textbook of Pediatrics, 17th edition.)
Gaucher disease
Fabry disease
Galactosemia
Question . 21. A 15-yr-old presents with chronic fatigue and severe bone pain of 1
year's duration. He has hepatosplenomegaly and a normal retinal examination.
Laboratory studies reveal normocytic anemia and thrombocytopenia. Radiographs of
the distal femur reveal Erlenmeyer flask deformities. The most likely diagnosis is:
Lymphoma
Gaucher disease
Explanation: This is a classic presentation for type I Gaucher
disease, a lipidosis most commonly seen in Ashkenazi Jews.
The central nervous system is not involved, but bone pain and
hematologic problems can be severe. Treatment is effective
with recombinant enzyme replacement infusions and is quite
successful. (See Chapters 74.4 and 74.5 in Nelson Textbook of
Pediatrics, 17th edition.)
Sandhoff disease
GM3 gangliosidosis
Acroparesthesias
Corneal opacities
Cardiomyopathy
Mental retardation
Explanation: This X-linked disorder causes severe debilitating
pain but no mental retardation. Treatment is effective with
recombinant enzyme replacement therapy. (See Chapters 74.4
and 74.5 in Nelson Textbook of Pediatrics, 17th edition.)
Angiokeratomas
Question . 23. A 14-mo-old girl presents with irritability, poor walking, genu
recurvatum, and hypotonia.
Metachromatic leukodystrophy
Explanation: This is the classic preservation of metachromatic
leukodystrophy (MLD), an autosomal recessive disorder with no
treatment. The patient's condition deteriorates progressively.
Metachromatic granules may be seen in the urine as well as
sural nerve biopsies. (See Chapters 74.4 and 74.5 in Nelson
Textbook of Pediatrics, 17th edition.)
I cell disease
GM3 gangliosidosis
Fabry disease
Hyperinsulinemia
Adrenal insufficiency
Mitochondrial disorder
Question . 25. A 6-day-old breast-fed infant has had poor feeding and vomiting
since birth. On physical examination, he is jaundiced, has hepatomegaly, and shows
excessive bruising. Laboratory investigations show elevated transaminase levels,
prolonged clotting time, and aminoaciduria. Galactosemia is suspected; however,
urine-reducing substance is negative. What is the most appropriate next step in
diagnosis?
Liver biopsy
Kidney biopsy
Question . 26. A 17-yr-old boy has a history of recurrent episodes of exercise
intolerance with muscle cramps. He is otherwise healthy and well. Which of the
following is most likely to develop during these episodes in this patient?
Myoglobinuria
Explanation: The history is compatible with muscle
glycogenosis. With decreased ability to release glucose from
muscle glycogen, myocyte injury occurs and places the patient
at risk for myoglobinuria and renal failure. (See Chapter 76 in
Nelson Textbook of Pediatrics, 17th edition.)
Abnormal liver function
Aminoaciduria
Cardiac arrhythmia
Metabolic acidosis
IV glucose
Oral Polycose
Oral Pedialyte
Oral fructose
Explanation: Fructose must first be converted to glucose
within the hepatocyte. Under normal circumstances, the
intermediary metabolite, glucose-6-phosphate, will then be
released to the circulation after enzymatic conversion to
glucose by hepatic glucose-6-phosphatase. This enzyme is
deficient or missing in this form of glycogen storage disease.
(See Chapter 76 in Nelson
Question . 28. A 5-mo-old infant with gross motor delay, hypotonia, and
cardiomegaly has a creatine kinase level of 860 IU/L. Of the following, which is the
most likely diagnosis?
Hypothyroidism
Prader-Willi syndrome
Pompe disease
Explanation: Pompe disease is a glycogen storage disease
that affects the heart and skeletal muscle. Cardiac involvement
causes heart failure and a shortened P-R interval on the ECG.
Treatment with recombinant enzyme replacement has shown
promise in the management of Pompe disease. (See Chapter
76 in Nelson Textbook of Pediatrics, 17th edition.)
Down syndrome
Hepatosplenomegaly
Coarse facies
Dysostosis multiplex
X-linked inheritance
Explanation: All the mucopolysaccharidoses are inherited as
autosomal recessive disorders except Hunter syndrome (MPS
II), which is inherited as an X-linked trait. (See Chapter 77 in
Nelson Textbook of Pediatrics, 17th edition.)
Corneal clouding
Mitral regurgitation
Pericarditis
Explanation: Storage in endothelial cells can cause coronary
artery disease and even myocardial infarction. Cardiomyopathy
may be present in infancy and is associated with endocardial
fibroelastosis. Valve disease necessitating valve replacement
usually occurs in older children. (See Chapter 77 in Nelson
Textbook of Pediatrics, 17th edition.)
Cardiomyopathy
Endocarditis
Question . 31. A 3-yr-old boy was normal at birth but developed progressive
coarsening of the face and developmental delay. In addition to coarse facies and
mental retardation, the physical examination reveals a cardiac systolic regurgitant
murmur, hepatomegaly, joint stiffness, and short stature. CT scan reveals
hydrocephalus. There is no corneal clouding. All affected family members have been
boys. The most likely diagnosis is:
Hurler syndrome
Galactosemia
Metachromatic leukodystrophy
Hunter syndrome
Explanation: This X-linked disorder affects only males, who do
not reproduce. The phenotype of severe Hunter syndrome
(MPS II) is similar to that of Hurler syndrome (MPS I), but it
does not include corneal clouding and it progresses at a slightly
slower rate. (See Chapter 77 in Nelson Textbook of Pediatrics,
17th edition.)
Mucopolysaccharidosis type III (Sanfilippo syndrome)
Question . 32. A 14-mo-old white boy presents with chorea of 2 months' duration.
Prior to this, he had failure to thrive and recurrent emesis. He was normal until age 4
mo, when hypotonia and vomiting began. Physical examination reveals hyperreflexia
and erosions on his lips and fingers. Laboratory data reveals a normal BUN and
ammonia levels and an elevated uric acid level. An older male sibling is in an
institution for severely disabled teens. The most likely diagnosis is:
GM1 gangliosidosis
Lesch-Nyhan syndrome
Explanation: This is a classic presentation of this X-linked
genetic disorder, which is characterized by complete deficiency
of the hypoxanthine-guanine phosphoribosyltransferase
enzyme. Partial enzyme deficiency may cause some cases of
severe gout with normal cerebral function. Treatment with
allopurinol reduces the hyperuricemia but does not alter the
CNS manifestations
Question . 33. A 4-yr-old girl presents with severe failure to thrive with weight of 18
lb and height of 30 inches, a high-pitched voice, a sclerodermatous appearance to
skin overlying the abdomen, nearly total alopecia, a small jaw and face relative to
the head circumference, and normal mental and motor development. The most likely
diagnosis is:
Cystic fibrosis
Marfan syndrome.
Hallermann-Streiff syndrome
Question . 34. An 18-yr-old girl complains of abdominal pain with menses that seem
out of proportion to the menstrual pain of her peers. She has intermittent
constipation and diarrhea. During a recent episode of pain, she was noted to have
hypertension, tachycardia, and urinary retention. Her urine was noted to have a port
wine discoloration when the urinary catheter was placed to relieve her acute urinary
retention. The most likely diagnosis is:
Mucopolysaccharidosis
Question . 35. A 3-day-old white girl was found unresponsive in the normal newborn
nursery. The mother was a 35-yr-old (gravida 3, para 2) with a normal pregnancy,
including screening tests negative for herpes simplex, group B streptococci, HIV,
diabetes (normal glucose tolerance test), and -fetoprotein. Her other children are
normal. The baby weighed 4.5 kg at birth and had Apgar scores of 9 and 9. There is
no hepatosplenomegaly or respiratory distress, but the baby has a weak cry, is
hypotonic, and responds poorly to stimuli. Immediate evaluation should include all of
the following except:
Blood culture
Blood electrolytes
Question . 36. The infant described in Question 35 has a blood glucose level of 22
mg/dL. The most appropriate therapy is:
Administration of prednisone
Administration of diazoxide
Question . 37. The infant described in Questions 35 and 36 initially becomes more
responsive and has normal tone. Three hours later she has a seizure, and her blood
glucose level is 18 mg/dL. The most appropriate next step in management is to:
Administer diazoxide
Galactosemia
Hyperinsulinemic hypoglycemia
Explanation: This is a classic case of persistent
hyperinsulinemic hypoglycemia, which was previously called
nesidioblastosis. Defects in the regulatory KATP channel, which
stimulates insulin release from the pancreatic islet cells, is the
most common of these disorders and may be familial or
sporadic. Treatment with diazoxide or octreotide may be
successful; some patients require pancreatic resection. (See
Chapter 81 in Nelson Textbook of Pediatrics, 17th edition.)
Question . 39. A 9-day-old full-term infant is admitted to the hospital with lethargy,
fever, and increasing jaundice. Physical examination also reveals hepatomegaly.
Laboratory results reveal a blood glucose value of 10 mg/dL, total and direct bilirubin
values of 15 and 7 mg/dL, respectively, and liver enzyme test shows AST??700
units/L, and ALT, 650 units/L. The next day, the blood culture is positive for a gram-
negative rod. The most likely diagnosis is:
Necrotizing enterocolitis
Galactosemia
Explanation: The combination of hypoglycemia, jaundice,
elevated liver enzyme values, and Escherichia coli sepsis is
classic for early-onset severe galactosemia. A white blood cell
defect may predispose to E. coli sepsis, and the toxic effects of
galactose-1-phosphate explain the hepatotoxicity. In this child,
who was fed cow's milk-based formula, the urine-reducing
substances (galactose) were positive. (See Chapter 76.2 in
Nelson Textbook of Pediatrics, 17th edition.)
Neonatal hepatitis
Biliary atresia
Question . 40. A previously healthy 6-mo-old presents with hepatomegaly, lethargy,
increasing jaundice, and severe emesis. The child appears dehydrated; the urine
also has a positive reaction for reducing substances. The child's diet has been solely
breast milk until age 5 mo, when fruit juices and baby food were added to the diet.
The most likely diagnosis is:
Galactosemia
Benign fructosuria
Question . 41. A 2-mo-old presents with failure to thrive, emesis, alopecia, rash, and
chronic metabolic acidosis. An older sibling died at age 3 mo with hypotonia and
chronic lactic acidosis. An important diagnostic study is determination of:
Muscle biopsy
Explanation: Muscle biopsy may confirm the diagnosis of
Pompe disease (glycogen storage disease, type II). Deficiency
of acid -glucosidase results in marked lysosomal glycogen
accumulation and primarily affects the heart and skeletal
muscle. Death in the infantile form is due to respiratory muscle
failure. (See Chapter 76.1 in Nelson Textbook of Pediatrics,
17th edition.)
Lumbar puncture
Question . 43. A 15-yr-old Ashkenazi Jewish girl is seen because of chronic fatigue.
On examination, she seems pale and thin and has a somewhat large abdomen. Her
spleen is felt in the iliac fossa. She is mentally alert and has a history of normal
development and normal school performance. Her blood count shows hemoglobin,
9.0 g/dL and a white blood cell count of 3,000/cu mm, with normal differential cell
count and no abnormal cells. Platelet count is 60,000/ L. The most likely diagnosis
is:
Tay-Sachs disease
Mucolipidosis type IV
Canavan disease
Question . 44. A 13-mo-old infant is found comatose in bed after sleeping later than
usual. On physical examination, the infant is afebrile and of normal size, and the
liver is palpated 4 cm below the costal margin. The plasma glucose level is 15
mg/dL; bicarbonate, 20 mEq/L;BUN, 35 mg/dL; ammonia, 295 mol/L; AST, 320
units/L; and ALT, 425 units/L. Bilirubin is normal. Urinalysis is negative for glucose,
ketones, protein, and reducing substances. Which of the following is the most likely
diagnosis?
Congenital hyperinsulinism
Isovaleric acidemia
Question . 45. Plasma very-long-chain fatty acids are elevated in all of the following
peroxisomal disorders except:
Zellweger syndrome
Pseudo-Zellweger syndrome
Neonatal adrenoleukodystrophy
Question . 46. Of the following physical findings noted in some patients with
hyperlipidemia, which is most likely in a 17-yr-old boy with heterozygous familial
hypercholesterolemia?
Arcus corneae
Xanthelasma
Urinary mucopolysaccharides
Question . 48. A 7-mo-old white girl presents with severe developmental delay and
episodes of vomiting. Physical examination reveals blue eyes, light skin with an
eczematoid rash, and hyperactive deep tendon reflexes. There is failure to thrive
and microcephaly. The most likely diagnosis is:
Child neglect
TORCH infection
VATER syndrome
Phenylketonuria
Explanation: Phenylketonuria presents with the gradual
appearance of these symptoms. All children appear normal at
birth. (See Chapter 74 in Nelson Textbook of Pediatrics, 17th
edition.)
Galactosemia
Cataracts
Explanation: Cataracts are unusual in tyrosinemia; they are
common in galactosemia. (See Chapter 74.2 in Nelson
Textbook of Pediatrics, 17th edition.)
Peripheral neuropathy
Cirrhosis
Hepatic carcinoma
Question . 51. A 4-yr-old blue-eyed white girl manifests a malar flush, mild mental
retardation, subluxation of the ocular lens, iridodonesis, and Marfan-like features
(tall, thin, arachnodactyly). The most likely diagnosis is:
Hawkinsinuria
Alcaptonuria
Piebaldism
Homocystinuria
Explanation: Homocystinuria is due to a deficiency of
cystathionine synthase. (See Chapter 74.3 in Nelson Textbook
of Pediatrics, 17th edition.)
Angelman syndrome
Question . 52. Additional complications that may occur in the patient described in
Question 51 include all of the following except:
Seizures
Thromboembolism
Osteoporosis
Scoliosis
Cardiomyopathy
Explanation: A through D are all correct. The hypercoagulable
state may even be present if homocysteine levels are elevated
without any other signs of homocystinuria. (See Chapter 74.3 in
Nelson Textbook of Pediatrics, 17th edition.)
Question . 53. In the patient described in Questions 51 and 52, treatment is initiated
with high-dose vitamin B6, but no response is observed. The most likely explanation
is:
Folate deficiency
Explanation: After high-dose folate treatment, the patient
responds to the primary therapy of high-dose vitamin B6. (See
Chapter 74.3 in Nelson Textbook of Pediatrics, 17th edition.)
Malabsorption
Gastric hypersecretion
Vitamin B1 deficiency
Vitamin C deficiency
Question . 54. A 10-day-old child manifests profound coma 1 day after an illness
characterized by emesis, poor oral intake, and hypotonia. Laboratory findings reveal
4+ ketonuria; arterial blood gas, 6.9 mm Hg; PCO2, 19 mm Hg; PO2, 95 mm Hg;
anion gap, 37 mEq/L; and absolute neutrophil count, 400/cu mm. The most likely
diagnosis is:
Galactosemia
Methylmalonic acidemia
Explanation: Methylmalonic acidemia (MMA) presenting like
this in a newborn has a poor prognosis, even if the child
survives the acute episode. (See Chapter 74.6 in Nelson
Textbook of Pediatrics, 17th edition.)
Phenylketonuria
Question . 55. In addition to routine supportive care, what additional therapy would
be most appropriate for the child described in Question 54?
Vitamin B12
Explanation: Some cases of MMA are responsive to large
doses (1-2 mg/24 hr) of vitamin B12. (See Chapter 74.6 in
Nelson Textbook of Pediatrics, 17th edition.)
Vitamin B1
Biotin
Vitamin C
Folate
Cerebral palsy
Encephalomyelitis
Alexander disease
Canavan disease
Explanation: Canavan disease due to excessive amounts of
brain N-acetylaspartate acid produces leukodystrophy with
macrocephaly and loss of developmental milestones.
Alexander disease is similar but progresses at a slower rate.
(See Chapter 74.14 in Nelson Textbook of
Question . 57. A 7-yr-old boy, previously an "A" student, demonstrates progressive
hyperactivity and is diagnosed with attention deficit hyperactivity disorder. Despite
therapy, his school performance deteriorates. He has difficulty understanding people
when spoken to on the telephone. Seizures develop 6 mo later. Physical
examination reveals slight diffuse hyperpigmentation, spasticity, and reduced deep
tendon reflexes. The most likely diagnosis is:
Guillain-Barré syndrome
Zellweger disease
X-linked adrenoleukodystrophy
Explanation: Adrenoleukodystrophy, a peroxisomal disorder,
presents with progressive dementia, seizures, MRI cerebral
white matter lesions (symmetrical periventricular sites), and
adrenal insufficiency (as determined by a poor cortisol
response to intravenous ACTH). (See Chapter 75.2 in Nelson
Textbook of Pediatrics, 17th edition.)
Charcot-Marie-Tooth neuropathy
Question . 58. The best diagnostic test for the patient described in Question 57 is
MRI angiography
Question . 59. A 16-yr-old boy presents with easy bruisability and chronic fatigue.
He has a 3-yr history of bone pain and poor growth. Physical examination reveals
hepatosplenomegaly. Laboratory studies reveal normal liver enzyme levels but a
hematocrit of 25% and a platelet count of 25,000/cu mm. X-ray films of the skeleton
reveal long bone lytic lesions and osteosclerosis. The most likely diagnosis is:
Leukemia
Tay-Sachs disease
Hunter syndrome
Gaucher disease
Explanation: Although leukemia is of concern, there are no
blasts in the blood or bone marrow, and the course is
somewhat protracted for acute leukemia. (See Chapter 75.4 in
Nelson Textbook of
Question . 60. The best diagnostic test for the patient described in Question 59 is:
Liver transplantation
Lovastatin administration
Plasmapheresis
Thrombophlebitis
Carbohydrate intolerance
Question . 2. False-positive VDRL test results are most likely to occur in:
Mononucleosis
Endocarditis
Tuberculosis
Gonorrhea
Chlamydia infection
Chancroid
Candida infection
pulmonary edema. He has hypertrophic lesions over the dorsum of the left
hand and the antecubital fossa. The most effective therapy is:
Intravenous glucose
Flumazenil
Disulfiram
Naloxone (Narcan)
Explanation: Narcan is indicated in this patient with
intravenous drug misuse and a heroin overdose.
Nonetheless, the patient will need the ABCs of
resuscitation addressed if he is cyanotic, and so forth.
Securing an airway while providing oxygen and artificial
ventilation is the first priority-followed by Narcan, the
antidote for opiates. (See Chapter 105 in Nelson Textbook
of Pediatrics, 17th ed.)
Intravenous calcium
Question . 5. Toluene (glue, solvents) misuse is associated with:
Hallucinations
Tolerance
Pulmonary edema
Peripheral neuropathy
Rhabdomyolysis
Testicular atrophy
Aggressive behavior
Cholestasis
Anorexia nervosa
Explanation: Such severe wasting is compatible with
anorexia nervosa. Bulimia does not produce such severe
weight loss. Additional features of anorexia nervosa include
bradycardia, hypothermia, amenorrhea, and hypokalemia.
(See Chapter 104 in Nelson Textbook of Pediatrics, 17th
ed.)
Bulimia nervosa
Addison disease
Pituitary adenoma
Pregnancy
Mental disorders
Asthma
Anemia
Explanation: Anemia is rare in adolescent males and
common in females. Nonetheless, hospitalization is usually
not warranted. (See Chapters 99 and 100 in Nelson
Textbook of Pediatrics, 17th ed.)
Gastrointestinal disorders
Injuries
Question . 9. Successful preventive measures to avoid morbidity and mortality
from adolescent automobile accidents include all of the following except:
Learning problems
Explanation: Learning problems were probably identified
earlier than in adolescence and are not part of the AAP
guidelines. They are part of the AMA's annual screening,
however. (See Chapter 100 in Nelson Textbook of
Pediatrics, 17th ed.)
Safety practices
Scoliosis
Breast examination
Eating disorders
Young adolescents
Late-maturing boys
Explanation: Late-maturing boys are at moderate risk.
Low-risk categories are older age, stable relationships, and
regular contraceptive use. (See Chapter 100 in Nelson
Textbook of Pediatrics, 17th ed.)
Drug use
Same-sex partner
Coercive sex
Travels overseas
Growth spurts
Explanation: Depression is probably under-reported in the
teenager. (See Chapter 101 in Nelson Textbook of
Pediatrics, 17th ed.)
Substance abuse
Death of a family member
Hypothyroidism
Mononucleosis
Exercise-induced asthma
Explanation: The other choices are important
considerations in the differential diagnosis. (See Chapter
101 in Nelson Textbook of Pediatrics, 17th ed.)
Depression
Substance abuse
Pseudotumor cerebri
Depression
Explanation: Depression requires a comprehensive
treatment plan. Untreated, it may last 7-9 mo; most patients
become depressed again in the next 7 years. (See Chapter
101 in Nelson Textbook of Pediatrics, 17th ed.)
Lead poisoning
Alcohol withdrawal
Schizophrenia
Question . 17. Risk factors for adolescent suicide include all of the following
except:
Chronic illness
Access to guns
Gender
Explanation: Males are more likely to complete suicide,
whereas females are more likely to attempt suicide. (See
Chapter 102 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 19. Diagnostic criteria for anorexia nervosa include all of the
following except:
Adrenal hypertrophy
Marijuana use
17-Hydroxylase deficiency
Question . 22. A 16-yr-old female has had headaches for 3 mo and visual
changes for 2 wk and now has galactorrhea. Her last normal menstrual period
was 4 mo ago. The most likely cause of her galactorrhea is:
Migraines
Adrenal insufficiency
Klinefelter syndrome
Phenothiazines
Anabolic steroids
Heroin
Albuterol
Explanation: All the rest plus at least a dozen other drugs
may produce gynecomastia in males. (See Chapter 106 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 24. A 16-yr-old girl has not had her first menstrual period. Her
mother had her first period at the age of 12 yr. The adolescent is short and has
poor breast development. A vaginal smear shows no estrogen effect, and
there is no withdrawal bleeding after administration of intramuscular
progesterone.Her serum FSH level is high. The most likely diagnosis is:
Hypothyroidism
Cervical stenosis
Autoimmune endocrinopathy
Question . 25. A 14-yr-old girl presents with vaginal bleeding that is more
prolonged and profuse than her usual periods, which are irregular and first
started 13 mo ago. She has pallor and tachycardia. The next step in her
evaluation is to:
Question . 26. The most likely diagnosis for the patient described in Question
25 is:
Ovarian tumor
Fibroids
Hemophilia
Leukemia
Question . 27. The most appropriate therapy for the patient described in
Questions 25 and 26 is administration of:
Premarin
Explanation: Estrogens such as Premarin or as part of a
combination oral contraceptive pill constitute the treatment
of choice. The iron-deficiency anemia must be treated with
iron.
Prednisone
17-Hydroxyprogesterone
Ibuprofen
DDAVP
Thrombophlebitis
Myocardial infarction
Hepatic adenoma
Diabetes mellitus
Uterine rupture
Explanation: A-D are correct but fortunately are quite rare
events and are even rarer in nonsmokers. (See Chapter
108 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 29. A 19-yr-old female patient tells you she had unprotected sex
yesterday with her steady partner. She does not want to become pregnant.
Your emergency treatment should be to give:
Question . 30. The best contraceptive for a 16-yr-old girl with a history of two
pregnancies while on combination
An intrauterine device
Condoms
Levo-norgestrel (Norplant)
Explanation: Norplant is a reasonable choice, but many
adolescents have trouble with its side effects (weight gain,
irregular periods) and often ask to have it removed. (See
Chapter 108 in Nelson Textbook of Pediatrics, 17th ed.)
A cervical cap
Environmental Health Hazards
Nelson Self Assessments website 17th Edition
Question . 1. A 2-yr-old boy presents with a peeling, erythematous rash on the hands
and feet. The mother reports that he has become ill tempered and refuses to walk
about, preferring to lie in bed. Physical examination reveals an irritable, pale child
with photophobia. Temperature is 98.5°F, heart rate is 80/min, and respiratory rate is
23/min. Tremor of the tongue is evident. Further history and follow-up evaluation
reveal that the child's elder brothers have been playing with liquid mercury. Which of
the following is the most likely diagnosis?
A. Measles
B. Fifth disease
C. Kawasaki disease
D. Acrodynia
Explanation: Acrodynia, characterized by erythemia, peeling, and neurologic
signs, is characteristic of mercury toxicity. (See Chapter 702 in Nelson)
E. Photosensitivity
A. Urine
Explanation: Urine collection makes this a more useful test to determine
mercury poisoning and because the differential diagnosis may include other
heavy metals or drug toxicity. (See Chapter 702 in Nelson Textbook of
Pediatrics, 17th ed.)
B. Blood
C. Hair
D. Saliva
E. Feces
A. Swordfish
B. Quicksilver
C. Milk
Explanation: Milk is an unusual source of mercury. (See Chapter 702 in )
D. Pesticides
E. Latex paint
F. Folk remedies
A. Peripheral neuropathy
B. Mental retardation
C. Anemia
D. Cerebral edema
Explanation: Cerebral edema is often noted with blood lead levels exceeding 100
µg/dL. (See Chapter 703 in Nelson Textbook of Pediatrics, 17th ed.)
E. Lead lines
A. Induce emesis
B. Perform nasogastric tube lavage
C. Instill mineral oil
D. Administer steroids
E. None of the above
Explanation: Choices A, B, and C are dangerous and may induce pulmonary
aspiration if emesis occurs. Steroids are of no value and may predispose to
infection. Supportive therapy is indicated and includes oxygen and fluids. (See
Chapter 704 in Nelson Textbook of Pediatrics, 17th ed.)
A. Chédiak-Higashi syndrome
B. Neurofibromatosis
C. Chronic mucocutaneous candidiasis
D. Ataxia-telangiectasia
Explanation: A child with ataxia-telangiectasia (AT), because of the associated
hereditary DNA repair defect, is unable to repair acute radiation damage.
Conventional doses of radiotherapy to treat lymphomas (to which AT
predisposes) have caused acute radiation sickness, and children have died. It is
important to diagnose ataxia-telangiectasia in young patients with lymphoma
to avoid radiotherapy. The other choices listed in the question are not
associated with severe acute radiation reaction. (See Chapter 700 in Nelson
Textbook of Pediatrics, 17th ed.)
E. Wiskott-Aldrich syndrome
Question . 9. About 500 children have just been exposed to radiation from a nuclear
power plant accident. The most appropriate first step in management of these children
should be to:
A. Rattlesnake envenomations
B. Scorpion envenomations
C. Black widow envenomations
D. Stonefish envenomations
E. Hymenoptera envenomations
Explanation: Antivenin is not necessary for Hymenoptera bites or stings, but
immune prophylaxis may be indicated for systemic reactions. (See Chapter
708 in Nelson Textbook of Pediatrics, 17th ed.)
A. Have the mother administer lemon juice or orange juice to neutralize the
alkaline crystals and come to your office
B. Have the mother administer water or milk and call you back in 2 hr
C. Have the mother administer water or milk and bring the child in for
esophagoscopy
Explanation: Immediately dilute the ingested drain cleaner with water or milk.
The ability to predict who will experience esophageal disease is poor; thus,
most clinicians recommend esophagoscopy within 12-24 hr of such an
ingestion. Steroids are of little value in the presence of esophageal lesions and
do not prevent stricture formation. (See Chapter 704 in Nelson Pedia, 17th ed.)
D. Simply observe the child because the crystals are so bitter that the child was
trying to spit them out when the mother called, and therefore no problems
should occur
E. Administer ipecac at home and bring the child in to see you
Question . 12. A 16-yr-old, 165-lb patient reports consuming 20-40 325-mg capsules
containing acetaminophen 1 hr ago. The most appropriate approach to treatment is to:
A. Measure the plasma level and determine potential toxicity from the level on
the nomogram
B. Wait until 4 hr after ingestion to measure the plasma level and do nothing else
C. Administer activated charcoal immediately and measure the plasma level of
acetaminophen 4 hr after ingestion
Explanation: The patient described in the question has ingested a potentially
significant amount of acetaminophen. Charcoal may reduce absorption, and
the ultimate predictor of toxicity (the 4-hr serum level) will determine the need
for N-acetylcysteine therapy. (See Chapter 704 in Nelson Textbook of
Pediatrics, 17th ed.)
D. Send the patient home because an ingestion of this magnitude is not toxic
E. Administer N-acetylcysteine at a dose of 140 mg/kg
Question . 13. A 5-yr-old child presents with a painful blister of unknown origin with
surrounding erythema on the palm of the hand and with low white cell and platelet
counts. There is also a history of mild nausea and vomiting occurring about 4-6 days
ago. The most likely diagnosis is:
A. Pemphigus
B. Stevens-Johnson syndrome
C. Thermal burn
D. Insect bite
E. Radiation burn from handling a highly radioactive source
Explanation: (See Chapter 700 in Nelson Textbook of Pediatrics, 17th ed.)
A. Multiple CT scans
B. Living in homes with a high radon level
C. Living in an area of high natural background
D. Exposure to radioactive iodine
Explanation: (See Chapter 700 in Nelson Textbook of Pediatrics, 17th ed.)
E. Paternal preconception radiation exposure
Question . 15. Compared with adults, young children are uniquely vulnerable to
chemical pollutants for all of the following reasons Except:
Question . 16. A 13-mo-old healthy child presents for a follow-up visit to address a
capillary blood lead level of 18 ?g/dL obtained routinely at a recent well child visit at
age 1 yr. The most appropriate next step in the evaluation and management of this
patient is to:
A. Benzene exposure in a child who drinks tap water from a private well
B. Fine-particulate exposure in an asthmatic child who lives in a home heated by
a wood-burning stove
C. Organophosphate exposure in a child whose mother applies pesticides for a
termite control company
D. Asbestos exposure in a child whose home has sealed asbestos insulation
covering pipes in the ceiling of an unfinished basement used for storage
Explanation: (See Chapter 701 in Nelson Textbook of Pediatrics, 17th ed.)
E. Mercury exposure in a pregnant woman who eats tuna fish twice a day as part
of a weight loss diet
A. Pesticides
B. Seafood
C. Folk remedies
D. Occupational exposures
E. All of the above
Explanation: Exposure to arsenic or mercury may occur with all of the sources
listed. (See Chapter 702 )
Question . 19. All of the following statements regarding arsenic poisoning are true
Except:
Question . 20. All of the following statements regarding mercury absorption are true
Except:
Question . 21. All of the following statements regarding mercury poisoning are true
Except:
A. Acute inhalation of elemental mercury vapor may result in fever, cough, chest
pain, dyspnea, and respiratory failure
B. Acute ingestion of inorganic mercury salts may result in corrosive
gastroenteritis, severe abdominal pain, acute tubular necrosis, and
cardiovascular collapse
C. Chronic inorganic mercury intoxication produces the classic triad of tremor,
neuropsychiatric disturbances, and gingivostomatitis
D. Acrodynia is an idiosyncratic hypersensitivity reaction to mercury
characterized by generalized pain, paresthesias, irritability, hypotonia, and an
acral rash
Question . 22. A 2-yr-old child presents in the emergency department following the
reported ingestion of a mouthful of lamp oil. The child reportedly vomited once at
home. The child has a heart rate of 160 beats/min, a respiratory rate of 48/min, and a
temperature of 37.2oC. A chest film is read as normal. The most appropriate therapy
for this child is to:
Question . 23. A teen-age girl presents in the emergency room with the story that she
got upset with her boyfriend and swallowed a "handful of aspirin" about 4 hr
previously. One hour afterward, after she began vomiting, she confessed to her
mother what she had done. On examination the patient has normal vital signs and is
asymptomatic except for the complaint of nausea. A serum salicylate level is ordered,
but the laboratory reports no salicylates in her blood. The most appropriate next step
in management is to:
Question . 24. A 15-yr-old boy is admitted to your care following the intentional
ingestion of 2 g of his own amitriptyline in a suicide gesture. He received activated
charcoal for GI decontamination. The patient is placed in the ICU for monitoring and
remains stable. He is receiving only 0.45% normal saline. You observe a change in
his cardiac monitor display with a widening of his QRS complex to 0.12 second and
occasional ectopic beats. The most appropriate next step in management is to:
A. Ignore these changes because they are still within normal limits
B. Add sodium bicarbonate to his IV fluids to try to raise his serum pH above 7.4
Explanation: (See Chapter 704 in Nelson Textbook of Pediatrics, 17th ed.)
C. Repeat a dose of activated charcoal
D. Begin a lidocaine infusion at an appropriate dose
E. Order a chest film
A. A cyclic antidepressant
B. Acetaminophen
C. Cocaine
D. An organophosphate insecticide
E. A salicylate
Explanation: (See Chapter 704 in Nelson Textbook of Pediatrics, 17th ed.)
A. Most bites and stings by spiders, snakes, and other venomous animals do not
require attention
B. All antivenins are animal-derived immunoglobulins and cause only delayed
hypersensitivity reactions
Explanation: (See Chapter 708 in Nelson Textbook of Pediatrics, 17th ed.)
C. Delayed hypersensitivity or serum sickness develops in up to 65% of patients
who receive equine-derived antivenin
D. In the United States, 95% of poisonous snakes are pit vipers
E. Pit vipers may be identified by their triangular heads, elliptical eyes, and
identifiable pit between the eyes and nose
A. In the United States the only significant morbidity from spiders is caused by
the black widow spider
B. The black widow spider is glossy black and has bright red or orange markings
on the ventral surface of the abdomen
Explanation: (See Chapter 708 in Nelson Textbook of Pediatrics, 17th ed.)
C. Antivenin should be used first to control the pain of a black widow bite
D. Most scorpion bites are life-threatening
E. Sea bather's eruption is caused by stingrays
Congenital malformations
Asphyxia
Sepsis
Question . 2. All of the following regarding the low-birthweight rate are true except:
Erythema toxicum
Pustular melanosis
Explanation: This is the classic presentation of this benign
neonatal rash. The flaccid vesicles contain neutrophils, which is
in contrast to the eosinophils seen in erythemia toxicum. (See
Chapter 83 in Nelson Textbook of Pediatrics, 17th edition.)
Incontinentia pigmentosa
Herpes gestationalis
Torticollis
Asymmetrical skull
Ear malalignment
Asymmetric face
th
Question . 8. Bilateral and multiple retinal hemorrhages, presenting in the 6 week
of life in a lethargic neonate without any other physical findings, are most likely due
to:
Birth trauma
Nuchal cord
Vacuum extraction
Child abuse
Explanation: Child abuse is often associated with bilateral
retinal hemorrhages, especially in what is called the "shaken
baby syndrome." Retinal hemorrhages may be noted
immediately after birth. Nonetheless, they should all resolve by
1 mo of age. (See Chapter 83 in Nelson Textbook of Pediatrics,
17th edition.)
Short frenulum
Cleft palate
Cleft lip
Bifid uvula
Question . 10. A 3.5-kg female born following repeat cesarean section is noted by
the nurses to be grunting at 10 min of age. You come to see the baby and note that
the grunting has stopped, the respiratory rate is 36/min, the pulse oximetry reading
is 99%, and the child looks vigorous. The most appropriate next step is to:
Perform a sepsis evaluation
Question . 11. The best description of the Apgar score is that it:
Question . 12. Reproductive technologies are associated with all of the following
pregnancy-related risks except a :
Esophageal atresia
Explanation: Esophageal atresia is most often associated with
polyhydramnios, as are other upper intestinal obstructive
lesions or disorders of fetal swallowing. (See Chapter 84 in
Nelson Textbook of Pediatrics, 17th edition.)
Pulmonary hypoplasia
Potter syndrome
Skeletal contractures
Question . 15. Fetal ultrasonography is of use for all of the following except:
Question . 16. Fetal tachycardia may be caused by all of the following except:
Maternal lupus erythematosus
Explanation: Maternal lupus may affect the fetal cardiac
conduction system, and it produces bradycardia by the
development of an antibody immune-related process. (See
Chapter 85 in Nelson Textbook of Pediatrics, 17th edition.)
Maternal fever
Prematurity
Fetal anemia
Question . 17. Immunologic diseases of the mother that may affect the fetus include
all of the following except:
Myasthenia gravis
Graves disease
Multiple sclerosis
Explanation: It is interesting that B might be a choice.
However, splenectomy reduces the destruction of maternal
platelet antibody complexes by the spleen, thus increasing the
mother's platelet count. Splenectomy does not reduce the IgG
antiplatelet antibodies, which can readily cross the placenta.
(See Chapter 85 in Nelson Textbook of Pediatrics, 17th edition.)
Brand of cigarettes
Altitude
Measuring fetal pH
Question . 20. Amnion nodosum is associated with all of the following except:
Oligohydramnios
Renal agenesis
Pulmonary hypoplasia
Flattened facies
Race
Infertility treatment
Bronchopulmonary dysplasia
Explanation: Both bronchopulmonary dysplasia (BPD) and a
patent ductus arteriosus (PDA) are associated with excessive
intravenous fluids in premature infants. Answers A, C, D, or E
are some reasons why fluid intakes may be increased, but at
the same time, the infant is placed at risk for BPD or a PDA.
(See Chapter 86 in Nelson Textbook of Pediatrics, 17th edition.)
Hyperbilirubinemia
Hypernatremia
Oliguria
Question . 24. Breast milk from a donor may have insufficient amounts of all of the
following nutrients except:
Protein
Calcium
Phosphorus
Vitamin D
Fetal-maternal hemorrhage
Tension pneumothorax
Jaundice
Explanation: Answers A to D, other congenital heart defects,
postnatal hemorrhage (CNS, liver, spleen), and sepsis can all
produce hypotension. (See Chapter 87 in Nelson Textbook of
Pediatrics
Question . 26. A 900-g infant with respiratory distress syndrome has persistent
hypotension despite administration of fluid boluses and dopamine. Epinephrine also
fails to elevate the blood pressure. The next step to manage the blood pressure is to
administer:
Albumin
Hydrocortisone
Explanation: Many studies have demonstrated the value of
administering hydrocortisone (Solu-Cortef) to VLBW infants
who respond poorly to fluid boluses and dopamine. (See
Chapter 87 in Nelson Textbook of Pediatrics, 17th edition.)
Hypertonic saline
Norepinephrine
Dobutamine
Question . 27. A 1-day-old infant born to a diabetic mother is noted to have tremors
of all extremities while awake. They disappear during sleep and are not associated
with eye movements. The glucose and calcium levels are normal. The most likely
diagnosis is:
Hypoglycemia
Kernicterus
Jitteriness
Explanation: This is a classic problem in infants of diabetic
mothers (IDMs). All jittery children should be examined
carefully and concern for a seizure considered. If the child
appears normal and has no abnormal eye movements, and if
the motion is sensory-dependent, is only present during active
wakefulness, and is stopped by simple pressure, it is probably
not a seizure. Nonetheless, it could be associated with a
serious problem such as hypocalcemia, hypoglycemia, or
opiate withdrawal. IDMs are often more jittery than other infants
but are also at risk for hypoglycemia and hypocalcemia. (See
Chapter 87 in Nelson Textbook of Pediatrics, 17th
Question . 28. A 5-day-old, large-for-gestational-age, 4,500-g boy has a bilirubin
level of 21 mg/dL. There is no anemia or polycythemia, but on examination he has a
large cephalohematoma. The next therapeutic activity should be to:
Administer phototherapy
Explanation: Phototherapy is clearly indicated. Aspiration or
incision and drainage (I + D) should not be done to manage a
cephalohematoma. (See Chapter 88 in Nelson Textbook of
Pediatrics, 17th edition.)
Ventricular-peritoneal shunt
Obtain a cord pH
Pink color
Doing an echocardiogram
Starting caffeine
Question . 35. A 32-wk gestational age infant develops grunting, flaring, and
retraction after birth. He requires 50% oxygen (O2) by hood to keep his oxygen
saturation above 95%. The next step in management, if he requires more O2, is to:
Head ultrasonography
Explanation: In a neonate with no signs of intraventricular
hemorrhage (IVH) and on the first day of life, one does not
need a head ultrasound. The others (B-E) are important to look
for other causes of respiratory distress and prepare to treat
empirically for the possibility of early-onset group B
streptococcal pneumonia. (See Chapter 90 in Nelson Textbook
of Pediatrics, 17th edition.)
Blood culture
Chest x-ray
Complete blood count
Question . 37. A 3-day-old, 790-g female infant had been ventilated for respiratory
distress syndrome and was being weaned effectively from the ventilator. Today she
is noted to have an active precordium, bounding pulses, and hypoxia with
hypercarbia. All of the following should be done to evaluate and manage her except:
Administer prostaglandin E2
Explanation: In a neonate with no signs of intraventricular
hemorrhage (IVH) and on the first day of life, one does not
need a head ultrasound. The others (B-E) are important to look
for other causes of respiratory distress and prepare to treat
empirically for the possibility of early-onset group B
streptococcal pneumonia. (See Chapter 90 in Nelson Textbook
of Pediatrics, 17th edition.)
Obtain an echocardiogram
Restrict fluids
Question . 38. The immediate treatment of choice for the patient described in
Question 37 is administration of:
Digoxin
Dobutamine
Dexamethasone
Indomethacin
Explanation: Indomethacin, and perhaps ibuprofen when
approved by the FDA, inhibits prostaglandin synthesis,
facilitating medical closure of a PDA. If medical treatment is
unsuccessful, surgical ligation is performed. (See Chapter 90 in
Nelson Textbook of Pediatrics, 17th edition.)
Vitamin E
Polycythemia
Renovascular hypertension
Explanation: Systemic hypertension may be a complication of
treating persistent pulmonary hypertension of the newborn
(PPHN) by ECMO or from umbilical artery catheterization. (See
Chapter
Question . 40. A term baby girl has two episodes of bile-stained emesis at 24 hr
after birth. There is a history of excessive amniotic fluid volume. The most
appropriate diagnostic test is:
Blood culture
Barium enema
CT scan
Question . 41. Meconium plug is associated with all of the following except:
Hypermagnesemia
Cystic fibrosis
Hirschsprung disease
Prematurity
Explanation: Although prematurity may cause delayed
passage of meconium (NPO, immature colonic function), it is
not associated with a higher incidence of meconium plugs.
(See Chapter 91 in Nelson Textbook of Pediatrics, 17th edition.)
Question . 42. All of the following are true about necrotizing enterocolitis except:
Epidemics occur
Question . 43. High risk factors for neonatal jaundice include all of the following
except:
Neonatal polycythemia
Asian heritage
Post dates
Explanation: Postmature infants have a lower incidence of
jaundice unless polycythemia is present. Other risk factors for
jaundice include hemolysis, Gilbert disease, breast-feeding,
prematurity, diabetic mother, bruising, intestinal obstruction,
hypothyroidism, and diseases producing cholestatic disorders.
(See Chapter 91 in Nelson Textbook of Pediatrics, 17th edition.)
Hepatic ultrasonography
Question . 45. The hour-specific bilirubin assay (see accompanying figure) best
predicts:
Hemolysis
Kernicterus
Sepsis
Biliary atresia
Question . 46. All of the following are true about breast milk jaundice except:
Question . 47. All of the following are true about tin protoporphyrin except:
Question . 48. A term female infant is born with Apgar scores of 9 and 9. At 15 hr of
age, she is noted to be pale. The vital signs reveal tachycardia; there is no
hepatosplenomegaly or jaundice. The family history is not contributory, and the
review of the labor and delivery do not reveal any sources of blood loss. Her
hematocrit at 16 hr of age is 30%. The reticulocyte count is 15%, whereas the
platelet and WBC counts are normal, as is the blood smear. The bilirubin is 2 mg/dL.
The next important step in her evaluation is to do:
Coombs test
Kleihauer-Betke test
Explanation: The Kleihauer-Betke test is performed on
maternal blood and tests for the presence of fetal hemoglobin
containing erythrocytes from a fetal-to-maternal transfusion. A
low bilirubin suggests that there is no hemolysis, and a normal
examination, except for tachycardia, suggests no internal blood
loss. Fetal-to-maternal bleeding can be chronic or acute. (See
Chapter 92 in Nelson Textbook of Pediatrics, 17th edition.)
Apt test
1. Kernicterus
Explanation: C. Both
2. Jaundice on day 1
Explanation: C. Both
4. Anemia
Explanation: C. Both
5. Intracranial hemorrhage
Explanation: D. Neither, unless associated with premature
death
6. In utero treatment
Explanation: B. Rh
8. Iron deficiency
Explanation: D. Neither, unless exchange transfusion
9. Hydrops fetalis
Explanation: B. Rh
10. Hepatosplenomegaly
Explanation: B. Rh, is seen occasionally with ABO
incompatibility (See chapter 92 in Nelson Textbook of
pediatrics, 17th edition.)
Trisomy 21
Adrenogenital syndrome
Question . 52. A term fetus is noted to have bilateral dilation of the renal pelvis and
ureter. Amniotic fluid volume is adequate, and the bladder size looks normal. After
birth, the child voids spontaneously within 24 hr. The most appropriate diagnostic
approach to this child is:
Intravenous pyelogram
Nesidioblastosis
Intracranial hemorrhage
Hypoglycemia
Pyridoxine deficiency
Hypocalcemia
Explanation: This infant has late neonatal onset tetany, which
is usually due to ingesting cow's milk with a very high
phosphate content. However, some infants breast-fed by a
mother at nutritional risk may develop hypocalcemia or, later in
infancy, rickets. The patient responded to intravenous calcium
and was sent home on supplemental vitamin D. Infants with
hypocalcemia often have only peripheral neuromuscular signs
and appear alert during what appears to be a seizure. (See
Chapter 95 in Nelson Textbook of Pediatrics, 17th edition.)
Question . 54. The best method to identify prenatal drug misuse is:
Meconium testing
Explanation: Meconium drug testing has become the standard
and reflects long-term drug misuse at a site of drug excretion
and storage. Urine test results may vary, depending on the
timing between drug intake and testing and the dose. (See
Chapter 95 in Nelson Textbook of Pediatrics, 17th edition.)
Question . 56. A 4.5-kg baby girl of a mother with classic diabetes develops
grunting after cesarean delivery. At 40 hr of age, the baby has tachycardia,
tachypnea, cyanosis, and a normal blood glucose level. A chest x-ray reveals
cardiomegaly, and you believe that the infant is in heart failure. A fetal
echocardiogram does not reveal any evidence of congenital heart anomalies. The
therapeutic agent of choice for this infant is:
Digoxin
Dobutamine
Propranolol
Explanation: This infant has cardiomyopathy associated with
infants of diabetic mothers. This is a form of ventricular septal
hypertrophy that can obstruct the left ventricular outflow tract
and cause heart failure and poor cardiac output. Inotropic
agents that increase the force of ventricular muscle contraction
exacerbate the obstruction and are contraindicated. (See
Chapter 96 in Nelson Textbook of Pediatrics, 17th edition.)
Epinephrine
Dopamine
Question . 57. A newborn boy is noted on physical examination to have a unilateral
cleft lip, bilateral postaxial polydactyly, microcephaly, intrauterine growth retardation,
and micropenis. You are unable to make a specific overall diagnosis. What is the
most appropriate initial diagnostic test for this patient?
Karyotype
Explanation: This constellation of findings suggests a
chromosomal abnormality. Multiple malformations however
may be of unknown etiology. Metabolic disorders rarely cause
multiple malformations but may result in normal formation with
subsequent changes, such as coarsening of the facial features
or microcephaly or macrocephaly. (See Chapter 97 in Nelson
Textbook of Pediatrics, 17th edition.)
17-hydroxyprogesterone assay
Question . 58. A 2-day-old female infant is noted to have a bilateral cleft lip and cleft
palate. Based on a careful physical examination, you determine that she is
otherwise completely normal from a structural standpoint. Neither parent has a cleft
lip or cleft palate. Upon careful questioning of the mother, you determine that she
was not taking any medications during her pregnancy. Based on a careful family
history, you further determine that no other family member is affected. Which of the
following recurrence risk figures would you give this baby's parents?
25%
0%
50%
3-5%
Explanation: Recurrence risks of what is traditionally thought
to be a polygenetic disorder are between 3-5%. This is seen in
congenital heart disease and other single-organ malformations
without a positive family history. (See Chapter 97 in Nelson
Textbook of Pediatrics, 17th edition.)
75%
Renal agenesis
Question . 60. The most effective way to prevent early onset of neonatal group B
streptococcal sepsis is:
2. Microdeletion 16p13.3
Explanation: A. Rubinstein-Taybi syndrome
5. Mandibular hypoplasia
Explanation: D. Pierre Robin syndrome
6. Tracheoesophageal fistula
Explanation: F. VATER syndrome
7. Anal atresia
Explanation: F. VATER syndrome
8. Radial hypoplasia
Explanation: F. VATER syndrome, (See Chapter 97 in Nelson
Textbook of pediatrics, 17th edition.)
Question . 63. An infant has the following findings at 5 min of life: pulse, 130/min;
cyanotic hands and feet; good muscle tone; and a strong cry and grimace. This
infant's Apgar score is:
9
Explanation: One point in the Apgar score is taken off for
color. (See Chapter 83 in Nelson Textbook of Pediatrics, 17th
edition.)
10
Question . 64. Which of the following is most appropriate for treating
hyperbilirubinemia (11.2 mg/dL) in a 3-wk-old, breast-fed infant with normal growth
and development?
Phototherapy
Exchange transfusion
Phenobarbital
Question . 65. A 2-wk-old infant is brought to the emergency room in coma with
retinal hemorrhages and severe pallor. He was born at home and was first seen by
a physician at 10 days of age and placed on amoxicillin for otitis media. His diet is
breast milk. The day before admission, his parents took him in a four-wheel-drive
vehicle on a hot day over a rough road in the mountains. Seizures began 8 hr later,
and his condition steadily deteriorated for the next 16 hr. He oozes blood from all
venipuncture sites. Diagnostic tests should include all of the following except:
Coagulation studies
Skeletal survey
CT scan
Lumbar puncture
Explanation: (See Chapter 92.4 in Nelson Textbook of
Pediatrics, 17th edition.)
Question . 66. Immediate therapy for the infant described in Question 63 should
include administration of:
Vitamin A
Vitamin B6 (pyridoxine)
Vitamin C
Vitamin E
Vitamin K
Question . 67. The most likely diagnosis for the child described in Question 63 is:
Pyridoxine deficiency
Severe scurvy
Child abuse
Hypervitaminosis A
Question . 68. The death of the infant described in Question 63 could have been
prevented by which one of the following measures:
Administration of AquaMEPHYTON (vitamin K) at birth
Explanation: This infant has a case of severe vitamin K
deficiency-hemorrhagic disease of the newborn. The next most
likely diagnosis is child abuse; most infants in coma with retinal
hemorrhages have been shaken, and a skeletal survey thus is
appropriate. The combination of home delivery (no
AquaMEPHYTON administered), breast-feeding (low vitamin K
content), and the amoxicillin treatment that eliminated normal
intestinal bacterial synthesis of vitamin K led to the tragic
demise of an otherwise normal infant. Of all possible preventive
measures, administration of vitamin K at birth would have been
the most effective. (See Chapter 92.4 in Nelson Textbook of
Pediatrics, 17th edition.)
Discontinuance of antibiotics
An air conditioner
Crigler-Najjar syndrome
Gilbert disease
Biliary atresia
Hypothyroidism
Explanation: Hypothyroidism was confirmed by the late arrival
of the newborn screening results, indicating high TSH and low
T4 levels. Treatment with thyroxine improved the jaundice and
the other signs. The hyperbilirubinemia is indirect
(unconjugated). Crigler-Najjar syndrome is a possibility and is
either autosomal dominant or recessive (check the family
history). However, there are signs other than jaundice that
suggest another disease. Biliary atresia is always a concern in
infants with delayed clearance of jaundice or worsening
jaundice after 2 wk of life. The hyperbilirubinemia is
predominantly direct (conjugated). Galactosemia should be
considered, especially in the presence of hypoglycemia, direct-
reacting jaundice, hepatomegaly, or ascites. (See Chapter 91.3
in Nelson Textbook of Pediatrics, 17th edition.)
Galactosemia
Hereditary spherocytosis
1. Megaesophagus
Explanation: G. Trypanosoma cruzi
4. Limb hypoplasia
Explanation: B. Varicella
5. Myocarditis
Explanation: C. Enteroviruses
6. Fetal anemia
Explanation: E. Parvovirus
7. Hydrocephalus
Explanation: F. Toxoplasmosis, (See Chapter 98 in Nelson
Textbook of Pediatrics, 17th edition)
Question . 72. Reasons to avoid the early discharge of a normal term infant include
all of the following except:
Positive VDRL
No stools
Question . 73. Matching:Maternal drugs and the fetus and newborn
A. Neonatal heart failure
B. Oligohydramnios
C. Spina bifida
D. Arthrogryposis
E. Facial-ear anomalies
F. Goiter
1. Accutane
Explanation: E. Facial-ear anomalies
3. Iodide
Explanation: F. Goiter
4. Ibuprofen
Explanation: B. Oligohydramnios
5. Valproate
Explanation: C. Spina bifida
6. Misoprostol
Explanation: D. Arthrogryposis, (See Chapter 85 in Nelson
Textbook of Pediatrics, 17th edition
Klumpke paralysis
Explanation: Klumpke paralysis involves injury to the 7th and
8th cervical nerves and the 1st thoracic nerve. It is usually
unilateral, due to traction injury of the brachial plexus. (See
Chapter 88 in Nelson Textbook of Pediatrics, 17th edition.)
Question . 75. After intubation and resuscitation, the patient in Question 70 remains
limp but appears aware and looks around, although the baby does not cry when the
toes are pinched. The most likely diagnosis is:
Congenital botulism
Narcotic overdose
Neurosyphilis
Administer glucose
Administer pyridoxine
Administer 1,35-dihydroxyvitamin D
Administer lorazepam
The Respiratory System Question
Nelson Self Assessments website 17th Edition
Question . 3. Which of the following functional findings is most likely in a 12-yr-old girl
who has developed acute rheumatic carditis with severe mitral insufficiency?
A. Increased peak expiratory flow
B. Increased vital capacity
C. Increased residual volume
D. Decreased functional residual capacity
Explanation: Cardiac failure produces interstitial and alveolar edema, which will
reduce the FRC. (See Chapter 357 in Nelson Textbook of Pediatrics, 17th ed.)
E. Increased CO diffusion capacity
Question . 8. A 5-mo-old infant develops signs of respiratory distress after coughing and
sneezing for 3 days. He has marked subcostal and intercostal retractions and a respiratory
rate of 80 breaths/min. Breath sounds are markedly diminished on both sides. Diffuse
crackles can be heard bilaterally. There is no stridor. Arterial oxygen saturation in 100%
oxygen by non-rebreather mask is 80%. The skin is pale and peripheral arterial pulses are
weak.Which of the following is the most appropriate immediate course of action?
A. Administration of corticosteroids
B. Intubation of the trachea and mechanical ventilation
Explanation: This child is in respiratory failure.An arterial blood gas
determination may be helpful, but persistent hypoxia (80% saturation on pulse
oximetry) while the patient is on 100% FIO2 is an indication for intubation and
mechanical ventilation.CPAP may be tried under very controlled circumstances
but rarely avoids intubation.(See Chapter 357 in Nelson Textbook of Pediatrics,
17th ed.)
C. Sampling of arterial blood and measurement of arterial pH and blood gases
D. Administration of normal saline
E. Administration of diuretics
A. Decreased hypoxic drive after correction of the hypoxemia has resulted in acute
hypercapnia
B. Pulmonary hypertension caused by chronic hypoxemia has produced increased
ventilation-perfusion inequality
C. Renal tubular compensation of prolonged hypercapnia has resulted in an elevation
of serum bicarbonate levels
Explanation: Owing to poor ventilatory muscular effort, the patient has been
hypoventilating for a long enough time to allow renal tubular reabsorption of
bicarbonate to compensate for the prolonged hypercarbia (respiratory
acidosis).Compensation cannot totally correct the pH to normal.If the drive for
ventilation was inhibited by the hyperoxia, the PCO2 would be even higher and
the pH lower. (See Chapter 357 in Nelson Textbook of Pediatrics, 17th ed.)
D. The patient has become dehydrated
E. A fixed intrapulmonary right-to-left shunt is responsible for the limited response
to administration of oxygen
Question . 10. A 4-mo-old African-American infant was found unresponsive in his crib
by his mother in the early morning and could not be resuscitated. He had been placed for
sleep on his back but was found on his stomach. At a well-child examination the previous
day, he had been found to be in good health and received his routine immunizations. He
was born at 36 wk of gestation and weighed 2,420 g. His medical history was otherwise
unremarkable. After a thorough scene investigation, autopsy, and review of the medical
history, the cause of death was determined to be sudden infant death syndrome (SIDS).
Which of the following factors has not been found to be associated with greater risk of
SIDS?
A. Prematurity
B. Movement to a prone position after having been placed supine to sleep
C. Immunizations
Explanation: Multiple studies have looked at the potential associations between
immunizations and SIDS.None has ever demonstrated a relationship with SIDS.
(See Chapter 360 in Nelson Textbook of Pediatrics, 17th ed.)
D. African-American heritage
E. Low birth weight
Question . 12. Of the following, the strongest risk factor associated with SIDS is:
Question . 13. All of the following measures are recommended by the American
Academy of Pediatrics to reduce the risk of SIDS except:
Question . 15. Which of the following is not an indication for adenoidectomy alone?
Question . 16. A 7-yr-old African-American boy is brought to your office by his parents,
who describe loud snoring, difficulty breathing, and obstructed breathing at night. His
teacher has complained that he seems inattentive and hyperactive, but his parents think he
is just a "high-energy" child. The father is obese and on CPAP for obstructive sleep
apnea, and his BMI is 20 kg/m2. Findings on physical examination are completely
unremarkable except for 2+ tonsillar hypertrophy and some mouth breathing.What is the
most appropriate next step in diagnosis?
A. Neuropsychological testing
B. Lateral soft tissue radiograph of the neck
C. CT study of the upper airway
D. Diagnostic testing for obstructive sleep apnea
Explanation: Although all of these are useful, at some point it is most wise to
perform dynamic testing for obstructive sleep apnea in a sleep laboratory.(See
Chapter 369 in Nelson Textbook of Pediatrics, 17th ed.)
E. ECG and echocardiogram
A. Insufficient sleep
B. Delayed sleep phase syndrome
C. Obstructive sleep apnea syndrome
Explanation: His snoring, BMI, and tonsillar hypertrophy strongly suggest
obstructive sleep apnea.It would be interesting if in addition to snoring the family
noted pauses between his noisy sleep-related breathing.(See Chapter 369 in
Nelson Textbook of Pediatrics, 17th ed.)
D. Narcolepsy
E. Idiopathic hypersomnia
Question . 18. You receive a follow-up note from your community cardiology colleague
that a mutual patient, a 7-yr-old boy with trisomy 21, has new findings of pulmonary
hypertension. The child had a VSD that spontaneously closed by age 2 yr. His room air
pulse oximetry value is 98%. The second heart sound is loud and the intensity of the P2
component is increased. ECG shows normal sinus rhythm and right ventricular
hypertrophy. Echocardiogram shows normal intracardiac anatomy with no evidence of a
PDA, but there is mild tricuspid regurgitation with an increased jet velocity across the
tricuspid valve. The heart size was normal on x-ray study. Your colleague is planning a
cardiac catheterization to assess the nature and severity of the pulmonary hypertension.
He also orders thyroid function studies.You see the child in your office for a pre-
catheterization general health assessment. The child, who is usually very cooperative, is
sleepy and irritable. You note prominent mouth breathing, 3+ tonsillar hypertrophy, and a
prominent pectus deformity.What is the most appropriate next step in management?
A. Digital trauma
B. Menstruation
Explanation: The five most common causes of epistaxis are on your hand (the
fingers!).Menstruation-related epistaxis is extremely uncommon. With severe
recurrent non-infection-related epistaxis, the child may have a coagulopathy such
as von Willebrand disease.(See Chapter 362 in Nelson Pediatrics, 17th ed.)
C. Family history of epistaxis
D. Sinus infections
E. Dry winter air
A. Turbinates
B. Nasopharynx
C. Posterior septum
D. Kiesselbach's plexus (anterior septum)
Explanation: This is an easily reachable area that is easily irritated by picking or
inflammation.(See Chapter 362 in Nelson Textbook of Pediatrics, 17th ed.)
E. Maxillary sinus
Question . 21. When a disk battery is seen as a foreign body in the nose of a child, which
of the following is the most important consideration in management?
Question . 24. An 18-mo-old girl has a 2-day history of rhinorrhea, pharyngitis, and low-
grade fever. During the night, she wakes with a barky cough, hoarseness, and inspiratory
stridor. Which of the following is the most likely etiologic agent?
Question . 25. A 2-yr-old boy is presented to the emergency department at 3 A.M. with a
chief complaint of fever and cough. His respiratory rate is 36/min, his temperature is
39oC, and his pulse oximetry reading is 96%. On physical examination he has a barky
cough and stridor only with crying. He is well hydrated, able to drink, and consolable.
What is the appropriate next step in patient management?
Question . 27. You are a primary pediatrician in an office where a third-year medical
student is doing her clerkship. You have just seen the fifth patient that day with a classic
clinical presentation for croup: barky cough, fever, and stridor when agitated. You once
again prescribe dexamethasone. The third-year medical student asks about the data for
the use of steroids in croup. Which of the following has not been demonstrated in studies
of the use of steroids in croup?
A. Shorter hospitalization
B. Decreased need for subsequent medical interventions
C. Oral dexamethasone is as effective as intramuscular administration
D. Decreased need for oxygen
Explanation: Dexamethasone has been quite effective in the management of
children with mild to moderate croup.Its efficacy in reducing the need for oxygen
in more severely affected children has not been demonstrated.(See Chapter 371)
E. Reduced hospitalization
Question . 28. A 4-yr-old boy presents with sore throat and fever of sudden onset. He has
difficulty swallowing and his breathing is labored. He is drooling and sitting upright and
leaning forward in a tripod position. What is the appropriate next step in patient
management?
A. Complete blood count and blood culture followed by immediate prophylactic
intravenous antibiotics
B. Lateral radiograph of the neck
C. Dose of oral dexamethasone
D. Direct laryngoscopy in the operating room
Explanation: This is the classic presentation for epiglottitis. Although this
disorder is uncommon in the era of immunization against H. influenzae type b,
physicians must be aware of this dangerous disease with its requirement for
immediate airway protection.(See Chapter 371 in NelsonPediatrics, 17th ed.)
E. Complete physical examination including inspection of the oral cavity
A. Erythromycin
B. Ciprofloxacin
C. Ampicillin
D. Gentamicin
E. Nafcillin
Explanation: This child has bacterial tracheitis as a complication of a previous
viral respiratory tract infection.The most likely bacterial organism is
Staphylococcus aureus, although other organisms may be responsible.Some
physicians might use ceftriaxone to cover these pathogens.(See Chapter 371 in
Nelson Textbook of Pediatrics, 17th ed.)
Question . 30. A 2½-yr-old girl has had symptoms of an upper respiratory infection for 1
week. Over the past 24 hours, fever and tachypnea developed, with worsening cough and
increased work of breathing. She has a temperature of 39.1o C, a respiratory rate of
40/min, and mild to moderate intercostal retractions. Oxygen saturation is 94-95%. Her
examination reveals diffuse wheezing, inspiratory rhonchi, and crackles in the right
anterolateral chest. Chest film shows a shaggy right heart border, generalized
hyperinflation, and peribronchial cuffing. White blood cell count is 18,000/mm3with
70% granulocytes.Of the following, which is the most appropriate next step in diagnosis?
A. Sputum culture
B. Lung puncture
C. Blood culture
Explanation: The child has bacterial pneumonia.A child this young usually does
not produce sputum or require a lung puncture.A blood culture is quite
appropriate.Viral PCR assay may be better than a viral culture. (See Chapter 379
in Nelson Textbook of Pediatrics, 17th ed.)
D. Viral culture
E. Cold agglutinins titer
A. Penicillin PO
B. Cefixime PO
C. Erythromycin PO
D. Cephalexin PO
E. Amoxicillin PO
Explanation: High-dose oral amoxicillin will be effective against most
pneumococci.With highly resistant pneumococci, treatment with intravenous
vancomycin is necessary.(See Chapter 379 in Nelson Pediatrics, 17th ed.)
Question . 32. A previously healthy 12-yr-old boy presents with upper respiratory
symptoms of 8 days' duration, with worsening cough and fever. The season is autumn.
Examination reveals a temperature of 39°C, a respiratory rate of 24/min, and inspiratory
crackles in both lung fields. Oxygen saturation is 93-94%. Chest film shows scattered
infiltrates in multiple lung fields, more focal consolidation in the right lower lobe, and
blunting of the right costophrenic angle. White blood cell count is 11,000/mm3 with a
normal differential.Which of the following is the most appropriate next step in diagnosis?
A. Sputum culture
B. Tuberculin skin testing
C. Throat culture
D. Cold agglutinins titer
Explanation: It is likely that this patient has Mycoplasma pneumonia.More
effective diagnostic tests include Mycoplasma PCR and IgM assays.(See Chapter
379 in Nelson Textbook of Pediatrics, 17th ed.)
E. Erythrocyte sedimentation rate
Question . 33. Which of the following is the most appropriate next step in the
management of the patient described in Question 32?
A. Erythromycin PO
Explanation: Erythromycin or azithromycin is quite effective in improving the
clinical course of Mycoplasma pneumonia. (See Chapter 379 in Nelson Textbook
of Pediatrics, 17th ed.)
B. Amoxicillin PO
C. No antibiotic therapy
D. Ceftriaxone IM
E. Cefuroxime IV
Question . 35. Gram stain of the pleural fluid from the patient described in Question 34
reveals gram-positive cocci in clusters.Which of the following is the most appropriate
treatment?
A. Ampicillin IV
B. Cefuroxime IV
C. Erythromycin IV
D. Erythromycin and ampicillin IV
E. Cefotaxime and vancomycin IV
Explanation: The child probably has pneumococcal pneumonia.It could be
pneumonia due to S. aureus, but there are no pneumatoceles.The pneumococcus is
becoming resistant to penicillins and even to cephalosporins.If it is a life-
threatening illness, vancomycin should be added. (See Chapter 379 in Nelson)
Question . 36. A 7-yr-old child with a 3-yr history of cough, intermittent wheezing, and
poor growth has two sweat chloride values of 36 and 41 mEq/liter. Additional diagnostic
testing to rule out cystic fibrosis should include:
A. Intussusception
B. Peritonitis
C. Pancreatitis
D. Distal intestinal obstruction syndrome (DIOS)
Explanation: DIOS, also called meconium ileus equivalent, is an obstruction due
to impacted stool.If the patient has been receiving high-dose pancreatic enzymes,
a fibrosing colonopathy must also be considered. (See Chapter 402 in Nelson)
E. Cholecystitis
Question . 38. A newborn infant fails to pass meconium for the first 48 hr. Abdominal
distention and emesis have occurred overnight. The next diagnostic steps would include:
Question . 39. A 3.5-kg male infant born at term after an uncomplicated pregnancy and
delivery develops respiratory distress shortly after birth and requires mechanical
ventilation. The chest radiograph reveals a normal cardiothymic silhouette but a diffuse
ground-glass appearance to the lung fields. Surfactant replacement fails to improve gas
exchange. Over the first week of life, the hypoxemia worsens. Results of routine cultures
and echocardiographic findings are negative. A term female sibling died at 1 mo of age
with "respiratory distress."Which of the following is the most likely diagnosis?
Question . 41. If the laboratory analysis confirms SP-B deficiency, what is the most
appropriate next step in management of the patient described in Question 39?
Question . 42. A 3.2-kg full-term female infant is delivered by vaginal delivery. She is
initially cyanotic and is in significant respiratory distress. Auscultation of the chest
reveals diminished breath sounds in the left hemithorax and a scaphoid abdomen. After
bag and mask ventilation, an endotracheal tube is placed. The point of maximal impulse
(PMI) is shifted to the right side of the chest.The most important initial intervention is:
A. Immediate bronchoscopy
B. Placement of a nasogastric tube
Explanation: This patient potentially has a diaphragmatic hernia and needs gas to
be removed or prevented from entering the bowel, which acts as a space-
occupying lesion in the chest.(See Chapter 370 in Nelson Textbook of Pediatrics,
17th ed.)
C. A chest radiograph to assess placement of endotracheal tube
D. Immediate surgery
E. Administration of epinephrine
Question . 44. A 15-yr-old boy with thoracic scoliosis undergoes evaluation for surgery.
History is unremarkable, and findings on physical examination are normal except for a
mild thoracic scoliosis. A Cobb angle of 25 degrees is noted on the chest radiograph. His
vital capacity is 80% of predicted, and his exercise tolerance is minimally reduced.What
is the most appropriate next step in treatment of this patient?
A. Repeat assessment in 6 mo
Explanation: Depending on where he is in his puberty growth spurt, the curve
may not change, or if he continues to grow, the curve may worsen.(See Chapter
410 in Nelson Textbook of Pediatrics, 17th ed.)
B. Reassurance that surgery will not be required
C. Spinal fusion surgery
D. Bone density assessment (DEA scan)
E. Physical therapy to correct scoliosis
Question . 45. A 7½-yr-old girl presents with a history of low-grade fever, nonproductive
cough, and mild dyspnea. After treatment with an oral antibiotic, the child began to show
some signs of improvement. However, the child subsequently experienced increasing
dyspnea, a productive cough, and wheezing. A chest radiograph demonstrates
hyperlucency. Spirometry shows a severe obstructive pattern. The most likely diagnosis is:
Question . 47. A previously healthy 2-yr-old girl is given oral antibiotic therapy for a
cough, fever, and patchy consolidation of the right lower lobe. No crackles are heard on
chest auscultation. The fever abates, the cough improves, but a follow-up chest film at 8
wk demonstrates even more dense consolidation involving the right lower lobe. Next
steps in the evaluation should include:
A. Bronchoscopy
Explanation: This child could have many problems such as a foreign body, but the
clinical picture is highly suggestive of a sequestration.If a pulmonary
sequestration is found, Doppler flow studies of the artery supplying the
sequestration will show the artery coming from the aorta.(See Chapter 370 in
Nelson Textbook of Pediatrics, 17th ed.)
B. Bacterial culture of the nasopharynx
C. Barium esophagram
D. Allergy skin testing
E. Lung biopsy
Question . 48. For the mechanically ventilated child, which medical condition is most
often associated with successful wean off all ventilatory support?
A. Central hypoventilation
B. Bronchopulmonary dysplasia
Explanation: Children with BPD usually are successfully weaned.The others in
choices A and C often become dependent on their ventilator.(See Chapter 411 in
Nelson Textbook of Pediatrics, 17th ed.)
C. Spinal muscular atrophy
D. None of the above
Question . 50. A 2-yr-old boy undergoing outpatient surgery for tonsillectomy vomits
while recovering from general anesthesia in the postoperative recovery area. Within 1-2
min he develops tachypnea, chest retractions, and hypoxemia. Which of the following is
the most likely explanation for these findings?
Question . 51. Of the following diagnostic tests, the most sensitive for detecting recurrent
airway aspiration is:
A. Tracheomalacia
B. Vascular ring
C. Laryngomalacia
Explanation: Laryngomalacia is common and often produces noisy breathing that
worsens with viral upper respiratory tract infections or in the supine position.(See
Chapter 370 in Nelson Textbook of Pediatrics, 17th ed.)
D. Tonsil and adenoid hypertrophy
E. Subglottic hemangioma
Question . 53. A 3-mo-old infant has had progressively worsening biphasic stridor. Her
parents report two brief episodes of croup. A 1-cm-diameter hemangioma is present on
her right thigh. Airway radiographs are most likely to show:
Question . 56. A 4-yr-old boy with a history of tracheoesophageal fistula (TEF) repair at
birth is evaluated for a chronic cough. The cough has persisted since he was discharged
from the hospital after his TEF repair. The cough is dry and barking and occasionally
associated with expiratory wheezing. The most likely cause of the chronic cough is:
A. Cough-variant asthma
B. Sinusitis
C. Tracheomalacia
Explanation: Tracheomalacia is very common after a TEF repair.Some patients
also develop reactive airways and reflux.(See Chapter 370 in Nelson Textbook of
Pediatrics, 17th ed.)
D. Gastroesophageal reflux
E. Subglottic stenosis
Question . 57. A 4-yr-old boy with two older sisters is evaluated for symptoms of
chronic hoarseness and strained voice, which has been present for several months. The
hoarseness is worse in the evening and lessens in the morning. He has no symptoms of
airway obstruction. The most likely cause of his symptoms is:
Question . 60. An 8-yr-old boy presents with a 24-hr history of fever, chills, cough,
dyspnea, and malaise. Examination reveals an ill-appearing child who is mildly
tachypneic with bibasilar crackles. There are no ill contacts; however, he did help his
grandmother clean her pigeon coop the day before presentation.The diagnosis of
hypersensitivity pneumonitis would be based primarily on:
Question . 61. A 17-yr-old boy previously well presents with a history of cough and
dyspnea 24 hr after working in a corn silo. Examination reveals a normal-appearing
young man who is mildly tachypneic with normal findings on lung auscultation. There
are no ill contacts. Silo filler's disease is typically a result of:
Question . 63. A 6-yr-old girl presents with a 1-mo history of mild cough, intermittent
low-grade fever, intermittent wheezing, and an episode of hemoptysis. Pulse rate is
100/min; respiratory rate is 25/min; lung ausculation reveals diffuse end-expiratory
wheeze. Chest film shows nonspecific bilateral diffuse infiltrates. There is marked
peripheral eosinophilia on complete blood count.The most likely diagnosis is:
Question . 65. A 15-yr-old boy presents with a history of chronic cough productive of
yellow-green sputum, dyspnea on exercise, digital clubbing, and poor weight gain. He
has a history of recurrent sinopulmonary infections. The patient is a thin-appearing young
man; his pulse rate is 95/min and respiratory rate is 24/min; auscultation of the lungs
demonstrates diffuse fine crackles and end-expiratory wheezing.The gold standard
technique for demonstrating bronchiectasis is:
Question . 67. A 3-yr-old child does well for the first 6 hr following surgery. Then
dyspnea and tachycardia develop, with rapid shallow respirations. On physical
examination the patient has decreased breath sounds and coarse rales on the right.Which
of the following is the most appropriate first step in treatment?
Question . 68. An 18-yr-old female patient presents with chest pain, tachypnea, and
cyanosis of sudden onset 1 wk after the birth of her first child. Her chest radiograph is
nondiagnostic, but her PaO2 is 60 mm Hg on 40% oxygen. The most likely diagnosis is:
A. Preeclampsia
B. Legionella pneumonia
C. A fractured rib
D. A pulmonary embolism
Explanation: Pulmonary embolism must be considered with the sudden onset of
chest pain, dyspnea, and cyanosis. A normal-appearing chest radiograph with
significant hypoxia is classic for pulmonary embolism. A spiral CT study is a
useful test to determine the presence of a pulmonary embolism. (See Chapter 395)
E. Hysterical hyperventilation
Question . 69. All of the following are gastrointestinal manifestations of cystic fibrosis
except:
A. Intussusception
B. Appendicitis
C. Colonic mucosal thickening
D. Gastric outlet obstruction
Explanation: Other causes of intestinal obstruction are possible and include
neonatal meconium ileus, congenital ileal atresia, neonatal mucus plus syndrome,
meconium ileus equivalent (from insufficient use of pancreatic enzyme
replacement), intussusception, inguinal hernia, and appendiceal obstruction. (See
Chapter 402 in Nelson Textbook of Pediatrics, 17th ed.)
E. Inguinal hernias
A. Incidence of 1 case per 3,500 black and 1 case per 17,000 white infants
Explanation: The incidence of cystic fibrosis is highest in northern European
whites (1 in 3500) and lowest in Asian infants in Hawaii (1 in 90,000). (See
Chapter 402 in Nelson Textbook of Pediatrics, 17th ed.)
B. Autosomal recessive inheritance
C. More than 700 gene mutations
D. F508 as the dominant mutation
E. WI282X mutation in 60% of Ashkenazi Jews
F. Severity of lung disease is not predictable by the gene mutation
A. Cyanosis
B. Clubbing
C. Cough
Explanation: The cough begins as dry and nonproductive but progresses to loose
with production of purulent sputum. (See Chapter 402 in Nelson Textbook of
Pediatrics, 17th ed.)
D. Wheezing
E. Nasal polyps
A. Chest radiograph
B. CBC
C. ECG
Explanation: This is a very high heart rate for a simple sinus rhythm. The child
is in heart failure, but the excessively high heart rate may be the cause, not the
result, of heart failure. (See Chapter 428 in Nelson Pediatrics, 17th ed.)
D. ABG analysis
E. Blood culture
Question . 2. What would be the most likely diagnosis in the case in Question 1?
A. Reentrant SVT
Explanation: This is a classic presentation of supraventricular tachycardia in
infancy. It is usually idiopathic and transient but does require rapid diagnosis
and treatment. It may also be present in utero. Always be sure the parents are
not giving the child over-the-counter cold remedies that contain
sympathomimetic agents, which may include "herbal" remedies that could
contain ephedra. (See Chapter 428 in Nelson Textbook of Pediatrics, 17th ed.)
B. Ventricular tachycardia
C. Sepsis
D. Anemia
E. Pneumonia
Question . 3. What would be the most appropriate next step in treatment for the case
in Question 1?
A. Electrical defibrillation
B. IV verapamil
C. Adenosine therapy
Explanation: Intravenous rapid push adenosine is the drug treatment of choice
for all cases of SVT, in infants and in patients of all ages. Verapamil was once
used in older patients, but in infants in heart failure, verapamil has serious
adverse effects (cardiac arrest) owing to its negative inotropic effects on an
already failing myocardium. (See Chapter 428 in Nelson Textbook of
Pediatrics, 17th ed.)
D. Antibiotic therapy
Blood transfusion
A. Asthma
B. Overuse injury
C. Musculoskeletal trauma
D. Coronary atherosclerosis
Explanation: Unless there is a strong family history of premature myocardial
infarction or sudden death, or unless symptoms are exacerbated by exercise,
chest pain in children is often due to musculoskeletal or pulmonary disorders.
Children may complain of chest pain after an adult family member has a
myocardial infarction. This is less likely to be coronary vessel disease and
more likely to be anxiety. Nonetheless, the clinician should be aware of more
serious causes in children with chest pain, dyspnea, or syncope with exercise.
(See Chapter 415 in Nelson Textbook of Pediatrics, 17th ed.)
E. Anxiety
A. Noonan syndrome
B. Tetralogy of Fallot
C. Rheumatic fever
Explanation: Pulmonary valve lesions in rheumatic fever are very unusual.
This lesion is common as a dysplastic valve in Noonan syndrome and in
Alagille syndrome, which is due to mutations in Jagged 1. Isolated PS is also
noted to have an increased frequency of Jagged 1 mutations without Alagille
syndrome. (See Chapter 420 in Nelson Textbook of Pediatrics, 17th ed.)
D. Alagille syndrome
E. Mutations of Jagged 1 gene
A. Recurrent emesis
B. Chronic wheezing
C. Tracheomalacia
D. Heart failure
Explanation: The vessels involved in vascular rings do not produce a shunt or
excessive blood flow. The main problems are mechanical impingement on the
trachea and/or esophagus and the symptoms resulting from these points of
obstruction. (See Chapter 425 in Nelson Textbook of Pediatrics, 17th ed.)
E. Cough
A. Tetralogy of Fallot
B. Stills murmur
C. Rheumatic fever
D. Cor pulmonale
E. Primary pulmonary hypertension
Explanation: Primary pulmonary hypertension is an idiopathic disorder. Some
familial cases have mutations in the gene for bone morphogenetic protein
receptor II. (See Chapter 426 in Nelson Textbook of Pediatrics, 17th ed.)
A. Vagal stimulation
Explanation: In infants, the vagal maneuver of choice is placing a plastic bag
containing iced saline completely over the nose and mouth. If this is
unsuccessful, intravenous adenosine is the next step. Vagotonic maneuvers in
older children include doing a Valsalva maneuver, straining, breath holding,
Question . 11. Disorders associated with complete heart block include all of the
following Except:
Question . 12. A previously healthy 7-yr-old girl has a 3-wk history of fever,
myalgias, and a positive blood culture for Staphylococcus aureus. The past medical
history is negative including a normal camp physical examination 6 mo ago, which
did not reveal any heart murmur. After repeating a blood culture, the next step in her
evaluation should be:
A. Chest radiograph
B. Complete blood count
C. Echocardiogram
Explanation: This patient has bacterial endocarditis of a previously normal
valve. S. aureus is a common pathogen producing endocarditis of a native
valve. The duration of the illness is too long for a simple viral illness, and in
the absence of bone or soft tissue findings, any person with a positive blood
culture for S. aureus should be considered as having endocarditis until proven
otherwise. (See Chapter 429 in Nelson Textbook of Pediatrics, 17th ed.)
D. Bone scan
E. Dental clinic appointment
Question . 13. Major findings in the Duke criteria for the diagnosis of endocarditis
include all of the following Except:
A. Endocarditis
B. Rheumatoid arthritis
C. Meningococcal sepsis
D. Glomerulonephritis
E. Rheumatic fever
Explanation: The sore throat represented an untreated episode of group A
streptococcal pharyngitis. Rheumatic fever presents acutely as a migrating
polyarthritis, pancarditis (valves, myocardium, pericardium), and erythema
marginatum (not in this patient). Delayed or chronic manifestations include
chorea or subcutaneous nodules. These all represent major criteria for the
diagnosis, but documentation of a previous streptococcal infection is also
required. (See Chapter 430 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 15. A 3-mo-old female infant has a history of poor feeding, shortness of
breath during feedings, failure to thrive, and chronic cough. Physical examination
reveals tachycardia and a gallop rhythm but no murmur. There is hepatomegaly but no
cyanosis. A chest radiograph reveals cardiomegaly. The most appropriate diagnostic
test is:
A. Echocardiogram
Explanation: The differential diagnosis includes myocarditis,
cardiomyopathies, anomalous coronary arteries, and arteriovenous
malformations in the liver or brain. The echocardiogram reveals poor
contractibility and a dilated cardiomyopathy. (See Chapter 431 in Nelson)
B. Electrocardiogram
C. Blood culture
D. Serum amino acids
E. Urine pH
Question . 16. After further evaluation and treatment for heart failure, the child
described in Question 15 should also be started on:
A. Selenium
B. Vitamin B1
C. Thyroid hormone
D. Carnitine
Explanation: Although deficiencies of all of these nutrients (or hormone) may
produce heart failure, the clinical picture and history are not compatible with
A-C. Many believe that all infants with cardiomyopathy should receive a trial
of carnitine after being evaluated for metabolic inborn errors of metabolism
associated with cardiomyopathy. (See Chapter 431 in Nelson Textbook of
Pediatrics, 17th ed.)
E. None of the above
A. Head ultrasonography
Explanation: This neonate has a febrile illness with heart failure. (See Chapter
431 in Nelson Textbook of Pediatrics, 17th ed.)
B. Echocardiography
C. Viral cultures and PCR assay
D. ECG
E. Liver function tests
F. Blood culture
A. Heart transplantation
B. Pleconaril
Explanation: Pleconaril is a potent antiviral agent that is very effective against
enteroviruses. It is the agent of choice for treatment of severe enteroviral
infections. (See Chapter 431 in Nelson Textbook of Pediatrics, 17th ed.)
C. Ribavirin
D. Intravenous immunoglobulins
E. Oseltamivir
A. Sodium bicarbonate
B. Morphine
C. Prostaglandin E1
Explanation: The murmur may represent a patent ductus arteriosus (PDA). If
the PDA closes, marked cyanosis would supervene, resulting in acidosis,
shock, and death. Prostaglandin E1 (PGE1) maintains patency of the ductus
arterious between the pulmonary artery and the aorta. (See Chapter 423 in
Nelson Textbook of Pediatrics, 17th ed.)
D. Digoxin
E. Positive pressure ventilation
A. Cardiomyopathy
B. Anomalous coronary artery
C. Tetralogy of Fallot
Explanation: The child described has tetralogy of Fallot with exercise-induced
cyanosis. The more serious episode is a cyanotic, blue, or "tet" spell and may
be due to decreased systemic vascular resistance, increased pulmonary artery
pressure, or right ventricular outflow tract obstruction. The murmur of
tetralogy (the pulmonary stenosis) often disappears or lessens during a spell.
(See Chapter 423 in Nelson Textbook of Pediatrics, 17th ed.)
D. Constipation
E. Breath-holding spell
Question . 22. Therapy of a "blue" or "tet" spell could include all of the following
Except:
A. Epinephrine
Explanation: Epinephrine is potentially dangerous because it may exacerbate
inotropy and contractile forces, which may obstruct the right ventricular
infundibulum. Indeed, propranolol has been used to treat "tet" spells. (See
Chapter 423 in Nelson Textbook of Pediatrics, 17th ed.)
B. Knee-chest position
C. Oxygen
D. Morphine
E. Sodium bicarbonate
F. Phenylephrine
A. Myocarditis
B. Hypoplastic left heart syndrome
Explanation: Poor pulses, reduced left ventricular forces on ECG, cardiogenic
shock, and severe cyanosis are typical of hypoplastic left heart syndrome. (See
Chapter 424 in Nelson Textbook of Pediatrics, 17th ed.)
C. Anomalous coronary arteries
D. Total anomalous venous return
E. Tetralogy of Fallot
Question . 24. A previously well 3½-mo-old presents with poor feeding, diaphoresis
during feeding, and poor growth. Vital signs reveal a respiratory rate of 70/min, pulse
of 175/min, and blood pressure of 90/65 mm Hg in the upper and lower extremities.
The cardiac examination reveals a palpable parasternal lift and a systolic thrill. A
grade 4 holosystolic murmur and a mid-diastolic rumble are noted. The chest
radiograph reveals cardiomegaly. The most likely diagnosis is:
A. Cardiomyopathy
B. Myocarditis
C. VSD
Explanation: A large VSD with a large left-to-right shunt produces significant
heart failure. The age at onset usually corresponds to the time when the
normally high fetal pulmonary vascular resistance declines in the first 1-3 mo
of life. With decreasing pulmonary artery pressure, the left-to-right shunt
increases. (See Chapter 419.6 in Nelson Textbook of Pediatrics, 17th ed.)
D. Coarctation of the aorta
E. Transposition of the great arteries
Question . 25. The initial treatment of choice for a symptomatic patient with isolated
pulmonic stenosis is:
A. Pericarditis
Explanation: Paradoxic pulse is also noted in asthma. (See Chapter 432 in
Nelson Textbook of Pediatrics, 17th ed.)
B. Endocarditis
C. Rheumatic fever
D. Myocarditis
E. Postperfusion syndrome
Question . 27. The radiographic finding of notching of the ribs is associated with:
A. Pulmonary hypertension
B. Anomalous pulmonary venous return above the diaphragm
C. Coarctation of the aorta
Explanation: Rib notching is caused by increased collateral arteries trying to
supply the lower trunk and extremities and bypass the aortic coarctation. (See
Chapter 420.6 in Nelson Textbook of Pediatrics, 17th ed.)
D. Systemic hypertension
E. Aortic insufficiency
Question . 29. A 5-mo-old previously well infant is found to have a loud holosystolic
murmur (4/6) at the left sternal border. The first and second heart sounds are normal;
there is no tachycardia, rumble, or gallop; and hepatomegaly is not noted. The child
feeds well and has grown adequately. You suspect:
A. A restrictive VSD
Explanation: A small VSD (<0.5 cm2) produces a loud murmur, with perhaps
a thrill but no other abnormalities, owing to the limited left-to-right shunt.
Many of these defects will close spontaneously. (See Chapter 419 in Nelson
Textbook of Pediatrics, 17th ed.)
B. Anomalous left coronary artery
C. A VSD with a 4:1 shunt
D. Tetralogy of Fallot
E. Single ventricle
A. Pulmonic stenosis
B. Aortic stenosis
C. Ventricular septal defect
D. Patent ductus arteriosus
Explanation: A PDA often presents like a large VSD except that there is a
continuous murmur as well as the diastolic runoff, which produces the wide
pulse pressure and bounding pulses. (See Chapter 419 in Nelson, 17th ed.)
E. Anomalous coronary artery
Question . 31. The differential diagnosis for the lesion in Question 30 includes all of
the following Except:
A. Truncus arteriosus
B. Aorticopulmonary window
C. Sinus of Valsalva aneurysm rupture
D. Aortic valve insufficiency
E. Critical aortic stenosis from a bicuspid valve
Explanation: Aortic stenosis without significant aortic regurgitation
(insufficiency) produces an inactive precordium, normal or weak pulses, and
pressure overload of the left ventricle. (See Chapter 419 in Nelson, 17th ed.)
Question . 32. For the patient described in Questions 30 and 31, treatment is best
performed by which of the following method(s)?
A. Intravenous indomethacin
B. Surgical closure
Explanation: A PDA manifesting in any patient other than a premature infant
does not close spontaneously. Surgery carries low morbidity and even lower
mortality. However, the availability of transcatheter closure with coils or
umbrellas has reduced the need for surgery in most patients. (See Chapter 419)
C. Catheter coil closure
D. Digoxin until the PDA closes spontaneously
E. Angiotensin-converting enzyme inhibitor
Question . 33. A neonate manifests cyanosis and hepatomegaly. There is a grade 4/6
systolic ejection murmur without an audible ejection click. The ECG reveals tall,
spiked P waves and right ventricular hypertrophy. The best method to evaluate this
patient is to perform:
A. Chest x-ray examination
B. Vector cardiography
C. Immediate cardiac catheterization
D. MRI
E. Echocardiogram
Explanation: Echocardiology has replaced most methods of visualizing the
anatomy of congenital and other heart lesions. In many circumstances, the
Question . 34. The most likely diagnosis in the patient described in Question 33 is:
Question . 35. The treatment of choice for the lesion in the neonate described in
Questions 33 and 34 is:
A. Digoxin
B. Propranolol (Inderal)
C. Surgical shunt
D. Balloon valvuloplasty
Explanation: Balloon pulmonary valvuloplasty is a remarkable nonsurgical
method to dilate the valve and partially relieve the obstruction to right
ventricular outflow. (See Chapter 420 in Nelson of Pediatrics, 17th ed.)
E. Valve replacement
Question . 36. A 12-yr-old boy tries out for a middle school hockey team. He has a
history of a heart murmur as an infant, but the doctor thought it would go away.
During the tryout, he experiences severe dyspnea and becomes light-headed. At your
office, he has a normal rhythm, pulse, and blood pressure and is no longer dizzy.
There is a grade 4/6 systolic ejection murmur that radiates to the neck. There is also
an ejection click. An ECG reveals left ventricular hypertrophy. The next step in his
management should be:
A. Pulmonic stenosis
B. Mild aortic stenosis
C. Severe aortic stenosis
Explanation: Severe aortic stenosis may develop gradually, progressing over
5-10 yr. (See Chapter 420 in Nelson Textbook of Pediatrics, 17th ed.)
D. Patent ductus arteriosus
E. Williams syndrome
Question . 38. For the patient described in Question 36, treatment is best
accomplished with
Question . 39. An 8-yr-old boy from the former Soviet Union is brought to your
office because of a heart murmur and dusky blue skin. He has marked clubbing of the
fingers and toes, and his hematocrit is 70%. He has a grade 4/6 holosystolic murmur.
His chest film reveals a normal pulmonary blood flow as well as a right-sided aortic
arch. The most likely diagnosis is:
Question . 40. The reason that the hematocrit is so high in the patient described in
Question 39 is:
A. Chronic hypoxia
Explanation: Chronic hypoxia produces both the clubbing and the
polycythemia. High hematocrits (usually >65% on a central blood sample)
usually produce hyperviscosity, which impairs tissue perfusion. Therefore, up
to a point, the raised hematocrit improves oxygen delivery; once
hyperviscosity develops, the tissue microcirculation is compromised. (See
Chapter 427 in Nelson Textbook of Pediatrics, 17th ed.)
B. It was taken in a low cardiac output state
C. It was a peripheral finger stick
D. Polycythemia improves flow through VSD
E. Hyperviscosity aids flow to the pulmonary artery
A. Embolic stroke
B. Cerebral thrombosis
C. Cerebral abscess
Explanation: Cerebrovascular accidents result from a combination of
polycythemia and the right-to-left shunting in patients with TOF. Strokes are
more common in children younger than 2 yr and in those with iron-deficiency
anemia. Cerebral abscess formation is more common in children older than 2
yr. (See Chapter 427 in Nelson Textbook of Pediatrics, 17th ed.)
D. Migraine
E. Moyamoya disease
Question . 42. The most likely cause of sudden death in an athlete immediately after
forceful blunt trauma to the chest is:
A. Commotio cordis
Explanation: This unusual event places the heart in asystole, which is
unfortunately refractory to almost all resuscitative efforts. At the scene,
defibrillation may improve the outcome if done within minutes of the episode.
(See Chapter 428 in Nelson Textbook of Pediatrics, 17th ed.)
B. Myocardial infarction
C. Lacerated coronary artery
D. Ruptured cardiac tendineae
E. Hemorrhagic pericarditis
Question . 43. An 8-yr-old girl presents with chest pain of 1 day's duration. Five days
before onset of the pain, she had fever, chills, and myalgias. Physical examination
reveals an uncomfortable, anxious, afebrile patient with tachycardia, no murmur, and
distant heart sounds. The chest radiograph shows cardiomegaly without pulmonary
edema. There is a paradoxical pulse of 22 mm Hg. The most likely diagnosis is:
A. Myocarditis
B. Cardiomyopathy
C. Kawasaki disease
D. Pericarditis
Explanation: Pericarditis, in this child due to coxsackievirus infection, often
presents as chest pain, tachycardia, narrow pulse pressure, and a pulsus
paradoxus. The chest radiograph demonstrates cardiomegaly, which can be
enlargement due to myocardial dilatation or expansion of the pericardial space
from fluid. (See Chapter 432 in Nelson Textbook of Pediatrics, 17th ed.)
E. Sepsis
A. Rheumatic fever
B. SLE
C. Juvenile rheumatoid arthritis
D. Post-meningococcal immune complexes
E. Chronic atrial fibrillation
Explanation: Immune complex and other immune mechanisms may produce a
pericardial effusion, pericarditis, and rarely cardiac tamponade. (See Chapter
432 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 1. An 8-yr-old child presents with enamel defects on the permanent central
and lateral incisors. At what time would a metabolic disturbance affecting the ameloblast
have occurred?
A. Enamel defects
B. Tooth shape abnormalities
C. Enamel hypoplasia
D. Gingival enlargement
E. Tooth discoloration
Explanation: Yellow-brown discoloration or even color changes that are visible
with a fluorescent lamp have been reported with long periods of tetracycline use
before the age of 8 yr. (See Chapter 288 in Nelson Textbook of Pediatrics, 17th
edition.)
A. Osteogenesis imperfecta
B. Cleidocranial dysostosis
C. Ectodermal dysplasia
Explanation: Variations in size or shape, but not in number, of teeth are noted in
the other syndromes. (See Chapter 292 in Nelson Textbook of Pediatrics, 17th
edition.)
D. Pierre Robin syndrome
E. All of the above
Question . 7. A 2-yr-old presents to your office with black spots and missing enamel on
the maxillary anterior teeth. The most likely etiology of this condition is:
Question . 8. A 5-yr-old child presents to your practice with pain from a tooth. The
parent says that for the last week the child has been waking up at night, crying from tooth
pain. Your plan includes:
A. Referral to a dentist
B. Prescription for an antibiotic
C. Prescription for an analgesic
D. All of the above
Explanation: This child most likely has an apical tooth abscess. Caries are usually
painless unless an abscess develops. Penicillin is an appropriate antibiotic. (See
Chapter 293 in Nelson Textbook of Pediatrics, 17th edition.)
A. Malocclusion
B. Gingival enlargement
Explanation: Gingival hyperplasia is classically seen in patients receiving
phenytoin (Dilantin). Not all patients get this complication. (See Chapter 294 in
Nelson Textbook of Pediatrics, 17th edition.)
C. Increased rate of dental caries
D. Notching of the vermilion border
E. All of the above
Question . 10. A football coach calls you about a 15-yr-old who just had a central incisor
knocked out on the field. You tell the coach to:
A. Put the tooth in milk and bring the child to your office
B. Try to reimplant the tooth and take the child to the dentist
Explanation: The best place to put a dislodged tooth is back in its socket.
Reimplantation of the tooth (rinse it first, but don't scrub it) is the best approach in
a cooperative patient. (See Chapter 295 in Nelson Textbook of Pediatrics, 17th
edition.)
C. Wrap the tooth in a damp paper towel and bring the tooth and child to your office
D. Do not worry about finding the tooth, but take the child immediately to the
emergency department
A. Infants
B. Children with AIDS
C. Children receiving antibiotics
D. Children with nutritional deficiencies
E. All of the above
Explanation: Oral candidiasis is quite common in all infants and should be a
concern if it doesn't respond to topical therapy or if it occurs in the presence of
other opportunistic infections, recurrent otitis media, or chronic diarrhea and
failure to thrive. (See Chapter 296 in Nelson Textbook of Pediatrics, 17th
edition.)
Question . 12. Long-term xerostomia is a high risk factor for dental caries. It can be
associated with:
A. Dehydration
B. Anticholinergic drugs
C. Sj gren syndrome
D. Tumoricidal dose of radiation in the area of the salivary glands
E. All of the above
Explanation: Dry mouth is uncommon in children but must be considered in high-
risk populations as noted in this question. (See Chapter 297 in Nelson Textbook
of Pediatrics, 17th edition.)
Question . 13. The most common developmental abnormality of the exocrine pancreas is:
A. Cystic fibrosis
B. Pancreas divisum
Explanation: Pancreas divisum is a common finding now that CT, MRI, and
ultrasonography readily identify this anatomic abnormality. It may or may not
predispose to the development of pancreatitis. Most people with pancreatitis do
not have pancreas divisum. Whether most people with pancreas divisum develop
pancreatitis is unknown, but it is unlikely. (See Chapter 328 in Nelson Textbook
of Pediatrics, 17th edition.)
C. Annular pancreas
D. Pancreatic pseudocyst
E. Choledochal cyst
A. Chronic pancreatitis
B. Congenital lipase deficiency
C. Cystic fibrosis
Explanation: In the developed countries, cystic fibrosis is the most common
etiology of pancreatic insufficiency. This is present in more than 90% of children
with cystic fibrosis and is usually present at birth. In developing countries,
malnutrition is the most common cause of pancreatic insufficiency. (See Chapter
330 in Nelson Textbook of Pediatrics, 17th edition.)
D. Shwachman-Diamond syndrome
E. Pearson syndrome
Question . 15. All of the following tests or determinations may be useful in the diagnosis
of acute pancreatitis Except:
A. Serum amylase
B. Serum lipase
C. Abdominal ultrasound examination
D. Fecal fat
Explanation: Determination of fecal fat content is useful in the diagnosis of fat
malabsorption from hepatobiliary or pancreatic disease. Acute pancreatitis is not
associated with significant steatorrhea. Chronic pancreatitis may cause fat
malabsorption. (See Chapter 332 in Nelson Textbook of Pediatrics, 17th edition.)
E. Serum amylase isoenzymes
Question . 16. A 10-yr-old boy develops pancreatitis following a blow to the abdomen.
During a 5-day hospitalization, he is treated with intravenous fluids and analgesics and is
discharged home on a low-fat diet. Four weeks later he has recurrence of abdominal pain
and vomiting. The most likely diagnosis is:
A. Fibrosing colonopathy
Explanation: Excessive quantities of oral pancreatic enzyme replacements can
produce fibrosing colonopathy. If insufficient enzymes were used, a meconium
ileus-like picture could develop. (See Chapter 331 in Nelson Textbook of
Pediatrics, 17th edition.)
B. Crohn disease
C. Distal intestinal obstruction syndrome (meconium ileus equivalent)
D. Acute pancreatitis
E. Intussusception
Question . 18. A 5-mo-old boy was clinically diagnosed with gastroesophageal reflux at
3 mo of age. Treatment with cimetidine resolved his constant crying and even seemed to
improve his spitting. His weight continues in the 50th percentile. On a follow-up visit,
however, his parents report that for the past 2 wk he once again has begun frequent
regurgitation, hiccups, and irritability. He is breast-fed and is given occasional
supplements of cow's milk-based formula. His examination is normal. Which of the
following is the most appropriate intervention?
A. Reassurance
B. Fundoplication
C. Upper endoscopy with biopsies
D. Adjustment of the dose of cimetidine
Explanation: This child responded well to the initial therapy with an H2-blocking
agent. With his continued growth along the 50th percentile, he has outgrown his
dose of cimetidine. He still has reflux, and more efficient acid suppression is
required to heal the esophagitis and improve the child's condition. (See Chapter
304 in Nelson Textbook of Pediatrics, 17th edition.)
E. Daily use of antacids
Question . 19. A 2-mo-old Bangladeshi boy, born in the United States, has been coughing
since birth. The coughing episodes are particularly pronounced during feeding. His
mother also mentions occasional choking and gagging episodes. His immunizations are
up-to-date and there is no history of travel. Which of the following will be the most
appropriate diagnostic test?
A. Extended pH monitoring
B. Tuberculin skin test
C. Pressure-injection barium swallow
Question . 20. A 6-yr-old girl with documented ?1-antitrypsin deficiency presents to the
emergency department for assessment of large-volume hematemesis. Physical
examination is remarkable for clear lung fields, pallor, and splenomegaly. Hepatomegaly
and petechiae are absent. Which of the following is the most likely source of the
hematemesis?
Question . 21. A 3-mo-old infant presents for a well-child evaluation. Which of the
following complaints would be a cause for concern?
Question . 22. An 8-yr-old boy presents with a recurrent history of vomiting. Vomiting
episodes last 24 to 48 hr and usually end abruptly. There have been four episodes over
the last 8 mo. Growth is normal, and the child is well between episodes. Which of the
following is most likely to develop in this patient?
A. Pancreatitis
B. Appendicitis
Question . 23. A 6-wk-old infant has a thoracotomy for transposition of the great vessels.
Following surgery, the infant develops loose stools. Stool cultures are negative and the
stool is Hemoccult-negative. Fecal pH is 6.0. The infant fails to gain weight. Chest x-ray
shows a pleural effusion. Which of the following would be the most appropriate dietary
intervention?
Question . 24. A 6-wk-old male infant presents with a 3-wk history of intermittent
vomiting and a weight loss of 300 g. Serum electrolytes are as follows: sodium, 147
mEq/L; potassium, 2.9 mEq/L; HCO3 -, 32 mEq/L; and chloride, 89 mEq/L. The most
likely diagnosis is:
A. Gastric volvulus
B. Adrenogenital syndrome
C. Hypertrophic pyloric stenosis
Explanation: This is the classic history of pyloric stenosis in a child. The
hypochloremic hypokalemic metabolic alkalosis helps in the diagnosis. Physical
examination immediately after feeding may reveal the olive-shaped pyloric
obstruction, while ultrasonography or an upper gastrointestinal contrast study will
demonstrate the hypertrophied pylorus as the site of obstruction. Adrenogenital
syndrome often presents with emesis and diarrhea with acidosis, hyponatremia,
and hyperkalemia. (See Chapter 310 in Nelson Textbook of Pediatrics, 17th
edition.)
D. Malrotation with volvulus
E. Cyclic vomiting
A. Calcifications on KUB
B. Inversion of the superior mesenteric artery and vein noted on abdominal
ultrasound examination
Explanation: This child has a malrotation and may have obstruction due to a
volvulus or Ladd bands. An upper gastrointestinal contrast study will reveal an
abnormal position of the duodenum and any obstructing lesions. An associated
volvulus may produce bowel infarction and is a surgical emergency. (See Chapter
311 in Nelson Textbook of Pediatrics, 17th edition.)
C. Dilated distal small bowel loops on KUB
D. Target sign on abdominal ultrasound examination
E. Dilation of the rectum and colon on barium enema
Question . 26. A 4-yr-old girl presents with a 1-day history of a painless, maroon-colored
stool. She appears comfortable and in no distress or pain but is pale. Pulse is 110/min.
Hemoglobin level is 9.8 g/dL. The most appropriate step to establish the diagnosis is:
Question . 27. A 2-mo-old infant has a history of infrequent bowel movements and poor
weight gain. Physical examination reveals a thin, poorly nourished child with abdominal
distention. Rectal examination reveals normal tone, and the infant subsequently passes an
explosive, foul-smelling stool. All the following may be useful in establishing the
diagnosis Except:
A. Colonoscopy
Explanation: Colonoscopy is not indicated in children suspected of having
Hirschsprung disease. This is a classic presentation, especially if it was known
that he needed a glycerin suppository and rectal stimulation to stool in the nursery
after 72 hours of not passing meconium. The disease is more common in males.
(See Chapter 313 in Nelson Textbook of Pediatrics, 17th edition.)
B. Un-prepped barium enema
C. Rectal suction biopsy
D. Full-thickness rectal biopsy
E. Rectal motility
Question . 29. A 3-yr-old hearing-impaired child is found playing with his hearing aid.
No battery can be found, and the child is noted to be drooling. The most appropriate next
step in treatment would be:
Question . 30. A 14-yr-old girl has a 6-mo history of recurrent abdominal pain. The pain
is characterized as periumbilical to epigastric, lasting 20 to 30 min, with a frequency of
two or three times per week. The pain is relieved following the passage of stool. Her
mother has had similar symptoms intermittently since the age of 12 yr. There has been no
fever, rash, joint symptoms, or weight loss. No blood has been noted in the stool. The
most appropriate next step in the evaluation or management of this patient would be:
A. Abdominal CT scan
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. Trial of dietary fiber
Explanation: Both mom and daughter probably have irritable bowel syndrome.
The disease is of unknown etiology but is not "psychological." Dietary fiber is a
good first line of therapy. (See Chapter 323 in Nelson Textbook of Pediatrics,
17th edition.)
D. Colonoscopy
E. Gluten-free diet
Question . 32. A female newborn has a single perineal orifice. The chance that this baby
has associated urologic problems is:
A. <10%
B. 30%
C. 60%
D. 90%
Explanation: This is a high-risk anomaly and is associated with a major risk for
urologic problems of the bladder and kidneys. (See Chapter 325 in Nelson
Textbook of Pediatrics, 17th edition.)
E. None of the above
Question . 33. A baby is born with no anal opening and obvious features of Down
syndrome. The most likely type of anorectal malformation in this baby is:
A. Cloacal defect
B. Rectovaginal fistula
C. Rectovestibular fistula
Explanation: This fistula may not be completely obstructed. The child may "pass"
meconium as well. Without direct observation of the perineum, the imperforate
anus may be missed. (See Chapter 325 in Nelson Textbook of Pediatrics, 17th
edition.)
D. Rectoperineal fistula
E. None of the above
Question . 35. A 9-yr-old boy complains of lower gastrointestinal bleeding and mucous
drainage. He appears well and denies nausea or vomiting, but notes occasional crampy
abdominal pain. Heart rate and blood pressure are normal, and rectal examination reveals
velvety polyps. The boy's father and grandfather have undergone colectomies as young
adults. The next appropriate step is:
A. Colonoscopy
Explanation: This child most likely has familial adenomatous polyposis coli and
is at risk for developing multiple polyps for the rest of his life; more serious is the
risk of developing colonic cancer within one or more of the polyps. The incidence
of familial adenomatous polyps is 1:8000 people. Patients require annual
colonoscopy. (See Chapter 326 in Nelson Textbook of Pediatrics, 17th edition.)
B. Proctocolectomy
C. COX-2 inhibitor therapy
D. CT scan
E. Clinical follow-up until age 25 yr
Question . 36. A 10-yr-old girl is brought for evaluation because her mother was found
to have familial adenomatous polyposis coli (APC). Genetic screening identified identical
APC gene mutations in mother, aunt, and grandfather, but no mutations were identified in
the girl's APC gene. The girl requires:
A. Colonoscopy
B. Proctocolectomy
C. Annual physical examination
Explanation: This autosomal dominant gene is responsible for familial
adenomatous polyps with a high risk of malignant transformation. If the gene is
known in the family and the patient does not have that gene, her risk is no greater
than that of the general population. (See Chapter 326 in Nelson Textbook of
Pediatrics, 17th edition.)
D. CT scan
E. Repeat genetic testing in 1 yr
Question . 38. A 4-yr-old boy presents with diarrhea and headaches. He appears to have
a limp, which favors the left leg. On examination, he has a poorly defined mass in the left
flank and a blood pressure of 170/100 mm Hg. Abdominal CT scan demonstrates a large
paraspinous mass on the left. The next step in the care of this boy is to:
Question . 39. A 12-yr-old girl presents with severe crampy abdominal pain. The pain
resolves after 30 min in the emergency department. On examination, she is found to have
freckles on the lips, buccal mucosa, and gums. The abdomen is not tender on
examination. The next most appropriate step is to:
A. Urinary catecholamines
B. Urinary 5-hydroxyindoleacetic acid (5-HIAA)
Explanation: Carcinoid is uncommon in children and may present as a
nonsecreting tumor or one with identical features to those in adults, as noted in
this case. (See Chapter 326 in Nelson Textbook of Pediatrics, 17th edition.)
C. Serum ACTH
D. Serum serotonin
E. Serum parathyroid hormone
Question . 41. A 4-yr-old boy in good health presents with a 3-day history of a tender
mass, 2 cm in diameter, midway between the umbilicus and the xyphoid process. He is
afebrile, is eating normally, and has an otherwise normal physical examination. The most
likely diagnosis is:
A. Metastatic neuroblastoma
B. Rhabdomyosarcoma of the abdominal wall
C. Incarcerated epigastric hernia
Explanation: This is a typical site for an epigastric hernia, which usually does not
contain bowel and is thus usually identified as an asymptomatic mass. (See
Chapter 354 in Nelson Textbook of Pediatrics, 17th edition.)
D. Lipoma
E. Infected dermoid cyst
Question . 42. Although the toxic dose of fluoride is many times greater than the dose
needed to cause mild fluorosis (mottling of dental enamel), the dose associated with
mottling in young infants is how many times the dose from fluoridated water?
A. 2-5 times
Explanation: The therapeutic window for mild mottling of teeth from fluoride is
narrow. (See Chapter 293 in Nelson Textbook of Pediatrics, 17th edition.)
B. 10-20 times
C. 100-200 times
D. 1000 times
Question . 44. A 16-yr-old girl with a past history of hypothyroidism, which developed
at age 10 yr, now manifests fever, anorexia, amenorrhea, and jaundice of 4 months'
duration. The direct bilirubin level is 6 mg/dL, and the total bilirubin value is 11 mg/dL.
Results of the tests for hepatitis A, B, C, D, and E are negative, and the serum IgG level
is 16.5 g/L. The most likely diagnosis is:
A. Mononucleosis
B. Chronic active hepatitis
Explanation: Choices A, B, and C must be considered because each may produce
similar hepatic and extrahepatic manifestations. Chronic active hepatitis of the
autoimmune type (lupoid hepatitis) is often associated with other autoimmune
diseases (the patient described in the question had Hashimoto thyroiditis) and is
more prevalent in adolescent females. High titers of liver-kidney microsomal
antibodies are present. The antinuclear antibody response is also positive in many
patients. (See Chapter 343 in Nelson Textbook of Pediatrics, 17th edition.)
C. 1-Antitrypsin deficiency
D. Hepatoblastoma
E. Wilson disease
Question . 45. An 18-yr-old boy complains of right upper respiratory quadrant pain and
fever for 2 wk. Physical examination reveals hepatomegaly, no icterus, and right lower
quadrant fullness. Four weeks before admission, he returned from Mexico, where he
received an over-the-counter medication for an illness characterized by abdominal pain,
nausea, and emesis. The most likely diagnosis is:
A. Amebiasis
B. Hepatitis
C. Hepatic abscess (bacterial)
Explanation: In the patient described in the question, the hepatic abscess
developed as a complication of a partially treated ruptured appendix after acute
Question . 46. A 10-yr-old girl who had biliary atresia treated with the Kasai procedure
in infancy now manifests increasing clumsiness, reduced deep tendon reflexes, and
ataxia. The most likely diagnosis is:
A. Hepatic encephalopathy
B. Vitamin A deficiency
C. Encephalitis
D. Vitamin E deficiency
Explanation: Vitamin E deficiency has a long latency (years) before it eventually
produces ataxia, posterior (spinal cord) column signs, and peripheral neuropathy.
Early treatment with water-soluble vitamin E may prevent and reverse these
neurologic processes. (See Chapter 337 in Nelson Textbook of Pediatrics, 17th
edition.)
E. Kernicterus
Question . 48. A 5-yr-old girl with cirrhosis and portal hypertension experiences
increasing abdominal distention and fever. Shifting dullness and a puddle sign, as well as
abdominal tenderness, are noted on physical examination. Paracentesis reveals cloudy
fluid. Culture of the ascitic fluid is most likely to reveal:
A. Pseudomonas
B. Candida albicans
C. Pneumococci
Explanation: The pneumococcus is a common pathogen producing peritonitis
(primary) in any condition causing ascites (nephrosis, cirrhosis). Next in
frequency is Escherichia coli. (See Chapter 352 in Nelson Textbook of Pediatrics,
17th edition.)
D. Serratia
E. Haemophilus influenzae
A. Pain on swallowing
B. Emesis without nausea
C. Drooling due to obstruction
D. Difficulty swallowing
Explanation: Dysphagia is a sensation that swallowing is difficult because of
something being "stuck." Odynophagia is pain on swallowing. (See Chapter 287
in Nelson Textbook of Pediatrics, 17th edition.)
E. Reflux dyspepsia
Question . 50. All of the following statements regarding cyclic vomiting are true Except: